First episodes of psychosis in Afro-Caribbean and White people. An 18-year follow-up population-based study

The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis

Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f² = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.

Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK

Objective

The review aims to identify the extent and nature of research on mental disorders and their care in immigrant populations in three major European countries with high levels of immigration, i.e. Germany, Italy, United Kingdom (UK).

Methods

Peer-reviewed publications on the subject from the three countries between 1996 and 2004 were analyzed. The research questions addressed, the methods used, and the results obtained were assessed.

Results

Thirteen papers reporting empirical studies were found from Germany, four from Italy and 95 from the UK. Studies addressed a range of research questions and most frequently assessed rates of service utilization in different immigrant groups. The most consistent finding is a higher rate of hospital admissions for Afro-Caribbean patients in the UK. Many studies had serious methodological shortcomings with low sample sizes and unspecified inclusion criteria.

Discussion

Despite large scale immigration in each of the three studied countries, the numbers of relevant research publications vary greatly with a relatively high level of empirical research in the UK. Possible reasons for this are a generally stronger culture of mental health service research and a higher number of researchers who are themselves from immigrant backgrounds in the UK.

Conclusion

Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.

Where next for understanding race/ethnic inequalities in severe mental illness? Structural, interpersonal and institutional racism

In this article we use the example of race/ethnic inequalities in severe mental illness to demonstrate the utility of a novel integrative approach to theorising the role of racism in generating inequality. Ethnic minority people in the UK are at much greater risk than White British people of being diagnosed with a severe - psychosis related - mental illness, and this is particularly the case for those with Black Caribbean or Black African origins. There is entrenched dispute about how we might understand the drivers of this inequality. To address this dispute we build on, and to a certain extent refine, established approaches to theorising structural and institutional racism, and integrate this within a theoretical framework that also incorporates racist/discriminatory interactions (interpersonal racism). We argue that this provides a conceptually robust and thorough analysis of the role of inter-related dimensions of racism in shaping risks of severe mental illness, access to care, and policy and practice responses. This analysis carries implications for a broader, but integrated, understanding of the fundamental drives of race/ethnic inequalities in health and for an anti-racism public health agenda.

Jumping to conclusions at first onset of psychosis predicts longer admissions, more compulsory admissions and police involvement over the next 4 years: the GAP study

BACKGROUND

Jumping to conclusions (JTC), which is the proneness to require less information before forming beliefs or making a decision, has been related to formation and maintenance of delusions. Using data from the National Institute of Health Research Biomedical Research Centre Genetics and Psychosis (GAP) case-control study of first-episode psychosis (FEP), we set out to test whether the presence of JTC would predict poor clinical outcome at 4 years.

METHODS

One-hundred and twenty-three FEP patients were assessed with the Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and the probabilistic reasoning 'Beads' Task at the time of recruitment. The sample was split into two groups based on the presence of JTC bias. Follow-up data over an average of 4 years were obtained concerning clinical course and outcomes (remission, intervention of police, use of involuntary treatment - the Mental Health Act (MHA) - and inpatient days).

RESULTS

FEP who presented JTC at baseline were more likely during the follow-up period to be detained under the MHA [adjusted OR 15.62, 95% confidence interval (CI) 2.92-83.54, p = 0.001], require intervention by the police (adjusted OR 14.95, 95% CI 2.68-83.34, p = 0.002) and have longer admissions (adjusted IRR = 5.03, 95% CI 1.91-13.24, p = 0.001). These associations were not accounted for by socio-demographic variables, IQ and symptom dimensions.

CONCLUSIONS

JTC in FEP is associated with poorer outcome as indicated and defined by more compulsion police intervention and longer periods of admission. Our findings raise the question of whether the implementation of specific interventions to reduce JTC, such as Metacognition Training, may be a useful addition in early psychosis intervention programmes.

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data

BACKGROUND

Evidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations.

METHODS

For this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137.

FINDINGS

Our search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03-3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62-3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07-1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22-4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21-1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages.

INTERPRETATION

BAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention.

FUNDING

University College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

BACKGROUND

As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales.

METHODS

Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses.

RESULTS

Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes.

CONCLUSIONS

Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform.

TRIAL REGISTRATION

CRD42017071663.

Culturally adapted Family Intervention (CaFI) for African-Caribbean people diagnosed with schizophrenia and their families: a mixed-methods feasibility study of development, implementation and acceptability

Background

African-Caribbean people in the UK experience the highest incidence of schizophrenia and the greatest inequity in mental health care. There is an urgent need to improve their access to evidence-based care and outcomes. Family intervention (FI) is a National Institute for Health and Care Excellence-approved psychosocial intervention. Although clinically effective and cost-effective for schizophrenia, it is rarely offered. Evidence for any research into FI is lacking for ethnic minority people generally and for African-Caribbean people specifically.

Aims

(1) To assess the feasibility of delivering a novel, culturally appropriate psychosocial intervention within a ‘high-risk’ population to improve engagement and access to evidence-based care. (2) To test the feasibility and acceptability of delivering FI via ‘proxy families’.

Design

A mixed-methods, feasibility cohort study, incorporating focus groups and an expert consensus conference.

Setting

Two mental health trusts in north-west England.

Participants

We recruited a convenience sample of 31 African-Caribbean service users. Twenty-six family units [service users, relatives/family support members (FSMs) or both] commenced therapy. Half of the service users (n = 13, 50%), who did not have access to their biological families, participated by working with FSMs.

Interventions

An extant FI model was culturally adapted with key stakeholders using a literature-derived framework [Culturally adapted Family Intervention (CaFI)]. Ten CaFI sessions were offered to each service user and associated family.

Main outcome measures

Recruitment (number approached vs. number consented), attendance (number of sessions attended), attrition (number of dropouts at each time point), retention (proportion of participants who completed therapy sessions), and completeness of outcome measurement.

Results

Of 74 eligible service users, 31 (42%) consented to take part in the feasibility trial. The majority (n = 21, 67.7%) were recruited from community settings, seven (22.6%) were recruited from rehabilitation settings and three (9.7%) were recruited from acute wards. Twenty-four family units (92%) completed all 10 therapy sessions. The proportion who completed treatment was 77.42% (24/31). The mean number of sessions attended was 7.90 (standard deviation 3.96 sessions) out of 10. It proved feasible to collect a range of outcome data at baseline, post intervention and at the 3-month follow-up. The rating of sessions and the qualitative findings indicated that CaFI was acceptable to service users, families, FSMs and health-care professionals.

Limitations

The lack of a control group and the limited sample size mean that there is insufficient power to assess efficacy. The findings are not generalisable beyond this population.

Conclusions

It proved feasible to culturally adapt and test FI with a sample of African-Caribbean service users and their families. Our study yielded high rates of recruitment, attendance, retention and data completion. We delivered CaFI via FSMs in the absence of biological families. This novel aspect of the study has implications for other groups who do not have access to their biological families. We also demonstrated the feasibility of collecting a range of outcomes to inform future trials and confirmed CaFI’s acceptability to key stakeholders. These are important findings. If CaFI can be delivered to the group of service users with the most serious and persistent disparities in schizophrenia care, it has the potential to be modified for and delivered to other underserved groups.

Future work

A fully powered, multicentre trial, comparing CaFI with usual care, is planned.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 32. See the NIHR Journals Library website for further project information.

Immigrants' outcome after a first-episode psychosis

AIM

Immigration is a risk factor for psychosis emergence, and previous studies show that immigrants are less likely to engage in treatment for psychosis. However, the literature on outcome is scant and heterogeneous. This study was designed to compare first-generation (FGI) and second-generation immigrants (SGI) to non-immigrants' symptomatic and functional outcomes 2 years after a first-episode psychosis (FEP).

METHODS

A 2-year prospective longitudinal study of 223 FEP patients between 18 and 30 years took place in two early intervention services (EIS) in Montreal, Canada.

RESULTS

Forty-two per cent of the sample were immigrants (FGI (n = 56), SGI (n = 38)). Compared with non-immigrants, immigrants had similar symptomatic and functioning profiles at baseline, 1 and 2 years, except that fewer SGI had a history of homelessness and more were living with their families. FGI were less likely to have a substance use disorder but more likely to pursue their studies and to present depressive symptoms.

CONCLUSIONS

Even if immigrants are known to be at greater risk of developing psychosis, probably secondary to stress related to immigration, their symptomatic and functional outcomes, once engaged in EIS treatment, are similar to or sometimes better than non-immigrants' outcomes. Because immigrants tend to be less engaged in their follow-up, understanding why they disengage from treatment is crucial to develop better therapeutic approaches to better engage them as EIS treatment can improve their outcomes effectively.

Patterns of illness and care over the 5 years following onset of psychosis in different ethnic groups; the GAP-5 study

PURPOSE

Previous research has not provided us with a comprehensive picture of the longitudinal course of psychotic disorders in Black people living in Europe. We sought to investigate clinical outcomes and pattern of care in Black African and Black Caribbean groups compared with White British patients during the first 5 years after first contact with mental health services for psychosis.

METHODS

245 FEP cases aged 18-65 who presented to psychiatric services in 2005-2010 in South London (UK). Using the electronic psychiatric clinical notes in the South London and Maudsley NHS Foundation Trust (SLaM), extensive information was collected on three domains-clinical, social, and service use.

RESULTS

During the 5-year follow-up (mean = 5.1 years, s.d. = 2.4; 1251 person years) after first contact with mental health services, a higher proportion of Black African and Black Caribbean ethnicity had compulsory re-admissions (χ ² = 17.34, p = 0.002) and instances of police involvement during an admission to a psychiatric unit (χ ² = 22.82, p < 0.001) compared with White British ethnic group. Patients of Black African and Black Caribbean ethnicity did not differ from the ethnic group in overall functional disability and illness severity, or frequency of remission or recovery during the follow-up period. However, patients of Black ethnicity become increasing socially excluded as their illness progress.

CONCLUSIONS

The longitudinal trajectory of psychosis in patients of Black ethnicity did not show greater clinical or functional deterioration than white patients. However, their course remains characterised by more compulsion, and longer periods of admission.

Ten-year outcomes in first episode psychotic major depression patients compared with schizophrenia and bipolar patients

We aimed to investigate long-term outcomes in psychotic major depression patients compared to schizophrenia and bipolar/manic psychosis patients, in an incidence sample, while accounting for diagnostic change. Based on Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP and ÆSOP-10), a first episode psychosis cohort was followed-up 10years after first presentation. The Schedules for Clinical Assessment in Neuropsychiatry, WHO Life Chart and Global Assessment of Functioning were used to assess clinical, social and service use outcomes. Seventy-two PMD patients, 218 schizophrenia patients and 70 psychotic bipolar disorder/mania patients were identified at baseline. Differences in outcome between PMD and bipolar patients based on baseline and lifetime diagnosis were minimal. Differences in clinical, social and service use outcomes between PMD and schizophrenia were more substantial with PMD patients showing better outcomes on most variables. However, there was some weak evidence (albeit not quite statistically significant at p<0.05) based on lifetime diagnoses that PMD patients were more likely to attempt suicide (OR 2.31, CI 0.98-5.42, p0.055) and self-harm (OR 2.34, CI 0.97-5.68, p0.060). PMD patients have better social and service use outcomes compared to people with schizophrenia, but may be more likely to attempt suicide or self-harm. This unique profile is important for clinicians to consider in any risk assessment.

Culturally-adapted Family Intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: a feasibility study protocol of implementation and acceptability

BACKGROUND

African-Caribbeans in the UK have the highest schizophrenia incidence and greatest inequity in access to mental health services of all ethnic groups. The National Institute for Health and Care Excellence (NICE) highlights this crisis in care and urgent need to improve evidence-based mental healthcare, experiences of services and outcomes for this group. Family intervention (FI) is clinically and cost-effective for the management of schizophrenia but it is rarely offered. Evidence for FI with minority ethnic groups generally, and African-Caribbeans in particular, is lacking. This study aims to test the feasibility and acceptability of delivering Culturally-adapted Family Intervention (CaFI) to African-Caribbean service users diagnosed with schizophrenia.

METHODS/DESIGN

This is a feasibility cohort design study. Over a 12-month intervention period, 30 service users and their families, recruited from hospital and community settings, will receive ten one-hourly sessions of CaFI. Where biological families are absent, access to the intervention will be optimised through 'family support members'; trusted individuals nominated by service users or study volunteers. We shall collect data on eligibility, uptake, retention and attrition and assess the utility and feasibility of collecting various outcome measures including readmission, service engagement, working alliance, clinical symptoms and functioning, perceived criticism, psychosis knowledge, familial stress and economic costs. Measures will be collected at baseline, post-intervention and at 3-month follow-up using validated questionnaires and standardised interviews. Admission rates and change in care management will be rated by independent case note examination. Variability in the measures will inform sample size estimates for a future trial. Independent raters will assess fidelity to the intervention in 10 % of sessions. Feedback at the end of each session along with thematically-analysed qualitative interviews will examine CaFI's acceptability to service users, families and healthcare professionals.

DISCUSSION

This innovative response to inequalities in mental healthcare experienced by African-Caribbeans diagnosed with schizophrenia might improve engagement in services, access to evidence-based interventions and clinical outcomes. Successful implementation of CaFI in this group could pave the way for better engagement and provision across marginalised groups and therefore has potentially important implications for commissioning and service delivery in ethnically diverse populations. This study will demonstrate whether the approach is feasible and acceptable and can be implemented with fidelity in different settings.

Predictors of engagement in first-episode psychosis

Engagement with psychiatric services is critical for ensuring successful outcomes in patients experiencing a first episode of psychosis (FEP). However, it is not known how sociodemographic factors and patient beliefs about the causes of mental illness affect engagement. This study explored predictors of engagement in a cohort of 103 FEP patients presenting to an early-intervention service. Beliefs that mental illness is caused by social stress or thinking odd thoughts predicted higher engagement scores. Patients with no qualifications were found to have higher engagement scores than those educated to a higher level. Ethnicity, gender, age and socioeconomic factors were not significantly correlated with engagement scores. Duration of untreated illness (DUI) significantly predicted higher engagement scores, but only for values >1220days. Duration of untreated psychosis (DUP) was not a significant predictor of patient engagement scores. Patient beliefs about the causes of mental illness are an important factor to be taken into consideration and may represent a target of interventions to increase engagement in FEP.

Mental health in-reach in an urban UK remand prison

Purpose

– Prison mental health in-reach teams (MHITs) have developed in England and Wales over the last decade. Services have been nationally reviewed, but detailed descriptions of their work have been scarce. The purpose of this paper is to describe the functions of one MHIT in a busy, ethnically diverse, male remand prison in London, UK.

Design/methodology/approach

– Clinical and demographic data were collected for prisoners referred to the MHIT using a retrospective design over an 18-week period in 2008/2009 (n=111).

Findings

– Foreign national prisoners and sentenced prisoners were significantly under-referred. Most referrals were already known to community mental health services, although around a quarter accessed services for the first time in prison. Around a third presented with self-harm/suicide risks. Substance misuse problems were common. Although the MHIT had evolved systems to promote service access, prisoner self-referrals were limited.

Practical implications

– Foreign national prisoners require enhanced investment to improve service access. MHITs identify people with mental disorders for the first time in prisons, but better screening arrangements are needed across systems. An evaluation of multiple MHIT models could inform a wider delivery template.

Originality/value

– One of the first ground-level evaluations of MHITs in England and Wales.

A systematic review of ethnic variations in hospital admission and compulsory detention in first-episode psychosis

BACKGROUND

Marked ethnic variations in incidence, pathways to care and outcomes have been demonstrated in psychosis. Less research has focused specifically on first-episode psychosis (FEP), particularly adverse contacts such as compulsory detention and hospitalization. This is despite international initiatives to promote equity of care and active early intervention.

AIM

Systematically review current evidence for ethnic variations in rates of compulsory admission and hospitalization in FEP.

METHODS

Relevant articles published before December 2012 were identified from PubMed, PSYCInfo, and CINAHL together with manual searching of reference lists. Studies providing quantitative data on compulsory detention rates and/or hospitalization, comparing ethnic groups in FEP, were included and quality rated by independent raters.

RESULTS

All included studies (n = 7) provided data on compulsory detention while fewer (n = 3) focused on admission rates. Three studies reported increased detention in Black and minority ethnic groups, while one reported more hospitalization in White patients. Only two studies covered early intervention services (EIS).

CONCLUSIONS

There is a paucity of high quality, well powered studies addressing this important issue, especially in EIS settings. In order to best inform and evaluate fast-developing services, it will be essential to combine large methodologically robust studies with qualitative analysis of patient, carer, and staff experiences.

Psychosis and suicide risk by ethnic origin and history of migration in the Netherlands

BACKGROUND

There is an increased incidence of non-affective psychotic disorders (NAPD) among first- and second-generation migrants in Europe. The purpose of this population-based study was to compare the risk of suicide in Dutch natives and immigrants with or without NAPD.

METHODS

Cases of NAPD (n=12 580) from three Dutch psychiatric registers were linked to the cause of death register of Statistics Netherlands and were compared to matched controls (n=244 792) from the population register, who had no such diagnosis. Hazard ratios (HRs) of suicide were estimated and adjusted for age and gender by Cox regression analysis.

RESULTS

The presence of NAPD was strongly associated with suicide risk in each ethnic group. However, for all ethnic minority groups the HRs were somewhat lower than among Dutch natives, for whom the HR was 23.4 (95%-CI; 18.5-29.7). A closer examination revealed that suicide risk was influenced by the history of migration. While the risk for immigrants of the first generation, diagnosed with NAPD, was significantly lower than that for native Dutch patients (HR=0.45; 95%-CI: 0.28-0.73), the risk for those of the second generation was more similar to that for the Dutch (HR=0.85; 95%-CI: 0.51-1.40) (P value of history of migration=0.005).

CONCLUSION

Immigrants diagnosed with NAPD of the first generation appear to be protected against suicide, whereas this protection is waning among those of the second generation. This is the first study worldwide on suicide in migrants with NAPD and the first study of suicide in patients with NAPD in the Netherlands.

Course and outcome of psychosis in black Caribbean populations and other ethnic groups living in the UK: a systematic review

BACKGROUND

A higher incidence of psychosis has repeatedly been reported in black Caribbean populations in the UK. This has been attributed to a number of biological, psychological and sociocultural causes, including black Caribbean populations having a different illness course and outcome compared to other ethnic populations living in the UK.

AIMS

A systematic review of UK-based quantitative studies, which compared at least two aspects of outcome in black Caribbean populations and other ethnic populations living in the UK, was conducted to assess whether the current body of research suggests that there are differences in the course and outcome of psychoses for these populations.

METHOD

A wide variety of databases were searched using MeSH terms and keywords. Studies were evaluated according to specified inclusion criteria and analysed using predefined scoring criteria.

RESULTS

Searches yielded a heterogeneous collection of studies. Large variances in methodological approaches and the quality of studies were reported. Many studies reported little or no difference between black Caribbean and other ethnic populations living in the UK.

CONCLUSIONS

Emphasis is placed on the unreliability of these findings given the methodological limitations of the studies, and the need for higher-quality research in this area is highlighted.

Care-Seeking Pattern among Persons with Depression and Anxiety: A Population-Based Study in Sweden

Background. In primary care, a vast majority of patients affected with depression and anxiety present with somatic symptoms. Detection rate of psychiatric symptoms is low, and knowledge of factors influencing care seeking in persons affected by depressive and anxiety disorders on a population level is limited. Objective. This study aims to describe if persons, affected by depression and anxiety disorders, seek care and which type of care they seek as well as factors associated with care seeking. Method. Data derives from a longitudinal population-based study of mental health conducted in the Stockholm County in 1998-2010 and the present study includes 8387 subjects. Definitions of anxiety and depressive disorders were made according to DSM-IV criteria, including research criteria, using validated diagnostic scales. 2026 persons (24%) fulfilled the criteria for any depressive or anxiety disorder. Results. Forty-seven percent of those affected by depression and/or anxiety had been seeking care for psychological symptoms within the last year. A major finding was that seeking care for psychological symptoms was associated with having treatment for somatic problems. Conclusions. As a general practitioner, it is of great importance to increase awareness of mild mental illness, especially among groups that might be less expected to be affected.

Schizophrenia, social class and immigrant status: the epidemiological evidence

Background — By the mid-1960s, the importance of socio-economic status for schizophrenia had been demonstrated in terms of differences between social-class groups in prevalence and incidence rates, illness course and outcome, and treatment experience. In the causation – selection debate, however, opinion had swung in favour of the selection hypothesis. Aims — To reassess evidence on the social-class distribution of schizophrenia in Britain, and to compare this body of research with population-based studies of schizophrenia risk in socially disadvantaged ethnic minorities. Method — Systematic review of medical and psychological data-bases. Results — Epidemiological research, while confirming the importance of premorbid social decline, has also provided support for the environmental ‘breeder’ hypothesis. High psychosis rates have been confirmed in ethnic minori-ties; in particular among Afro-Caribbean and other Black immigrants whose low social status cannot be accounted for by selective downward social drift or segregation. Conclusions — There are striking parallels, both in the epidemiology of schizophrenia and in social characteristics, between the lower-class indigenous groups highlighted by earlier psychiatric surveys and African-Caribbean populations in Britain's inner cities today. These similarities underline the need for a broader perspective in the search for environmental risk factors.

Declaration of Interest: none.

Ethnicity and access to an inner city home treatment service: a case-control study

There is strong evidence suggesting ethnic variations in mental health service use and disproportionate numbers of people of black ethnic origin being admitted to hospital. The objective of this study was to establish whether people of black ethnic origin had equal access to home treatment in a mental health crisis. Using a case-control design, we selected a random sample of 240 inpatient episodes and compared them with a sample of 77 home treatment episodes over a 12-month period (1 April 2008-31 March 2009). We found no difference in the proportion of people of black ethnic origin being home treated in comparison to receiving an inpatient admission, although they experienced longer hospital admissions than people of other ethnic origin. Diagnosis, housing status and source of referral were found to be significant in influencing the choice of intervention in our multivariate analysis. People of black ethnic origin were found to use home treatment to the same extent as other ethnic groups in a mental health crisis, but further research is required for the early discharge function of home treatment teams to evaluate whether this aspect of care is experienced differently by different ethnic groups.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Mental health, health care utilisation of migrants in Europe

BACKGROUND

Migration during the 1990s has been high and has been characterised by new migrations. Migration has been a key force in the demographic changes of the European population. Due to the different condition of migration in Europe, variables related to mental health of migrants are: motivation for migration, living conditions in the home and in the host country.

AIMS

To give an overview on (i) prevalence of mental disorders; suicide; alcohol and drug abuse; (ii) access to mental health and psychosocial care facilities of migrants in the European region, and (iii) utilisation of health and psychosocial institution of these migrants.

METHODS

Non-system review of the literature concerning mental health disorders of migrants and their access to and their consumption of health care and psychosocial services in Europe.

RESULTS

It is impossible to consider "migrants" as a homogeneous group concerning the risk for mental illness. The literature showed (i) mental health differs between migrant groups, (ii) access to psychosocial care facilities is influenced by the legal frame of the host country; (iii) mental health and consumption of care facilities is shaped by migrants used patterns of help-seeking and by the legal frame of the host country.

CONCLUSION

Data on migrant's mental health is scarce. Longitudinal studies are needed to describe mental health adjusting for life conditions in Europe to identify those factors which imply an increased risk of psychiatric disorders and influence help seeking for psychosocial care. In many European countries migrants fall outside the existing health and social services, particularly asylum seekers and undocumented immigrants.

Early course of schizophrenia in a representative Dutch incidence cohort

PURPOSE

To describe the early course of psychotic disorders in general and to examine whether certain variables can predict the early course of schizophrenic disorders (DSM-IV: schizophrenia, schizophreniform or schizoaffective disorder).

SUBJECTS AND METHOD

Follow-up and re-diagnosis of a highly representative Dutch incidence cohort (N=181), thirty months after first contact with a physician for a psychotic disorder. Poor course was defined as a continuous psychotic illness or a score of less than 39 on the Global Assessment of Functioning scale.

RESULTS

The follow-up rate was 92%. 125 Subjects were diagnosed with a schizophrenic disorder. Poor course was present in 70 of these subjects (56%). Univariable analysis showed that male sex, heavy cannabis use during the follow-up period (sometimes or often more than one joint a day) and long duration of dysfunctioning before psychosis onset (>1 month) were predictors of poor course, while age at onset, ethnicity, socioeconomic status and duration of untreated psychosis (trend, p=0.08) were not. The effect of cannabis was confounded by sex. Multivariable analysis showed that male sex was the sole significant and independent predictor of poor course and explained 13% of the variation. The odds ratio for males, adjusted for duration of pre-psychotic dysfunctioning and cannabis use during the follow-up period, was 3.0 (95% CI, 1.0-8.9). STRENGTHS AND LIMITATIONS: This is the first study to examine the influence of cannabis in an epidemiological, highly representative sample. A limitation was the sample size.

CONCLUSION

Male sex is an independent risk factor for an unfavorable early course in schizophrenia.

Ethnicity and the Mental Health Act 1983

BACKGROUND

Black and minority ethnic (BME) patients are disproportionately detained under the Mental Health Act 1983. There has been no systematic exploration of differences within and between ethnic groups, nor of the explanations put forward for this excess.

AIMS

To systematically review detention and ethnicity, with meta-analyses of detention rates for BME groups, and to explore the explanations offered for ethnic differences in detention rates.

METHOD

Literature search and meta-analysis. Explanations offered were categorised, supporting literature was accessed and the strength of the evidence evaluated.

RESULTS

In all, 49 studies met inclusion criteria; of these, 19 were included in the meta-analyses. Compared with White patients, Black patients were 3.83 times, BME patients 3.35 times and Asian patients 2.06 times more likely to be detained. The most common explanations related to misdiagnosis and discrimination against BME patients, higher incidence of psychosis and differences in illness expression. Many explanations, including that of racism within mental health services, were not supported by clear evidence.

CONCLUSIONS

Although BME status predicts psychiatric detention in the UK, most explanations offered for the excess detention of BME patients are largely unsupported.

Early Psychosis Prevention and Intervention Centre long-term follow-up study of first-episode psychosis: methodology and baseline characteristics

AIM

This paper reports the rationale, methodology and baseline characteristics of a large long-term follow-up study of first-episode psychosis from a geographically defined catchment area.

METHOD

A total of 723 first-episode psychosis patients were recruited from a specialized early psychosis service between 1989 and 2001 and prospectively followed up at a median of 7.4 years after initial presentation. Participants' baseline demographic, clinical and functional characteristics are described. Sampling bias at study recruitment was assessed by comparison with a more complete sample of Early Psychosis Prevention and Intervention Centre (EPPIC) cases rated directly from the medical records.

RESULTS

  At baseline, 57% of the sample were diagnosed with schizophrenia or schizophreniform disorder, whereas the full range of psychotic disorders was represented. Statistical analysis confirmed that the sample recruited was representative of total EPPIC-treated incident cases.

CONCLUSIONS

The EPPIC long-term follow-up study is a large and epidemiologically representative first-episode psychosis cohort that has been subsequently prospectively followed up over a long period. Such a sample provides a rare opportunity to study the course and outcome of psychotic disorders.

Why are immigrants at increased risk for psychosis? Vitamin D insufficiency, epigenetic mechanisms, or both?

European researchers have observed that schizophrenia is 3 times more frequent in immigrants than in native-born subjects. This increased risk is even higher in dark-skinned immigrants, and the second generation is more affected than the first one. Immigrant status is an important environmental risk factor not only for schizophrenia but also for other psychoses. The explanations proposed to date have been mainly related to epidemiological biases and psychological reasons, such as racism or social defeat, but no biological hypotheses have been tested so far. This article proposes two biological hypotheses related to changes in sun exposure, changes in diet, and stress associated with immigration, which would explain the increased risk for psychosis associated with immigrant status. (1) Vitamin D insufficiency has been proposed as a risk factor for schizophrenia. The main source of vitamin D is through photosynthesis by sun exposure, and dark skins need more sun exposure to maintain adequate blood levels. Vitamin D insufficiency in adulthood could explain why dark-skinned immigrants develop psychosis when moving to high latitude countries, and its insufficiency during pregnancy could explain why the observed risk is higher in the second generation. (2) The second hypothesis is that of epigenetics, with psychosis resulting from modifications in gene expression caused by changes in diet and/or stress related to immigration. The role of homocysteine and the vitamin B-complex, especially folic acid, in these changes in DNA transcription would vary according to the polymorphism of the methylenetetrahydrofolate reductase gene. The vitamin D insufficiency and epigenetics hypotheses are consistent with yet unexplained findings well known in the epidemiology of schizophrenia, such as the increased risk in the urban environment, the excess of winter births, the excess of schizophrenia births after maternal famine, and the shorter interbirth period before a schizophrenia birth. In order to test these hypotheses, epidemiological studies of psychosis and immigration should include objective measures of skin color, which is predicted to be a more important risk factor than ethnicity. They should measure vitamin D, homocysteine and vitamin B-complex status and assess the polymorphisms of the vitamin D receptors and the methylenetetrahydrofolate reductase gene. If confirmed, these hypotheses would lead to effective and inexpensive preventive measures which would markedly decrease the rates of psychosis and schizophrenia, as well as the burden and stigma of these diseases, and greatly improve the mental health of immigrants.

Ethnic differences in mental health service use among patients with psychotic disorders

BACKGROUND

There are concerns that ethnic minority patients are over-represented in inpatient mental health settings, but under-utilise community services. This study aims to compare the use of community mental health services between African-Caribbean and White patients with psychosis, before and after the introduction of new community services, and to investigate their impact on inpatient treatment.

METHODS

The sample was drawn from epidemiologically representative patients with psychotic disorders living in two catchment areas in South London, one of which was developing intensive community treatments. Service utilisation was measured at baseline and at 2-year follow-up using the Client Service Receipt Interview (CSRI). The mean number of contacts with specific services was compared between the two groups over time.

RESULTS

A total of 92 White and 48 African-Caribbean patients were compared. The latter were more likely to be younger (P = 0.004), have shorter illness duration (P < 0.001), and had more detentions under the Mental Health Act (P = 0.003). No significant differences were seen in use of community services over time. However, intensive treatment led to a significant reduction in hospital days for African Caribbean patients compared to White patients in the intensive sector and all patients in the standard sector.

CONCLUSIONS

Intensive community treatments reduced inpatient days in African Caribbean patients. Further effort is needed to improve the cultural sensitivity of community mental health services.

Psychotic symptoms in the general population of England--a comparison of ethnic groups (The EMPIRIC study)

BACKGROUND

There is considerable evidence that incidence of schizophrenia and other psychoses varies across ethnic groups in the UK, with particularly high rates for people of African-Caribbean origin.

AIMS

The aims of this shady were to estimate in a community-based sample of people from ethnic minorities: 1) the prevalence of psychotic symptoms; and 2) risk factors for reporting psychotic symptoms.

METHOD

Face-to-face interviews were carried out with a probabilistic sample of 4281 adults from six ethnic groups living in the UK. Psychotic symptoms were measured using the psychosis screening questionnaire (PSQ).

RESULTS

There was a twofold higher rate of reporting psychotic symptoms on the PSQ in Black Caribbean people compared with Whites. Adjustment for demographic factors had little effect on this association.

CONCLUSION

Prevalence rates of psychotic symptoms were higher in people from ethnic minorities, but were not consistent with the much higher first contact rates for psychotic disorder reported previously, particularly in Black Caribbeans.

Risk factors and the prevalence of neurosis and psychosis in ethnic groups in Great Britain

BACKGROUND

Our aim was to examine whether variations in the prevalence of neurosis and psychosis between ethnic minorities throughout Great Britain are explained by social disadvantage.

METHOD

A total of 10,108 adult householders throughout Great Britain were assessed in a two-stage survey with the Revised Clinical Interview Schedule (CIS-R) and Psychosis Screening Questionnaire (PSQ). Respondents with a positive PSQ or who received a diagnosis of, or treatment for, psychosis were examined by a psychiatrist using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Data on respondents' preferred ethnic group were collapsed into four groups: Whites, African-Caribbean or Africans, south Asians and other.

RESULTS

Ethnic grouping was strongly associated with: unemployment; lone parent status; lower social class; low perceived social support; poverty (indicated by lack of car ownership) and having a primary social support group of less than three close others. All these associations applied to the group Africans and Afro-Caribbeans, but only some applied to the other groups. No ethnic group had significantly increased rates of neurosis. Only the African-Caribbean group were at significantly increased risk of a psychotic disorder (odds ratio 4.55; 95% CI: 1.13, 18.30). After adjustment for risk factors, the odds of psychosis were lower (odds ratio 2.97; 95% CI: 0.66, 13.36).

CONCLUSIONS

The excess of psychosis in Africans and Afro-Caribbeans in Great Britain appears to be partly explained by socio-economic disadvantage, but larger studies are needed to confirm this.

The role of engagement with services in compulsory admission of African/Caribbean patients

BACKGROUND

High rates of compulsory admission of African/Caribbean patients have been reported. Several factors have been associated with this finding. The roles of some factors related to engagement with services have not been empirically evaluated.

AIMS

The aim of this study was to assess the role of engagement factors in compulsory admission of African/Caribbean patients.

METHOD

A systematic case-note review was made of the admission process of 100 compulsorily and 100 voluntarily admitted patients; each group containing 50 randomly selected African/Caribbean and White British patients. Information about socio-demographic and engagement factors was collected and the findings compared.

RESULTS

Compulsorily admitted African/Caribbean patients had more factors indicative of poor engagement with services than patients in the other groups. Prior to admission, they were less likely to keep their appointments, comply with their medication, contact their GPs and were more likely to present late. Furthermore, they had more history of multiple compulsory admissions. The compulsorily admitted patients, irrespective of ethnicity, also engaged poorly with services.

CONCLUSIONS

Poor engagement with primary care and secondary mental health services of African/Caribbean patients appears to be contributing to their high rates of compulsory admission. This aspect of ethnic factors and compulsory admission requires further studies.

Impact of compulsory community treatment on admission rates: survival analysis using linked mental health and offender databases

BACKGROUND

There is controversy as to whether compulsory community treatment for psychiatric patients reduces hospital admission rates.

AIMS

To examine whether community treatment orders (CTOs) reduce admission rates, using a two-stage design of matching and multivariate analyses to take into account socio-demographic factors, clinical factors, case complexity and previous psychiatric and forensic history.

METHOD

Survival analysis of CTO cases and controls from three linked Western Australian databases of health service use, involuntary treatment and forensic history. We used two control groups: one matched on demographic characteristics, diagnosis, past psychiatric history and treatment setting, and consecutive controls matched on date of discharge from in-patient care.

RESULTS

We matched 265 CTO cases with 265 matched controls and 224 consecutive controls (total n=754). The CTO group had a significantly higher readmission rate: 72% v. 65% and 59% for the matched and consecutive controls (log-rank chi(2)=4.7, P=0.03). CTO placement, aboriginal ethnicity, younger age, personality disorder and previous health service use were associated with increased admission rates.

CONCLUSIONS

Community treatment orders alone do not reduce admissions.

Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry

It has been consistently reported that the African-Caribbean population in the UK are more likely than their White counterparts to access psychiatric services via the police and under compulsion. The reasons for these differences are poorly understood. This paper comprises two main parts. The first provides a comprehensive review of research in this area, arguing the current lack of understanding stems from a number of methodological limitations that characterise the research to date. The issue of ethnic variations in pathways to psychiatric care has been studied almost exclusively within a medical epidemiological framework, and the potential insights offered by sociological and anthropological research in the fields of illness behaviour and health service use have been ignored. This has important implications as the failure of research to move beyond enumerating differences in sources of referral to psychiatric services and rates of compulsory admission means no recommendations for policy or service reform have been developed from the research. The second part of the paper sets out the foundations for future research, arguing that the pathway to care has to be studied as a social process subject to a wide range of influences, including the cultural context within which illness is experienced. It is further argued that Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry, University of California Press, Los Angeles, 1980) Health Care System model offers a particularly valuable preliminary framework for organising and interpreting future research. It is only through gaining a more qualitative understanding of the processes at work in shaping different responses to mental illness and interactions with mental health services that the patterns observed in quantitative studies can be fully understood. This further reflects the need for a bridge between the social sciences and psychiatry if services are to be developed to respond to the increasing diversity of modern societies.

Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review

BACKGROUND

Inequalities of service use across ethnic groups are important to policy makers, service providers and service users.

AIMS

To identify ethnic variations in pathways to specialist mental health care, continuity of contact, voluntary and compulsory psychiatric in-patient admissions; to assess the methodological strength of the findings.

METHOD

A systematic review of all quantitative studies comparing use of mental health services by more than one ethnic group in the UK. Narrative analysis supplemented by meta-analysis, where appropriate.

RESULTS

Most studies compared Black and White patients, finding higher rates of in-patient admission among Black patients. The pooled odds ratio for compulsory admission, Black patients compared with White patients, was 4.31 (95% CI 3.33-5.58). Black patients had more complex pathways to specialist care, with some evidence of ethnic variations in primary care assessments.

CONCLUSIONS

There is strong evidence of variation between ethnic groups for voluntary and compulsory admissions, and some evidence of variation in pathways to specialist care.

Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health?

There is extensive evidence of racial/ethnic disparities in receipt of health care. The potential contribution of provider behavior to such disparities has remained largely unexplored. Do health and human service providers behave in ways that contribute to systematic inequities in care and outcomes? If so, why does this occur? The authors build on existing evidence to provide an integrated, coherent, and sound approach to research on providers' contributions to racial/ethnic disparities. They review the evidence regarding provider contributions to disparities in outcomes and describe a causal model representing an integrated set of hypothesized mechanisms through which health care providers' behaviors may contribute to these disparities.

Service contact and psychopathology in very-late-onset schizophrenia-like psychosis: the effects of gender and ethnicity

BACKGROUND

Epidemiological data on very-late-onset (>60 years) schizophrenia-like psychosis (SLP) are scarce. There are only two published follow-up studies.

OBJECTIVE

To examine the associations of gender and ethnicity with health service contact and psychopathology in SLP.

METHOD

We identified all new referrals of SLP to the Maudsley hospital between 1995-2000. Demographic details and information on the course of the illness were obtained from case notes. Those patients who agreed to take part were seen at home and assessed with respect to psychopathology and neurological side effects.

RESULTS

The median duration of illness at the time of assessment was 3 years (range 1-6 years). Male patients were more likely to be admitted to hospital compulsorily and to be lost to follow-up than female patients. Caribbean-born patients were more likely to refuse to take part than British-born patients. Of the 26 (48%) patients who were interviewed, 38% were experiencing paranoid symptoms, 94% of patients receiving medication were in regular contact with a community psychiatric nurse (CPN). Treatment response was dose related and was not increased by the use of a depot.

CONCLUSION

The effects of gender and ethnicity on outcome need to be further investigated through larger studies. High loss to follow-up amongst male patients may be indicative of a poor prognosis. Regular contact with a CPN may be more important than the use of a depot in maintaining treatment response.

Evaluating the use of a psychiatric intensive care unit: is ethnicity a risk factor for admission?

OBJECTIVE

This paper presents a descriptive study, undertaken in 1993, of a Psychiatric Intensive Care Unit (PICU) serving a deprived inner-city area, investigating the role of ethnicity as a risk factor for admission to the unit.

METHODS

Clinical and demographic data were collected on consecutive admissions to a PICU. Global Assessment of Function Scale scores were rated on admission and at discharge from the unit.

RESULTS

The majority of patients were male (63%) and the commonest DSM-IV diagnoses were schizophrenia (42%) and bipolar affective disorder (24%). Average length of stay was 13 days with patients making significant improvement in functioning during their stay. Fifty-five percent of PICU admissions came from ethnic minorities (compared with 25.6% of total hospital admissions and 20.9% of the local catchment area population aged between 16 and 65 years). There was no evidence that ethnic minority patients were being inappropriately admitted to the PICU.

CONCLUSIONS

It is likely that a variety of factors contributed to the high rate of PICU admission amongst ethnic minority patients, including an increased prevalence of major mental illness and more frequent cannabis abuse.

Studies of anticipation in bipolar affective disorder

Anticipation refers to the increase in disease severity or decrease in age of onset in successive generations. The concept evolved from the theories and dogma of degeneration that were pervasive in psychiatry and medicine in the late 19th century and into the early 20th century. The term was set aside with the criticism of geneticist Lionel Penrose, who argued that anticipation was the result of ascertainment biases. The renewed interest in anticipation followed the identification of its molecular genetic basis in the form of unstable trinucleotide repeats. Subsequently, several diseases have been studied clinically for the presence of anticipation. Although anticipation has been identified in many diseases, including bipolar disorder, only diseases showing a pattern of progressive neurodegeneration have been associated with unstable trinucleotide repeats. This review summarizes the research on anticipation in bipolar disorder and other secular trends in the patterns of the illness such as the cohort effect. The changing nature of bipolar disorder is likely to be a result of combined influences from several genes, some of which are likely to be in a state of flux, as well as environmental or cultural forces that converge to give the clinical picture of anticipation.

Research on the provider contribution to race/ethnicity disparities in medical care

OBJECTIVE

Little is known about why black patients and other ethnic/racial minorities are less likely to receive the best treatments independent of clinical appropriateness, payer, and treatment site. Although both provider and patient behavior have been suggested as possible explanatory factors, the potential role of provider behavior has remained largely unexplored. Does provider behavior contribute to systematic inequities? If so, why? The purpose of this paper is to build on existing evidence to provide an integrated, coherent, and sound approach to future research on the provider contribution to race/ethnicity disparities in medical care. First, the existing evidence suggestive of a provider contribution to race/ethnicity variance in medical care is discussed. Second, a proposed causal model, based on a review of the social cognition and provider behavior literature, representing an integrated set of hypothesized mechanisms through which physician behavior may contribute to race/ethnicity disparities in care is presented.

CONCLUSION

There is sufficient evidence for the hypothesis that provider behavior contributes to race/ethnicity disparities in care to warrant further study. Although there is some evidence of support of the hypotheses that both provider beliefs about of patients and provider behavior during encounters are independently influenced by patient race/ethnicity further systematic rigorous study is needed and is proposed as a major immediate research priority. These mechanisms deserve intensive research focus as they may prove to be the most promising targets for interventions intended to ameliorate the provider contribution to disparities in care.

Are we meeting the psychological needs of Black African HIV-positive individuals in London? Controlled study of referrals to a psychological medicine unit

The changing pattern of HIV infection in the UK includes an increase in the number of infections acquired as a result of heterosexual contact and Black African individuals represent a sizeable proportion of those affected. In most UK centres for the treatment of HIV infection, clinicians have limited experience in caring for Black African patients, and there is a dearth of information about the recognition and management of mental health problems in this patient group. In this investigation the proportion of Black African individuals looked after in a large centre for the care of HIV infection in London was compared with the proportion of such patients referred for specialist mental health help, the results revealing that Black Africans were almost three times less likely to be referred for specialist mental health care. A case control investigation of those referred to mental health services showed that Black Africans were more likely to be suffering from AIDS at the time of referral, be referred for assessment of possible organic brain disease, and more likely to be found to be suffering from major depression or organic brain disease. Reasons for the lesser likelihood of referral to the mental health service are considered, including the possible failure of staff to recognize psychological morbidity in Black Africans, or reluctance and fear on the part of patients to be referred to services that may be perceived as threatening.

Understanding the excess of psychosis among the African-Caribbean population in England. Review of current hypotheses

BACKGROUND

Increased rates of schizophrenia continue to be reported among the African-Caribbean population in England.

AIMS

To evaluate the competing biological, psychological and social explanations that have been proposed.

METHOD

Literature review.

RESULTS

The African-Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African-Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings.

CONCLUSIONS

More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

Comparison of the outcome and treatment of psychosis in people of Caribbean origin living in the UK and British Whites. Report from the UK700 trial

BACKGROUND

The comparative outcome of psychosis in British Whites and UK African-Caribbeans is unclear. Some report that African-Caribbeans have worse outcome, whereas others claim better symptomatic outcome and a more benign course.

AIMS

To compare the course, outcome and treatment of psychosis in African-Caribbeans and British Whites in a large multi-centre sample.

METHOD

A secondary analysis of 708 patients with research diagnostic criteria-defined psychosis from a 2-year, randomised controlled trial of case management. Outcome measures (hospitalisation, illness course, self-harm, social disability and treatment received) were adjusted for socio-economic and clinical differences between groups at baseline using regression analysis.

RESULTS

African-Caribbeans were less likely to have a continuous illness and to receive treatment with antidepressant or psychotherapy.

CONCLUSIONS

The outcome of psychosis is complex but differs between UK African-Caribbeans and British Whites. This may reflect risk factors that increase the rate of psychosis in UK African-Caribbeans. Treatment differences require further investigation.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovsky's sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over one's life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.

Ethnicity and outcome of psychosis

BACKGROUND

An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.

AIMS

To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.

METHOD

A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.

RESULTS

Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.

CONCLUSIONS

The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study

BACKGROUND

An increased incidence of psychotic disorders has repeatedly been reported among African-Caribbeans in the UK.

AIMS

To test whether the increased incidence of psychotic disorders in first- and second-generation African-Caribbeans in the UK could be caused by a relative excess of affective-related psychoses with good prognosis.

METHOD

Thirty-three patients of African-Caribbean family origin identified in a population-based study of first-episode psychoses were compared with the remaining cases. Three-year outcomes and patterns of course were compared.

RESULTS

There was a trend for better outcomes in African-Caribbean patients for symptoms and social disability, but patterns of course were similar (odds ratio = 0.9 (0.50 to 2.00)) [corrected]. Pattern of course improved after adjustment for confounding by gender, social class, age, diagnosis and duration of untreated illness (odds ratio = 0.59 (0.21 to 1.66)) [corrected]. Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African-Caribbean group.

CONCLUSION

Pattern of course of psychosis did not differ significantly by ethnic family background. An excess of good-prognosis affective psychoses is an unlikely explanation for increased rates of psychosis in African-Caribbeans.