Commentary

Swaran P. Singh is a senior lecturer in psychiatry at St George's Hospital Medical School (Department of General Psychiatry, St George's Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 0RE). He is developing an early intervention service for young people with psychotic disorders in south-west London. His research interests include onset, epidemiology and outcome of psychosis, acute psychotic disorders, ethnic influences in mental health and medical education.

Bhugra & Bhui (2001, this issue) remind us of the social factors pertaining to the reported excess of schizophrenia in the Black Caribbean population in the UK. They suggest that population density, social isolation and fragmented social networks might play an aetiological role in schizophrenia. This intriguing suggestion has, as yet, no empirical validation and needs careful evaluation. Such research will hopefully generate further testable hypotheses and inform the debate about the causes of schizophrenia.

Causal explanations appeal to our medical training. Some might argue, however, that the social consequences of schizophrenia deserve equal if not greater attention than aetiological research, since poor social outcomes may be more amenable to effective intervention than putative social causes. This is especially relevant to Black patients since social inequities in health care provision overlap ethnic boundaries. Given the emerging evidence that Black patients have a poor relationship with mental health services, the social consequences of schizophrenia may be particularly harsh for this group. The problems of poor outcome and engagement with health services therefore deserve special attention.

	Excess of schizophrenia in the Black population

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The methodological limitations of early research, such as sampling bias, lack of standardised assessments, problems of ascertaining population size and concerns about misdiagnosis, have, to some extent, been addressed in studies that have confirmed higher rates of psychosis in Caribbean men using standardised research instruments and correcting for undernumeration (Harrison et al, 1997). However, a recent community survey conducted by the Policy Studies Institute (Nazroo, 1997) did not find elevated prevalence rates of non-affective psychosis in Caribbean men compared with White men. Caribbean men had higher rates of depression but were less likely to have been offered medication by their GPs. After adjusting for social status, those in a lower social class had higher rates of mental illness across all ethnic groups. The survey had a relatively high ‘refusal to participate’ and excluded patients in hospital and forensic services, where young Caribbean men are overrepresented. However, these alone are inadequate explanations for the difference between the findings of this survey and previous research. Therefore, a wider question remains: are there systematic differences in how ethnic minority patients are treated at each level between primary care and tertiary referral centres?

	Ethnicity and outcome of psychosis

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It is widely accepted that outcome of schizophrenia is better in developing countries than in the West (Sartorius et al, 1977). However, medium-term follow-up studies have not confirmed this in ethnic minority populations living in the UK (Harrison et al, 1998; Goater et al, 1999). The reasons for this discrepancy are unclear. We do not as yet know whether (and if it does, how) emigration influences family dynamics and support mechanisms in migrant communities. Commonly held views that some ethnic populations ‘stay closer to their original culture’ and are ‘supportive’ may be overgeneralisations that ignore socioe-conomic factors for which ethnicity is a proxy variable. Intergenerational and economic differences within ethnic groups may play a greater role in determining family communication, attitudes and coping mechanisms than differences between ethnic groups. We do not know about the protective influences, if any, of a stable family structure on the outcome of psychosis. Are extended families better able to contain distress, share burden of care and reduce the patient's sense of alienation, demoralisation and hopelessness? Bhugra & Bhui cogently remind us that such questions need careful empirical validation without recourse to assertions that simply reinforce cultural stereotypes.

	Ethnicity, care pathways and engagement

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The Keys to Engagement review (Sainsbury Centre for Mental Health, 1998) suggested that nationally, about 15 000 patients with serious mental disorders and multiple needs are not engaged with mental health services. A Danish study found that 26% of patients had dropped out of psychiatric treatment 1 year after first hospitalisation (Tehrani et al, 1996). Poor engagement therefore is not necessarily a function of chronicity. Despite the magnitude of the problem, there has been very little research on why patients disengage from psychiatric services. Several strands of evidence point towards a poor relationship between mental health services and Black patients, for whom effective engagement may be particularly important. GPs are less likely to identify psychological symptoms in ethnic minority patients (Odell et al, 1997). Black patients are more likely to deny having problems (Perkins & Moodley, 1993). Hence, at primary care level Black patients may be selectively disadvantaged in early recognition and appropriate referral. Black patients are more likely to come into contact with services through adverse pathways to care. Ethnicity itself is a strong determinant of coercive hospital treatment, independent of age, gender, marital status, social class, diagnosis and risk (Singh et al, 1998). Black patients are also less likely to be compliant with medication early in the course of their illness (Goater et al, 1999). While stereotypical views of young Black men may contribute to this excess of compulsory detentions, it is also likely that Black patients are less willing to accept voluntary admission. Coerced patients are not grateful for their experience of hospitalisation, even if they retrospectively agree that they had needed it (Gardner et al, 1999). Coercion is therefore particularly destructive of engagement.

Improving engagement
Poor engagement and mistrust of services creates a spiral of increasing disengagement as Black patients perceive mental health services as racist and authoritarian, do not comply with medication and decline voluntary admission, thereby increasing the risk of compulsory detention. Thus, each episode of care where compulsory detention is necessary causes further disenchantment among Black patients and becomes both a cause and a consequence of worsening engagement. Simplistic explanations of racism underlying all such issues serve only further to drive a wedge between services and their users.

The onus for improving engagement and ensuring adequate care is upon the services and not upon the Black community or patients. Politically correct recourse to ‘colour-blind’ policy-making and service provision may do a great disservice to a very vulnerable and needy group of patients. The challenge for future research is to design studies that neither underplay the importance of psychosocial factors by focusing too narrowly on ethnicity nor ignore differences in how various ethnic groups relate to, and are treated by, psychiatric services.

	References

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Bhugra, D. & Bhui, K. (2001) African–Caribbeans and schizophrenia: contributing factors. Advances in Psychiatric Treatment, 7, 382–291.

Gardner, W., Lidz, C. W., Hoge, S. K., et al (1999) Patients' revisions of their beliefs about the need for hospitalisation. American journal of Psychiatry, 156, 1385–1391.[Abstract/Free Full Text]

Goater, N., King, M., Cole, E., et al (1999) Ethnicity and outcome of psychosis. British Journal of Psychiatry, 175, 34–42.[Abstract/Free Full Text]

Harrison, G., Glazebrook, C., Brewin, J., et al (1997) Increased incidence of psychotic disorders in migrants from the Caribbean in the UK. Psychological Medicine, 27, 299–307.

Harrison, Amin, S., Singh, S. P., et al 1998) Outcome of psychosis in people of African-Caribbean family origin. Population-based first-episode study. British Journal of Psychiatry, 175, 43–49.[Abstract/Free Full Text]

Nazroo, J. Y. (1997) Ethnicity and Mental Health. London: Policy Studies Institute.

Odell, S. M., Surtees, P. G., Wainwright, N. W., et al (1997) Determinants of general practioner recognition of psychological problems in a multi-ethnic inner-city health district. British Journal of Psychiatry, 171, 537–541.[Abstract/Free Full Text]

Perkins, R. E. & Moodley, P. (1993) Perception of problems in psychiatric inpatients: denial, race and service usage. Social Psychiatry and Psychiatric Epidemiology, 28, 189–193.[CrossRef][Medline]

Sainsbury Centre for Mental Health (1998) Keys to Engagement. London: Sainsbury Centre for Mental Health.

Sartorius, N., Jablensky, A. & Shapiro, R. (1977) Two-year follow up of the patients included in the WHO international pilot study of schizophrenia. Psychological Medicine, 7, 529–541.[Medline]

Singh, S. P., Croudace, T., Beck, A., et al (1998) Perceived ethnicity and the risk of compulsory detention. Social Psychiatry and Psychiatric Epidemiology, 33, 39–44.[CrossRef][Medline]

Tehrani, E., Russel, J., Borg, L., et al (1996) Dropping out of psychiatric treatment: a prospective study of a first admission cohort. Acta Psychiatrica Scandinavica, 94, 266–271.[Medline]

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