High rates of psychosis for black inpatients in Padua and Montreal: different contexts, similar findings

"Dem sey mi mad": a scoping review of the attitudes and beliefs of English-speaking Afro-Caribbeans about psychosis

Introduction

The mental health disparities suffered by the English-speaking Afro-Caribbean diaspora living with psychosis in North America and the United Kingdom have been well described for decades, but the root causes of these disparities remain poorly understood. Part of the problem may be that the attitudes and beliefs of Caribbean communities regarding psychosis have never been systematically assessed. Such an inquiry could lay the foundation for changes to how psychiatric services for psychosis are implemented with migrant Caribbean communities. The ideal would be a re-design of services, or cultural adaptation of care, based on input from community members, patients, and their families, with the hope that disparities of care would be reduced or eliminated as clinicians co-create interventions that are more appropriate and acceptable to Caribbean people. To lay the groundwork of such an important endeavor, we investigated the shared attitudes, beliefs, experiences, practices, and traditions of English-speaking Afro-Caribbean people in relation to psychosis and psychiatric care.

Methods

We conducted a scoping review by searching Medline, PsychINFO and Scopus, reviewing 764 articles, and selecting 220 for thematic content analysis.

Results

We highlighted the heterogeneity in the Caribbean diaspora living in North America and the UK. Five principal themes emerged: (1) The enduring effects of colonialism on the psychiatric care of Afro-Caribbean migrants; (2) The effects of adaptation to migration on the experience of psychosis; (3) Pervasive cultural mistrust of psychiatry and mental health institutions; (4) A collective approach to life; and (5) The role of religion and spirituality in the understanding of psychosis.

Conclusion

Historical, sociocultural, and geopolitical themes characterize the English Afro-Caribbean experience of psychosis and inform culturally adapted clinical interventions for patients with psychosis and their families. Careful attention to these adaptations will reduce clinical bias and misdiagnosis, optimize adherence to treatment, engage patients and families in recovery, and ultimately, reduce treatment disparities while empowering Afro-Caribbean people and their communities. By bringing forward the themes in this chapter, individual clinicians will be given tools to change how they work with Caribbean people with psychosis in addition to laying the foundation for higher order changes in the mental health professions and society as a whole.

Incidence, Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review

OBJECTIVE

Black communities are increasingly concerned about psychosis, a worry echoed by provincial health-care systems across Canada. Responding to the lack of evidence on psychosis in Black communities, this scoping review examined the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received, and stigma faced by individuals with psychosis.

METHOD

To identify studies, a comprehensive search strategy was developed and executed in December 2021 across 10 databases, including APA PsycInfo, CINAHL, MEDLINE and Web of Science. Subject headings and keywords relating to Black communities, psychosis, health inequalities, Canada and its provinces and territories were used and combined. The scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA-ScR) reporting standard.

RESULTS

A total of 15 studies met the inclusion criteria, all of them conducted in Ontario and Quebec. Results highlight different disparities in psychosis among Black communities. Compared to other Canadian ethnic groups, Black individuals are more likely to be diagnosed with psychosis. Black individuals with psychosis are more likely to have their first contact with health-care settings through emergency departments, to be referred by police and ambulance services, and to experience coercive referrals and interventions, and involuntary admission. Black individuals experience a lower quality of care and are the ethnic group most likely to disengage from treatment.

CONCLUSION

This scoping review reveals many gaps in research, prevention, promotion and intervention on psychosis in Black individuals in Canada. Future studies should explore factors related to age, gender, social and economic factors, interpersonal, institutional and systemic racism, and psychosis-related stigma. Efforts should be directed toward developing trainings for health-care professionals and promotion and prevention programs within Black communities. Culturally adapted interventions, racially disaggregated data, and increased research funding are needed.

Addressing Stigma and Promoting Help-Seeking Among African Nova Scotian Youth Experiencing Psychosis and Other Mental Health Problems

OBJECTIVES

The purpose of this study was to gain an in-depth understanding of perceptions of mental illnesses (especially psychosis), help-seeking, barriers to help-seeking, and opportunities to facilitate help-seeking in the African Nova Scotian Community.

METHODS

A qualitative interpretive narrative approach, using the focus group method, was employed to engage African Nova Scotians in discussions on their perceptions and beliefs about mental illnesses and help-seeking in their communities. Youth in Early Intervention services, their caregivers, youth in the community, their caregivers, community leaders, and health service providers, were recruited from four locations in the Halifax Regional Municipality. A total of 75 individuals (37 female, 38 male) participated in the study. Narrative emplotment was used to analyse data from focus groups.

RESULTS

Findings from focus groups were categorized based on four areas of discussion: (a) perceptions about psychosis and other mental illnesses among youth, caregivers, service providers and community leaders (b) beliefs about help-seeking among youth, caregivers, services providers and community leaders; (c) barriers and facilitators to seeking help for mental illnesses; and (d) the content and format of educational resources to educate and support youth, families and communities.

CONCLUSIONS

Stigma surrounding mental illnesses in the community, lack of knowledge of illness and available services, concerns regarding negative involvement with police, or dismissal of difficulties by health care providers represent significant barriers to help-seeking in this community. Additionally, barriers include a lack of trust in health care services and a dearth of African Nova Scotian service providers. Bolstering capacity of community organizations to support and educate individuals around illness as well as fostering collaboration between health services and community organizations could reduce barriers to care. Future research should focus on examining ways to engage African Nova Scotians in collaboration with existing community organizations.

‘It Just Feels Like an Invasion’: Black First-Episode Psychosis Patients’ Experiences With Coercive Intervention and Its Influence on Help-Seeking Behaviours

Studies from the United States and United Kingdom show that Black patients are disproportionately diagnosed with psychosis and receive excess coercive medical intervention. There has been little discussion of this topic in Canada, and of how coercive interventions may have influenced Black patient attitudes towards mental health services. To address these issues, semi-structured interviews were administered to five Black men with first-episode psychosis (FEP) to (a) explore their experiences with coercive interventions and (b) describe how these experiences may have influenced help-seeking behaviours. Interpretative phenomenological analysis (IPA) was used to analyze the data. Four core themes and four additional themes emerged from the interviews. Patients described loneliness, not being heard, police contact and forced medication as influencing their attitudes towards mental health care. Further research is needed to develop reparative strategies to encourage reflection about and awareness of coercive intervention among Black FEP patients.

Gender-based violence among refugee women referred to a Cultural Consultation Service in Montreal

Gender-based violence (GBV) among female refugees/asylum seekers is a major underreported/understudied psychosocial issue. The aims of this study were: to describe the proportion of GBV-related experiences among female refugees/asylum seekers referred to a Cultural Consultation Service (CCS) in Montreal; to describe their sociodemographic and clinical characteristics; and to compare these characteristics among women who make GBV their principal refugee claim (Group A), those who did not but had suffered GBV (Group B1), and those who had never reported GBV (Group B2). Data on sociodemographic and clinical variables and GBV were gathered by chart review. Data were analyzed using chi-square for categorical and ANOVA for continuous comparisons. A total of 91 female refugees/asylum seekers were evaluated from 2000 to 2013; 80% (73/91) having reported GBV, with 38.5% (35/91) using GBV as the principal reason for seeking asylum in Canada (Group A), mainly due to intimate partner violence (IPV). Fully 66.6% (38/56) of women who sought asylum for reasons other than GBV reported having experienced GBV (Group B1). When compared to the other groups, Group A women exhibited a number of statistically significant differences: they tended to migrate alone (p < .001), be divorced/single (p = .02), have more suicidal thoughts/behaviors (p < .001), and report a history of IPV (p < .001). Women from Group B1 were more likely to be diagnosed with Affective Disorders (p = .045), and to have suffered sexual violence (p < .001). Results suggest that GBV is frequently experienced by refugee/asylum seeker women in this small, tertiary care clinical sample. When assessing refugee women such as these, differences in the kind of violence suffered, migration process, family/social support, and clinical related features should be taken into account and explored by clinicians in a culturally appropriate and safe manner.

Ethnoracial Differences in Coercive Referral and Intervention Among Patients With First-Episode Psychosis

OBJECTIVE

Using a retrospective sample, the authors sought to determine whether Black patients with first-episode psychosis (FEP) in Canada were at a higher risk for coercive referral and coercive intervention than non-Black patients with FEP.

METHODS

Retrospective data from patients referred to an FEP program in 2008-2018 were collected via chart review (N=208). The authors used chi-square and logistic regression analyses to explore the relationships among race-ethnicity, diagnosis of psychosis, and coercive referral and intervention.

RESULTS

Results showed that Black persons of Caribbean or African descent with FEP were significantly more likely to be coercively referred (χ²=9.24, df=2, p=0.010) and coercively treated (χ²=9.21, df=2, p=0.010) than were non-Black individuals with FEP. Age and violent or threatening behavior were predictors of coercive referral. Ethnoracial status, age, and violent or threatening behavior were predictors of coercive intervention.

CONCLUSIONS

This study contributes to the dearth of research on Black Canadians and offers insight into factors that may place patients with FEP at risk for coercive treatment. More research is needed to explore the role that ethnoracial status may play in hospital admissions and to uncover the role of racial prejudices in the assessment of danger.

The wounds that do not heal: Black expendability and the traumatizing aftereffects of anti-Black police violence

Purpose

The murders of Black people at the hands of police in 2020 have led to global protests that have called on public officials to defund or abolish the police. What has been drowned out in these conversations, however, is the traumatizing aftereffects of anti-Black police violence as a public health crisis. In this paper, I argue that the racial terrorism of anti-Black police violence is a deeply felt wound in Black communities that extends beyond the individuals who directly experience it and that this type of collective trauma must be understood as an urgent public health crisis.

Design/methodology/approach

Using published studies and online commentaries on anti-Black police violence and its mental health impacts in Canada and the United States, this paper examines the mental health impacts of anti-Black police violence at both the individual and community levels.

Findings

A public health response to the traumatizing aftereffects of anti-Black police violence and other forms of state violence must highlight important policy imperatives, such as policies of action focused on improving the public health system. It must also encompass a recognition that the public health crisis of anti-Black police violence is not solvable solely by public health agencies alone. Rather, strategic opportunities to address this crisis arise at every level of governmental interaction, including law enforcement, health care, employment, business, education and the media.

Originality/value

While the impact of anti-Black police violence on the mental health of Black individuals has been emerging in the literature over the last several years, what has been less focused on and what I address in this paper is how the threat of that violence lingers in Black communities long after the protestors have packed up their megaphones, resulting in collective trauma in Black communities.

Cultural Consultation in Context: A Comparison of the Framing of Identity During Intake at Services in Montreal, London, and Paris

Cultural diversity poses a challenge to mental Health care systems in many settings. Specialized cultural consultation services have been developed in a number of countries as a way to supplement existing services. The objective of this paper is to compare and contrast cultural consultation services in Montreal, London, and Paris to determine how culture and society have shaped the evolution of these services to meet local sensitivities and imperatives. Historical contexts of the sites, their descriptions and origins, how they categorize cultural, ethnic, and linguistic diversity, and their intake procedures are compared and contrasted according to a standardized template of themes. Data came from site visits and participant observation at each site. For historical, political, and cultural reasons, categorization of diversity and intake procedures differ markedly by site: Montreal focuses on language categories and language proficiency; London enumerates ethnic diversity according to officially mandated categories; and Paris does not gather ethnic data on its patients in any form. The process of cultural consultation, specifically its triage and intake procedures, is profoundly influenced by local histories and social norms that are maintained by professional cultures of psychiatry in each setting. To properly place their patients in context, cultural psychiatrists must not only aim to understand the culture of the other, but also must consider the culture of the mainstream society and how it shapes the delivery of services.

Reported immigration and medical coercion among immigrants referred to a cultural consultation service

Members of visible minorities are commonly targets of social coercion related to immigration and medical measures. Social coercion is associated with poor mental health outcomes and mistrust of medical services. This study will determine if Afro-Canadian immigrants referred to a Cultural Consultation Service (CCS) in Montreal report more or less medical and immigration coercion compared with other ethnic minorities. We reviewed the charts of 729 referrals to the CCS and gathered data on the 401 patients included in the study. Chi-square statistics examined the relation between minority group and self-reported coercion. Binary logistic regression models controlled for standard sociodemographic variables in addition to ethnicity, language barrier, length of stay in Canada since immigration, refugee claimant status, referral source, presence of psychosis in the main diagnosis, and presence of legal history. Patients were diverse and included 105 Afro-Canadians, 40 Latin Americans, 73 Arab and West Asians, 149 South Asians, and 34 East and Southeast Asians. Being Afro-Canadian was significantly and positively associated with medical coercion (p = .02, 95% CI = 1.15-4.57), while being South Asian was negatively and significantly associated with immigration coercion (p = .03, 95% CI = .29-.93). Members of visible minority communities are not equal in their reported experience of social coercion after arriving to Canada. Future research clarifying pathways to mental health care for immigrants and the experience of new Canadians in immigration and health care settings would give needed context to the findings of this study.

Creating a cultural analysis tool for the implementation of Ontario's civil mental health laws

Ethno-racial people with mental health disabilities experience multiple inequities and differential outcomes when interacting with Ontario's civil mental health laws. Given the increasing multi-racial population in Ontario, there is a need to develop mechanisms to address these intersecting issues. Other countries that have created evaluative tools for mental health legislation include the United Kingdom and Australia. Australia's Rights Analysis Tool, the United Kingdom's Race Equality Impact Assessment, the Scottish Recovery Tool, and the World Health Organization's Mental Health and Human Rights checklist are examples of evaluative tools developed for mental health legislation. Such a tool does not exist in Canada, let alone in Ontario specifically. Thus, this study developed a Cultural Analysis Tool (CAT) consisting of specific and meaningful thematic questions that can be used by practitioners when addressing issues of culture and equity for ethno-racial people with mental health disabilities interacting with Ontario's civil mental health laws. It is hoped that the CAT, and the research underlying its development, will enable practitioners to critically question whether cultural and intersecting concerns are being appropriately addressed within an ethno-racial client's case and, furthermore, how equitable outcomes can be achieved. This article describes and analyzes the methodology, research and qualitative data used to develop the CAT. It then presents and examines the CAT itself. The qualitative data was drawn from thirty-five semi-structured interviews with seven members of each of the following groups: (1) ethno-racial people with mental health disabilities including in-patients and ex-patients, (2) lawyers who practice in the area of mental health law, (3) health care professionals including psychiatrists, nurses and social workers, (4) service providers such as front-line case workers at mental health agencies and (5) adjudicators, government advisors and academics. After an analysis of these data, the CAT's questions were refined through an expert review (involving the qualitative technique of member-checking) using three focus groups comprised of ethno-racial people with mental health disabilities, mental health lawyers and service providers and health care professionals.

The relative impact of socioeconomic status and childhood trauma on Black-White differences in paranoid personality disorder symptoms

The current study examines mechanisms of racial differences in symptoms of paranoid personality disorder (PPD) in a sample of adults ages 55-64 from the St. Louis, MO area. Socioeconomic status (SES) and childhood trauma were tested as intervening variables in the association between race and PPD symptoms using structural equation modeling. PPD symptoms were modeled as a latent variable composed of items from the PPD scales of the Multi-Source Assessment of Personality Pathology self and informant reports and the Structured Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Personality. Childhood trauma was measured using the Traumatic Life Events Questionnaire, and SES was a composite of parent education, participant education, and annual household income. Blacks exhibited higher levels of PPD symptoms across the 3 personality measures, reported significantly lower SES, and reported greater childhood trauma. The proposed model was a good fit to the data, and the effect of race on PPD symptoms operated mainly through SES. The indirect effect through SES was stronger for males. Findings suggest that racial differences in PPD symptoms are partly explained by problems more commonly experienced by Black individuals.

Different rates of first admissions for psychosis in migrant groups in Paris

PURPOSE

The association between migration and psychosis has been reported in the past decades in many European countries. Despite large-scale migration into France, epidemiological data on the incidence of psychosis in this population are lacking. In this study, we compare the incidence rates of first admission for psychosis among natives and first generation migrants.

METHODS

Two-hundred and fifty-eight patients aged 15+ with first admission for psychosis were identified in the catchment area of the 20th district of Paris between 2005 and 2009. Standardised incidence rates and incidence rate ratios were calculated for migrant and native groups.

RESULTS

We found higher rates of admissions for psychosis in the migrant group (IRR 2.9, 95 % CI 0.9-9.8) compared to individuals born in France. Among migrants, incidence was higher in individuals from Sub-Saharan Africa compared to natives (IRR 7.1, CI 95 % 2.3-21.8), whereas the incidence was similar for those from Europe (IRR 1.2, CI 95 % 0.3-5.1) and from North Africa (IRR 1.4, CI 95 % 0.4-5.6).

CONCLUSIONS

Our findings suggest that Sub-Saharan migrants were identified as the most vulnerable migrant group for developing psychosis in France, but additional work is warranted to confirm these trends.

Country of birth and hospital treatment for psychosis in New South Wales

BACKGROUND

Migration has been found to be a risk factor for schizophrenia in several high-income countries.

AIM

To examine whether overseas migrants to New South Wales (NSW) have higher rates of admission to psychiatric hospitals for psychotic disorders, including schizophrenia and mania, compared to people born in Australia.

METHODS

The country of birth of people admitted to public mental health units for the treatment of psychotic illness and for non-psychotic disorders between 2001 and 2010 was compared to the country of birth for the NSW population in the 2006 census. Meta-analysis was used to estimate the odds of being admitted for any psychotic disorder, for a schizophrenia-related psychosis and for mania compared to non-psychotic disorder, for those born in Australia, New Zealand and for nine global regions.

RESULTS

Those born in Oceania (including Melanesia, Fiji, Samoa, Tonga and other Polynesian islands, but excluding Hawaii and New Zealand) had the highest odds of admission for the treatment of psychosis compared to a non-psychotic disorder and had the highest odds of being admitted with a diagnosis of schizophrenia or mania.

CONCLUSIONS

In the years 2001-2010, those born in Oceania were at an increased risk of admission to NSW psychiatric hospitals for the treatment of psychotic illness.

Cognitive deficits and ethnicity: a cohort study of early psychosis patients in The Netherlands

PURPOSE

Incidence rates of psychotic disorders are higher in immigrant groups compared to native populations. This increased risk may partly be explained by misdiagnosis. Neurocognitive deficits are a core feature of psychotic disorders, but little is known about the relationship between migration and cognition in psychotic disorders. We examined whether immigrant patients have cognitive deficits similar to non-immigrant patients, in order to investigate the plausibility of misdiagnosis as explanation for increased incidence rates.

METHODS

Patients who made first contact for non-affective psychotic disorder were assessed in the cognitive domains sustained attention, immediate recall and delayed recall. Immigrant patients were compared to Dutch patients on cognitive performance.

RESULTS

407 Patients diagnosed with a non-affective psychotic disorder completed cognitive assessment (157 Dutch, 250 immigrants). Both Dutch and immigrant patients showed large cognitive deficits. Between-subgroup comparisons revealed large cognitive deficits for immigrants compared to Dutch, especially for immigrants from Morocco, Turkey and other non-Western countries.

CONCLUSIONS

These results indicate that immigrant status is associated with poorer cognitive functioning in early psychosis. The findings argue against diagnostic bias as an explanation for the increased incidence of psychotic disorders in immigrants.

Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec

OBJECTIVE

To explore differences in severity and nature of symptoms of first-episode psychosis (FEP) according to ethnic group and migrant status.

METHOD

We administered rating scales to assess positive and negative symptoms, as well as general psychopathology, to 301 consecutive patients presenting with an FEP within a defined catchment area in Montreal, Quebec, classified according to ethnicity and migrant status. Symptom scores of Euro-Canadian patients without a recent history of migration, that is, the reference group (n = 145), were compared with those of African and Afro-Caribbean (n = 39), Asian (n = 27), Central and South American (n = 15), Middle Eastern and North African (n = 24), and European and North American (n = 39) patients.

RESULTS

Except for referral source, there were no significant differences between ethnic groups on any demographic variables. The African and Afro-Caribbean group had a higher level of negative symptoms (especially alogia) and general psychopathology scores on the Positive and Negative Syndrome Scale (especially, uncooperativeness, preoccupation, and poor attention), compared with the reference group. Ethnic groups did not differ on the Scale for the Assessment of Positive Symptoms scores.

CONCLUSIONS

A comparison of FEP patients from different ethnic groups and native-born Euro-Canadians revealed no significant differences in the nature of positive symptoms at first presentation or in age at onset, suggesting that there was no evidence for the hypothesis that ethnic minorities are misdiagnosed as psychotic. Increased severity of negative symptoms and general psychopathology, specifically among the black ethnic minority group, may have implications for the role of ethnicity for the treatment and outcome of the initial episode of psychotic disorders.