Setting up psychiatric services: cross-cultural issues in planning and delivery

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.

Culture and therapist self-disclosure

Cognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.

Key learning aims

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The current status of culturally adapted mental health interventions: a practice-focused review of meta-analyses

In recent years, there has been a steadily increasing recognition of the need to improve the cultural competence of services and cultural adaptation of interventions so that every individual can benefit from evidence-based care. There have been attempts at culturally adapting evidence-based interventions for mental health problems, and a few meta-analyses have been published in this area. This is, however, a much debated subject. Furthermore, there is a lack of a comprehensive review of meta-analyses and literature reviews that provide guidance to policy makers and clinicians. This review summarizes the current meta-analysis literature on culturally adapted interventions for mental health disorders to provide a succinct account of the current state of knowledge in this area, limitations, and guidance for the future research.

Developing culturally sensitive cognitive behaviour therapy for psychosis for ethnic minority patients by exploration and incorporation of service users' and health professionals' views and opinions

BACKGROUND

Studies of cognitive behaviour therapy (CBT) for schizophrenia demonstrate that African-Caribbean and Black African patients have higher dropout rates and poor outcomes from treatment.

AIM

The main aim of the study was to produce a culturally sensitive adaption of an existing CBT manual for therapists working with patients with psychosis from specified ethinic minority communities (African-Caribbean, Black-African/Black British, and South Asian Muslims). This will be based on gaining meaningful understanding of the way members (lay and service users) of these minority communities typically view psychosis, its origin and management including their cultural influences, values and attitudes.

METHOD

This two-centre (Hampshire and West London) qualitative study consisted of individual semi-structured interviews with patients with schizophrenia (n = 15); focus groups with lay members from selected ethnic communities (n = 52); focus groups or semi-structured interviews with CBT therapists (n = 22); and mental health practitioners who work with patients from the ethnic communities (n = 25). Data were analyzed thematically using evolving themes and content analysis. NVivo 8 was used to manage and explore data.

RESULTS

There was consensus from the respondent groups that CBT would be an acceptable treatment if culturally adapted. This would incorporate culturally-based patient health beliefs, attributions concerning psychosis, attention to help seeking pathways, and technical adjustments.

CONCLUSION

While individualization of therapy is generally accepted as a principle, in practice therapists require an understanding of patient-related factors that are culturally bound and influence the way the patient perceives or responds to therapy. The findings of this study have practical implications for therapists and mental health practitioners using CBT with people with psychosis from BME communities.

A comparison of African-Caribbean and White European young adults' conceptions of schizophrenia symptoms and the diagnostic label

BACKGROUND

Discrepancies in the experiences of different ethnic groups in mental health services exist, such as in the persistently higher rates of schizophrenia diagnosis found among the African-Caribbean population compared to the white European population in the UK. Some hypotheses consider whether this is due to greater stigmatizing attitudes to mental illness in the African-Caribbean community, leading individuals to avoid treatment-seeking and an increased incidence of schizophrenia. This study aimed to investigate recognition and evaluation of schizophrenic symptoms across African-Caribbean and white European individuals.

METHOD

One hundred and twenty eight adult students from London colleges completed a questionnaire assessing stigma beliefs, evaluation of symptoms as mental illness and help-seeking beliefs, in response to symptom vignettes.

RESULTS AND DISCUSSION

African-Caribbean participants indicated less stigmatizing beliefs towards both the symptoms and diagnostic label of schizophrenia compared to the white European participants. White European participants were more likely to label vignettes as implying 'mental illness' and also more likely to recommend professional health treatment. These results are inconsistent with a hypothesis that on average African-Caribbean people stigmatize schizophrenia more than white European people. While white European participants' beliefs were more likely to follow a western model of mental illness, African-Caribbean participants were more likely to have alternative beliefs. The influence of racial discrimination, mental illness knowledge and societal structures are discussed.

Severe mental illness across cultures

OBJECTIVE

International studies have shown that the outcome of illnesses like schizophrenia vary across cultures. The good outcome in developing countries depends upon a number of factors.

METHOD

Using both primary and secondary sources, existing literature was reviewed. Using terms severe mental illness, culture and schizophrenia, Medline, Psychinfo and Embase were searched. Further searches were conducted using secondary searches.

RESULTS

The impact of culture and its components on the individual and their families influences compliance, engagement with services and expectations of treatment. Cultures also impact upon identity and explanatory models of individuals.

CONCLUSION

Severe mental illness is as likely to be affected by culture as other illnesses. Clinicians need to use multi-model assessment and management techniques.

Characteristics of patients and patterns of psychiatric service use in ethnic minorities

BACKGROUND

The differential uptake of psychiatric services by ethnic minorities has been widely reported. Less attention has been given to comparisons of these patients and variations in the types of interventions they receive.

AIMS

To assess whether for people accessing psychiatric services in the UK, differences exist across ethnic groups both in their sociodemographic characteristics and patterns of mental health care utilisation.

METHODS

All adults resident in an inner city health district and using psychiatric services during a six-month period were identified. Demographic, clinical and service use data were collected from staff and records. These were compared across black Caribbean, Indian, Pakistani, Irish and white ethnic groups for two broad diagnostic categories: psychotic/bipolar and depressive/neurotic disorders.

RESULTS

There were significant differences between ethnic groups on most demographic variables in each of the diagnostic categories. There were variations in the level of contact with different mental health professionals. The only significant difference in the use of specific services was for those with psychotic/bipolar disorders, black Caribbean patients being more likely to be detained in hospital compulsorily.

CONCLUSIONS

Ethnic diversity both in the characteristics of patients and their patterns of psychiatric care should be addressed when planning and developing services.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom

BACKGROUND

The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health.

OBJECTIVES

This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population.

DESIGN

Two-stage study comparing screening instruments against diagnostic interview.

SETTING

South, central and north Manchester.

SUBJECTS

Community-resident South Asians aged 60 years and over.

METHODS

Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%).

CONCLUSIONS

Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

The ethnic density effect: results from a national community survey of England and Wales

Using data from a community survey of 5196 ethnic minority and 2867 white respondents, together with data on local group concentration from the 1991 Census, the hypothesis was tested that ethnic group concentration is associated with lower levels of reported psychiatric symptoms. The hypothesis was broadly confirmed, both for within- and between-group differences. However, the effect was found to be modest in size and in one group, the Pakistani sample, was reversed. The findings are inconsistent with an explanation based on selection or drift. Linguistic factors contributed to, but did not explain the effects. Evidence on victimisation and mutual support suggests that social causation, in the form of reduced exposure to direct prejudice and increased social support, is a likely cause of the effect.

Community care: exploring the priorities of clients, mental health professionals and community providers

Co-ordinated joint service planning by all stakeholders is widely accepted as a valuable principle in the development of community support services for persons with severe mental illness. Even so, relatively little is known of the views and priorities of the different parties with regard to the elements that should make up the care and support system. This paper reports on a Dutch study in which clients, mental health care workers and community service professionals offered their opinions on what constitutes a support system that enables individuals with long-term mental illness to participate in the community. The results show that the respondents regarded a stable base as an essential prerequisite for the realisation of this objective. Within this general consensus, the clients stressed the importance of advocacy and sheltered meeting places; the mental health professionals emphasised the rehabilitative elements and the representatives of the generic community services felt that the key components in any such system were crisis intervention services and co-ordination at client and system level.