At the crossroads of anthropology and epidemiology: current research in cultural psychiatry in the UK

"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.

Cross-cultural differences in depression between White British and South Asians: Causal attributions, stigma by association, discriminatory potential

OBJECTIVES

Numerous facets of public and internalized mental illness stigma have been established. This study focuses on the stigma of being associated with someone with depression and cultural differences between a Western and an Eastern culture. The aim was to compare White British and South Asians living in the United Kingdom regarding their causal explanations for depression, stigma towards people with depression and stigma by association.

DESIGN

A cross-sectional design.

METHODS

White British and South Asians (N = 137) in the United Kingdom completed a survey measuring attributions about the aetiology of depression, discriminatory potential towards people with depression and stigma by association.

RESULTS

Results revealed that South Asians attributed greater supernatural, moral and psychosocial causes to depression, while White British endorsed greater biological beliefs. South Asians reported a greater discriminatory potential towards people with depression (lower willingness for closeness, greater desire for social distance) than White British. They also indicated greater affective, cognitive and behavioural stigma by association. Stigma by association mediated the relationship between cultural group and willingness for closeness as well as desire for social distance. Perceived dangerousness was a mediator for willingness for closeness.

CONCLUSIONS

These findings suggest that a greater consideration of the role of culture in the understanding of mental health is important to combat stigma towards individuals with depression and those close to them across Western and Eastern cultures.

A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: Perspectives of healthcare professionals

Introduction

Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long‐term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all.

Methods

Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call‐based software. Perspectives on barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee.

Results

Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs.

Conclusion

This study provides much‐needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person‐centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services.

Patient or Public Contribution

The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.

Contribution of Alcohol and Nicotine Dependence to the Prevalence of Depressed Mood in Different Ethnic Groups in The Netherlands: The HELIUS Study

Objective: Ethnic minorities report different levels of drinking and smoking and higher rates of depression compared to native populations. In this study we aimed to investigate in six ethnic groups whether tobacco and alcohol use were associated with depressive symptoms, which are more prevalent in ethnic minorities.Methods: Cross-sectional data from the multi-ethnic Healthy Life in an Urban Setting (HELIUS) study sample (N = 22,471) was used, comprising 4,580 native Dutch participants which were compared with participants from five ethnic minority groups (3,259 South Asian Surinamese, 4,292 African Surinamese, 2,262 Ghanaian, 3,891 Turkish, and 4,187 Moroccan).Results: Alcohol misuse was positively associated with depressed mood in all ethnic groups except for the Dutch and the Ghanaians. Nicotine dependence was positively associated with depressed mood in all ethnic groups except for the Ghanaian group.Conclusions: Alcohol misuse and nicotine dependence were significantly associated with depressed mood in most but not all ethnic groups and especially in men. However, across all groups the contribution of alcohol misuse and nicotine dependence to depressed mood was small. Prospective multi-ethnic studies should confirm whether the relations are causal and elucidate their direction.

Anthropological perspectives on the trajectory from institutionalisation to community care in Irish psychiatry

The trajectory of the anthropology of Irish psychiatry, like the trajectory of Irish psychiatry itself, is indelibly shaped by the history of Ireland's mental hospitals. This paper focuses on three works concerning the anthropology of psychiatry in Ireland: Nancy Scheper-Hughes's book, Saints Scholars and Schizophrenics: Mental Illness in Rural Ireland, an anthropological study (1977/2001); Eileen Kane's paper, 'Stereotypes and Irish identity: mental illness as a cultural frame', from Studies: An Irish Quarterly Review (1986) and Michael D'Arcy's conference paper, 'The hospital and the Holy Spirit: psychotic subjectivity and institutional returns in Dublin, Ireland' (2015), based on his PhD dissertation. All three publications explore the relationship between institutional and community psychiatric care in Ireland, concluding with the work of D'Arcy which, like much good anthropology, is rooted in the lived experience of mental illness and combines deep awareness of the past with tolerance of multiple, ostensibly contradictory narratives in the present.

Cultural Differences in Psychosis: The Role of Causal Beliefs and Stigma in White British and South Asians

While previous research has demonstrated the negative impact of stigma in individuals with mental health problems, little is known about cross-cultural differences in experiences and explanations of mental health, in particular in young people, despite the first episode of psychosis often occurring in adolescence. Aim of this study was to examine cultural differences in causal beliefs and stigma toward mental health, in particular psychosis. White British and South Asian young people ( N = 128) from two schools and colleges in the United Kingdom, aged 16 to 20 years, completed a cross-sectional survey. Results revealed significant associations between ethnic group and our dependent measures. White British reported more previous contact with a mental health service as well as with people with mental health problems than South Asians. They also reported lower stigma in form of a greater intentions to engage in contact with people with mental health problems. Furthermore, South Asians reported higher beliefs in supernatural causes of psychosis than White British. Psychotic experiences moderated the effect of ethnic group on supernatural beliefs, with South Asians reporting higher supernatural beliefs than White British when their own psychotic experiences were low to moderate. We discuss the implications of the findings, arguing that a greater culture-sensitive understanding of mental health is important to reach ethnic minorities with psychosis, and to challenge stigma toward psychosis from an early age on.

Conference proceedings of the 4th Masterclass Psychiatry: Transcultural Psychiatry - Diagnostics and Treatment, Luleå, Sweden, 22-23 February 2018 (Region Norrbotten in collaboration with the Maudsley Hospital and Tavistock Clinic London)

BACKGROUND

According to estimates from the European Commission, Europe has experienced the greatest mass movement of people since the Second World War. More than one million refugees and migrants have arrived in the European Union in the past few years. Mental health and primary care professionals are more likely than ever to meet patients from different cultures and backgrounds.

AIMS

To equip mental health and primary care professionals with transcultural skills to deal with patients from unfamiliar backgrounds.

METHOD

Lectures and case discussions to explore the latest advances in the diagnosis and treatment of serious mental health problems in a transcultural context.

RESULTS

Lectures covered transcultural aspects of mental health problems, treatment in different cultural and ethnic contexts, and assessment of risk factors for self-harm and harm in migrant populations.

CONCLUSIONS

Clinicians require a sound grounding in transcultural skills to confidently and empathically deal with patients from unfamiliar backgrounds.

Cultural neuroscience: ideas worth knowing

BACKGROUND

Neuroscience is now promising significant advances in medical practice, such that it can improve the art and science of personalized medicine. A new discipline of cultural neuroscience is now forming, and few clinicians, researchers or educators are aware of it.

AIMS

To set out a brief synopsis of cultural neuroscience.

METHODS

A narrative, nonsystematic, review of experts on cultural psychiatry and cultural neuroscience.

RESULTS

Cultural neuroscience proposes that culture and biology have co-evolved with mutually beneficial affordances inhuman abilities that promote positive selection that help people to flourish. Neuroscience can support and improve cultural interventions when applied in a pan-diagnostic manner to culturally specific groups, ethnic minorities, and migrants.

CONCLUSIONS

Cultural neuroscience is an exciting new discipline with the potential for clinical benefit. Cultural psychiatry can advance in this direction, and at the same time offer a critique of the culture of neuroscience.

On the Science of Consciousness: Epistemological Reflections and Clinical Implications

Consciousness has been one of the most important and tantalizing issues ever since the origin of philosophy and medicine. The concept of consciousness and the so-called "hard problem" (i.e., the mind-brain relationship) are highly complex topics that have yet to be elucidated, involving the realms of both science and philosophy with profound epistemological implications. In the lively debate on the foundations of the science of consciousness there are several potential biases of an essentially philosophical nature, such as those related to the paradigm and axioms adopted, and the ostensible logical contradiction between monism and dualism. Their origin dates back largely to Descartes' thinking and the birth of the new sciences as a compromise with the Inquisition, but they have been handed down through the Enlightenment and Positivism. A proper investigation of consciousness and the world of subjectivity demands a careful reflection on the paradigm of scientific medicine to identify possible flaws and overcome the limits of the mechanistic-reductionist approach.

A Mental Health Survey of Different Ethnic and Occupational Groups in Xinjiang, China

Poor mental health has become a serious social and public health-care burden. This cross-sectional study used multistage stratified cluster random sampling to gather mental health information from 11,891 adults (18-60 years) employed in various occupations categorized according to the Chinese Standard Occupational Classification. Mental health was measured by the General Health Questionnaire, and participants exceeding the cut-off score were defined as having poor mental health. The overall prevalence of poor mental health was 23.8%. The prevalence of poor mental health was significantly higher in the Han ethnic group than Kazak ethnic group and in health-care workers, teachers, and civil servants compared to manual workers. Females (odds ratios (OR) = 1.139, 95% confidence intervals (CI): 1.012-3.198) and knowledge workers (1.697, 1.097-2.962) were risk factors for poor mental health, while Kazak ethnicity (0.465, 0.466-0.937), other minority status (non-Han) (0.806, 0.205-0.987), and working ≥15 years in the same occupation (0.832, 0.532-0.932) were protective (p < 0.05). We concluded that the general level of mental health in Xinjiang, China, is higher in the Kazak ethnic group than the Han ethnic group. The prevalence of poor mental health is higher among knowledge workers than in manual workers due to high incidences of poor mental health in civil servants, health-care workers, and teachers.

Staff and caregiver attitude to coercion in India

OBJECTIVES

The objective of this study was to assess attitudes of Indian psychiatrists and caregivers toward coercion.

MATERIALS AND

Methods: The study was conducted at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore, India. Staff Attitude to Coercion Scale (SACS), a 15-item questionnaire, was administered to self-selected psychiatrists across India and caregivers from Mysore to measure attitudes on coercion. Data were analyzed using descriptive statistics and investigating differences in subgroups by means of Chi-square test, Student's t-test, and analysis of variance. Reliability of the SACS was tested in this Indian sample.

RESULTS

A total of 210 psychiatrists and 210 caregivers participated in the study. Both groups agreed that coercion was related to scarce resources, security concerns, and harm reduction. Both groups agreed that coercion is necessary, but not as treatment. Older caregivers and male experienced psychiatrists considered coercion related to scarce resources to violate patient integrity. All participants considered coercion necessary for protection in dangerous situations. Professionals and caregivers significantly disagreed on most items. The reliability of the SACS was reasonable to good among the psychiatrists group, but not in the caregiver group (alpha 0.58 vs. 0.07).

CONCLUSION

Caregivers and psychiatrists felt that the lack of resources is one of the reasons for coercion. Furthermore, they felt that the need on early identification of aggressive behavior, interventions to reduce aggressiveness, empowering patients, improving hospital resources, staff training in verbal de-escalation techniques is essential. There is an urgent need in the standardized operating procedure in the use of coercive measure in Indian mental health setting.

Experiences and explanations of mental ill health in a group of devout Christians from the ethnic majority population in secular Sweden: a qualitative study

OBJECTIVE

To explore existential meaning-making in an ethnic-majority subgroup with mental ill health and to increase knowledge about the importance of gaining access to such information in mental healthcare.

DESIGN

Qualitative study using in-depth interviews and systematic text condensation analysis.

PARTICIPANTS

17 devote Christians with an ethnic-Swedish background, 12 women and 5 men, 30-73 years old, from different congregations across Sweden, having sought medical care for mental ill health of any kind.

SETTING

The secular Swedish society.

RESULTS

A living, although asymmetric, relationship with God often was seen as the most important relationship, giving hope and support when ill, but creating feelings of abandonment and fear if perceived as threatened. Symptoms were interpreted through an existential framework influenced by their view of God. A perceived judging God increased feelings of guilt, sinfulness and shame. A perceived merciful God soothed symptoms and promoted recovery. Existential consequences, such as being unable to pray or participate in congregational rituals, caused feelings of 'spiritual homelessness'. Participants gave biopsychosocial explanations of their mental ill health, consonant with and sometimes painfully conflicting with existential explanations, such as being attacked by demons. Three different patterns of interaction among biopsychosocial and existential dimensions in their explanatory systems of illness causation were identified: (a) comprehensive thinking and consensus; (b) division and parallel functions and (c) division and competitive functions.

CONCLUSIONS

Prevailing medical models for understanding mental ill health do not include the individual's existential experiences, which are important for identifying risk and protective factors as well as possible resources for recovery. The various expressions of existential meaning-making identified in this devout religious subgroup illustrate that existential information cannot be generalised, even within a small, seemingly homogenous group. The three identified patterns of interactions formed a typology that may be of use in clinical settings.

Does culture impact on notions of criminal responsibility and action? The case of spirit possession

Multicultural societies such as the United Kingdom are host to people with diverse belief systems and behavioral norms. Whilst a country requires that all members of society conform to standardized legal requirements, cases arise that involve certain complexities related to the cultural or religious context in which a certain action was committed. This paper addresses the impact of culture on notions of criminal responsibility and action. Through a case study of a recent event in the United Kingdom, we explore whether a cultural defense is relevant for contextualizing incidents in which an individual commits a criminal action during an alleged period of spirit possession From this analysis, we suggest that using a cultural defense can aid understanding of an individual's relationship to the society that he or she identifies with and facilitate the practice of justice in a multicultural society.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.