Beliefs and delusions of West Indian immigrants to London

How people of African Caribbean or Irish ethnicity cope with long-term health conditions in UK community settings: A systematic review of qualitative, quantitative and mixed method studies

Living with a chronic or mental health condition can be challenging and requires considerable adjustment. As ways of coping are culturally influenced, it is important to understand how minority ethnic populations cope, to inform appropriate services. This review aimed to explore the coping strategies used by UK residents from an African Caribbean or Irish background between 1960 and 2020. A systematic literature search on strategies used to cope with chronic health conditions in both populations living in the United Kingdom identified 26 relevant studies. Data were extracted, quality of papers was appraised and critical interpretive synthesis was applied. Two major foci of the studies were coping strategies and barriers to coping. The main coping strategies were denial/scepticism, self-management, spirituality and religion. Within each population, there was variation in ways of coping. The review highlights the complex role of religion in influencing coping strategies. It demonstrates how personal and minority ethnic populations' experiences of service use are connected with stigma, fear and mistrust, which also act as barriers to seeking help and to coping. Coping with a chronic or mental health condition in the Irish and African Caribbean populations is under-researched. Stigma, fear and mistrust in services act as key barriers to help-seeking and religion is a prominent coping strategy. However, few detailed examples were given on how it was used to assist individuals when managing a chronic or mental health condition. Also due to a lack of research, firm conclusions cannot be drawn for the Irish population.

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.

Ideology, Camouflage or Contingency? Racism in British Psychiatry

"...Are we so sure that the racist form of intolerance results chiefly from the wrong ideas of this or that group of people about the dependence of cultural evolution on organic evolution? Might not these ideas be simply ideological camouflage for more concrete oppositions based on a desire to subjugate other groups and maintain a posi tion of power?"

Religious Delusions in a Xhosa Schizophrenia Population

Here, we assessed for the first time the frequency of religious delusions and the effect of treatment on religiosity and the phenomena of religious delusions in a Xhosa schizophrenia population. Religious delusions were present in 42 (70%) participants, and treatment significantly reduced religiosity (p = 0.02) as well as mean scores for certain phenomena associated with the delusions including changes in both thinking (p = 0.0001) and behaviour (p = 0.0001), as well as affective response to the delusion (p = 0.0001) The high frequency of religious delusions may indicate a higher tolerance for religious delusions in this community. It is therefore important to educate spiritual leaders on mental illness.

Religious psychopathology: The prevalence of religious content of delusions and hallucinations in mental disorder

BACKGROUND

Religious themes are commonly encountered in delusions and hallucinations associated with major mental disorders, and the form and content of presentation are significant in relation to both diagnosis and management.

AIMS

This study aimed to establish what is known about the frequency of occurrence of religious delusions (RD) and religious hallucinations (RH) and their inter-relationship.

METHODS

A review was undertaken of the quantitative empirical English literature on RD and RH.

RESULTS

A total of 55 relevant publications were identified. The lack of critical criteria for defining and classifying RD and RH makes comparisons between studies difficult, but prevalence clearly varies with time and place, and probably also according to personal religiosity. In particular, little is known about the content and frequency of RH and the relationship between RH and RD.

CONCLUSION

Clearer research criteria are needed to facilitate future study of RD and RH, and more research is needed on the relationship between RD and RH.

Obeah-illness versus psychiatric entities among jamaican immigrants: cultural and clinical perspectives for psychiatric mental health professionals

In order to provide culturally authentic healthcare, psychiatric-mental health nurses and other professionals must familiarize themselves with the culture-specific syndromes, idioms of distress, beliefs and practices that may present among the diverse patient groups with whom they work. Psychiatric conditions relating to the Jamaican belief in "Obeah" are specific, culturally-interpreted phenomena that psychiatric nurses may encounter among Jamaican patients. This paper describes the phenomenon of Obeah and its influences on the worldview of life, health, illness; psychiatric conditions in the form of culture-bound syndromes; and help-seeking behaviors throughout Jamaican cultural communities. Inability to understand the obeah-illness concept from a culturally-interpreted perspective may be constrictive and result in less-than-optimal care. Armed with the knowledge of the concept of Obeah from a core belief perspective, how it influences psychiatric presentations, and embracing its significance to the Jamaican health belief model will assist in building a workable, caring, best-practice framework aimed toward a clinical and practice paradigm for this unique folk-health belief system.

Valuing psychiatric patients' stories: belief in and use of the supernatural in the Jamaican psychiatric setting

The aim of this study was to examine illness presentation and understand how psychiatric patients make meaning of the causes of their mental illnesses. Six Jamaican psychiatric patients were interviewed using the McGill Illness Narrative Interview Schedule. Of the 6, 3 representative case studies were chosen. The hermeneutic phenomenological approach and the common sense model were used in the formulation of patients' explanatory models. Results indicate that psychiatric patients actively conceptualized the causes and resultant treatment of their mental illnesses. Patients' satisfaction and compliance with treatment were dependent on the extent to which practitioners' conceptualization matched their own, as well as practitioners' acknowledgement of patients' concerns about causation, prognosis, and treatment.

Traditional and alternative therapy for mental illness in Jamaica: patients' conceptions and practitioners' attitudes

The aim of this study was to investigate traditional and alternative therapy for mental illness in Jamaica: patients' conceptions and practitioners' attitudes. The sample included 60 psychiatric patients selected from Ward 21 at the University of the West Indies, Kingston as well as Princess Margaret outpatient clinic, and 30 Afro-centric psychiatric nurses, psychiatrist and clinical psychologists from Kingston and St. Thomas, Jamaica. Patients were interviewed with the Short Explanatory Model Interview (SEMI) and practitioners completed a self administered questionnaire on attitudes towards traditional and alternative medicine. Results indicate that among psychiatric patients more than a third expressed the belief that the overall cause of their mental illness was as a result of supernatural factors. In general, the majority of patients felt that their perception of their problems did not concur with the western practitioner, which in turn caused distress for these patients. In case for those who also sought traditional medicine, they were more inclined to feel pleased about their interaction and the treatment they received. Results from western trained practitioners found that although they acknowledged that traditional medicine plays a major role in the treatment of mental illness among psychiatric patients the treatment was not advantageous. For the most part when all three traditional approaches were examined alternative medicine seemed more favourable than traditional healing and traditional herbal treatment. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems in treating mental illness.

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.

First-contact incidence rate of schizophrenia on Barbados

BACKGROUND

The incidence rate for broad schizophrenia among second-generation African-Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors.

AIMS

To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997).

METHOD

A 12-month study of all persons in the 18-54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using World Health Organization screening and measurement instruments.

RESULTS

On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10,000 (95% CI 1.97-3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10,000 (95% CI 2.3-4.1), which is significantly lower than the comparable rate for London's African-Caribbeans of 6.6/10,000 (95% CI 4.5-8.7).

CONCLUSIONS

The very high rate for broad schizophrenia among African-Caribbean people in the UK is probably due to environmental factors.

Autoenucleation--a culture-specific phenomenon: a case series and review

Cases of autoenucleation may provide a good example of the pathoplastic effects of culture. To further characterize this phenomenon, the author reviewed the medical literature and conducted a retrospective search of the local psychiatric hospital records. Medline search did not show a single case of autoenucleation in the non-European Christian culture. Descriptive accounts of the identified seven patients show they were all psychotic at the time of the act, and five had a history of prior drug abuse. Most were religiously preoccupied before the act and displayed prominent affective symptoms, and they all interpreted the Biblical text literally. The association of sight and the concept of sin is discussed in a wider cultural context, and it is proposed that autoenucleation may be unique to the Christian West.

Psychiatry and the popular conception of possession among the Bangladeshis in London

Two detailed case histories of young people possessed by spirits are presented to show that expressions of distress are shaped by cultural beliefs from the very inception. It stands in marked contrast to the Western psychiatric view of possession beliefs as cultural explanations offered for underlying pathological processes. This has serious implications for the practice of psychiatry in increasingly multi cultural societies.

A follow-up of second generation Afro-Caribbeans and white British with a first admission diagnosis of schizophrenia: attitudes to mental illness and psychiatric services of patients and relatives

A sample of second generation Afro-Caribbeans and white British with a diagnosis of schizophrenia, and their relatives, were interviewed 5-10 years after first admission. There was no difference between Afro-Caribbeans and whites on measures of satisfaction, conceptualization about illness and attitudes to different types of treatment and management. However black relatives were more likely to attribute causation of illness to substance use and to view services as racist. Most black patients and relatives thought that black day centres would be beneficial.

Psychiatric phenomenology across countries: constitutional, cultural, or environmental?

Some literature on the significance of culture on psychiatric phenomenology and also literature on psychiatric phenomenology in immigrants, particularly in Great Britain, are reviewed. It is pointed out that paranoid and religious phenomenology is particularly common in some immigrant groups and that this can be understood to some extent as a reflection of cultural factors. In order to elucidate more the role of culture in psychiatric phenomenology in immigrants to Great Britain the socio-cultural backgrounds of the immigrants and in particular the Africans, the West Indians and the Asians are discussed in some details. The phenomenology of psychiatric illness as recorded in a hospital based population of diverse cultural backgrounds in a London hospital was studied to see if any variations across the various cultural groups could be understood in terms of cultural factors. It was found that paranoid and religious phenomenology was more associated with African and West Indian groups for cultural reasons rather than their socio-environmental and racial status in Britain. Paranoia was directed to fellow immigrants rather than to the host population. It is concluded that paranoia and religious phenomenology do not necessarily have the same clinical significance in various cultural groups. It is also pointed out that hallucinations, and in particular auditory hallucinations and First Rank Symptoms of schizophrenia, which have assumed diagnostic significance in some cultures, may not necessarily have the same significance in other cultures.

From vice to madness: the semantics of naturalistic and personalistic understandings in Trinidadian local medicine

Whilst the common analytical distinction between 'naturalistic' and 'personalistic' paradigms of medical knowledge has some immediate heuristic value and may indeed closely resemble the explicit schema elaborated by informants, interpretation of the semantics of bush medicine and madness in Creole Trinidad suggests that the two types of knowledge are not incompatible, nor mutually exclusive, nor distinct. The vices of ganja and rum use may be interpreted within the hot-cold classification of bush medicine but, like other vices and like the more 'intrapersonal' categories of pressure, grinding, studiation and tabanka, they may be understood as leading to madness. A common idiom of opposition and catharsis unites them, providing a higher level of analytical generality manifest in a range of local social institutions, and one rooted in post-colonial Afro-Caribbean experience and ideology.

Mental illness among immigrant minorities in the United Kingdom

Cross-cultural studies on immigrants from Pakistan and the New Commonwealth are reviewed, with emphasis on epidemiology and differences in clinical presentation. Their referral to the psychiatric service is also examined and deficiencies are noted. Awareness of transcultural issues among health professionals need to be increased in order to achieve diagnosis and improvements in health care.

Paranoid disorder--environmental, cultural or constitutional phenomenon?

At a London hospital the prevalence and types of recorded paranoid disorders, and their characteristics were extracted from the files of in-patients of various cultural groups. It was found that West Indians and Africans had more paranoid colouring in their psychiatric illness than any other group. Other immigrant groups had less paranoid features than the English group. The self or a family member was the commonest focus of intended harm in all the cultural groups. Supernatural modes of injury were common in the West Indians and Africans. It is argued that in immigrants paranoid disorder is not merely due to discrimination consequent on their migrant status, but that cultural factors inherent in the immigrants are also of etiological importance.

Cross-cultural study of religious phenomenology in psychiatric in-patients

Case notes of patients from nine different cultural groups admitted to a London hospital were scrutinized for religious background and religious phenomenology. With the exception of preaching behaviour there were no statistically significant cultural differences, but certain trends were apparent. The pattern of religion in each cultural group could be understood in terms of the historical and geographical origins of these groups. Religious phenomenology was better explained in terms of deep-seated cultural factors rather than current religion.

Content of grandiose phenomenology across cultures

The content of grandiose ideas and delusions in patients of various cultural groups admitted to a London psychiatric hospital were compared. There were no overall differences but certain trends were apparent. It was found that religion was the commonest content of grandiose symptoms in all the groups. Its frequency was higher in the African and Jamaican groups, an observation that can be understood from the cultural background of these groups. The other types of content, namely royals, identity and ability were less frequent in all groups.

Psychiatric hospital admissions in Bristol. II. Social and clinical aspects of compulsory admission

Three groups of patients admitted compulsorily from populations with markedly different rates of compulsory psychiatric admissions were compared on a range of social and clinical data. Whilst West Indian and white patients from inner city areas differed in many respects, they were both more likely than other patients to be referred to the psychiatric services through police agencies, with little GP involvement and were often admitted from public places following disturbed behaviour. However, levels of violence and threatening behaviour were no higher among inner city patients, black or white, and once admitted, these groups showed similar treatment compliance to white patients who had been admitted compulsorily from suburban areas. Implications for primary care and delivery of psychiatric services are discussed.

Frequency and clinical significance of delusions across cultures

The pattern of delusions in a cross-cultural hospital population was studied. It was found that there were cultural differences in persecutory, grandiose and religious, and sexual and fantastic delusions, accounted for mainly by the relatively higher frequencies in the African and West Indian cultural groups. These phenomena can be understood in terms of the cultural backgrounds of these groups. It is further argued that similarly defined persecutory delusions have a wide clinical significance that goes beyond schizophrenia in some cultural groups.

Some social and phenomenological characteristics of psychotic immigrants

Various studies have shown: (i) increased rates of psychoses in immigrants to Britain, and a particularly high rate of schizophrenia in the West Indian- and West African-born; and (ii) a greater proportion of atypical psychoses in immigrants. A retrospective study of psychotic inpatients from a London psychiatric unit demonstrated increased rates of schizophrenia in patients from the Caribbean and West Africa. These patients included a high proportion of those with paranoid and religious phenomenology, those with frequent changes of diagnosis, formal admissions, and married women. The West Indian-born had been in Britain for nearly 10 years before first seeing a psychiatrist and, if they had an illness with religious symptomatology, were likely to have been in hospital for only 3 weeks. Rates of schizophrenia without paranoid phenomenology were similar in each ethnic group. It is suggested that the increase in the diagnosis of schizophrenia in the West Indian-born, and possibly in the West African-born, may be due in part to the occurrence of acute psychotic reactions which are diagnosed as schizophrenia.

Acute psychotic reactions in Caribbean-born patients

A prospective study of patients with religious delusions identified 24 West Indian and West African patients. Those who had none of Schneider's first-rank symptoms of schizophrenia (principally West Indians) differed from those who did by virtue of early religious commitment, life-long religious experiences, an acute admission precipitated by social events, a greater chance of having their diagnosis changed, less than 10 different PSE syndromes, the absence of 'twentieth-century' delusions, and the presentation of malevolent witchcraft as the sole explanation of the episode. It is suggested that this group can usefully be considered as demonstrating an acute psychotic reaction of the type previously described in Africa and the Caribbean.

A study of mental illness in Asians, West Indians and Africans living in Manchester

First admission rates have been determined for immigrants living in Manchester. They show that immigrants as a whole had about twice the rate of British-born subjects, but that various subgroups had rates still higher, including those aged 35-44 and Asian women. According to hospital diagnoses the psychiatric conditions responsible for these increased rates are schizophrenia (in all groups) and neuroses and personality disorders (in the Asians). A case note study of the psychopathology showed, however, that the most characteristic symptoms of schizophrenia were not more common in the immigrants. It is concluded that most of the immigrants are suffering from paranoid psychoses, not schizophrenia.

The consequences of unplanned repatriation

In attempting to resolve the issue of the relative importance of environmental and genetic factors in mental illness migration studies have been inconclusive (Dohrenwend and Dohrenwend, 1969). Among West Indian immigrants an increased incidence of mental disorder as compared to the native population and the population at home has been suggested (Hemsi, 1967). Other workers have attached great importance to environmental factors in explaining the atypical picture of West Indian mental illness (Gordon, 1965; Tewfik and Okasha, 1965).

Cross-cultural studies of symptomatology in schizophrenia

This paper is an attempt to review some of the main cross-cultural studies of symptomatology in schizophrenia. Although it is shown that there are cultural variations of symptomatology, the reliability of these observations seems to be questionable. The inclusion of behaviour of different description into the concept of schizophrenia throws serious doubts on the usefulness and desirability of this concept as presently used in cross-cultural studies. However, problems of reliability or validity of observations at the cross-cultural level pose similar problems, encountered at the inter-individual. A more reliable and rigorous system of classification is needed to differentiate between normal and schizophrenic behaviour in different cultures or within the same culture. Cross-cultural studies suggest that some responses (e.g., conceptual) are more amenable to the influence of culture than others (e.g., physiological). Thus if it is demonstrated that different cultural groups show similar responses on some relatively culture-free tasks (e.g., EEG. pupillary responses) it would be plausible to suggest similar processes cross-culturally. These processes may underlie behaviour disorders such as schizophrenia despite the inter-individual or cross-cultural differences in their manifestations.

Mentally ill West Indian immigrants

At present there exist in the literature numerous references to mental illness in different cultures; these vary from consideration of disorders peculiar to certain cultures, e.g. Koro, Latah, Amok, Wihtigo, etc., well reviewed by Yap (Yap, 51) to the problems of acculturation and mental illness. Examples of the latter include the studies of Tooth and Carothers, the latter suggesting that Westernization and detribalization increased the incidence of psychosis in Africans (Carothers, 2; Tooth, 45). Slotkin (42) pointed to the paranoid schizophrenia phenomena among acculturated Menomini. Hallowell (14, 15) found significant Rorschach differences between acculturated and unacculturated Salteaux.

PSYCHIATRIC MORBIDITY OF WEST INDIAN IMMIGRANTS IN AN URBAN GROUP PRACTICE

Since 1948 a number of papers published in Great Britain have demonstrated the feasibility of studying the incidence and prevalence of both major and minor psychiatric disorders in general practice (3, 4, 7, 8, 10, 11, 14, 16, 17, 18). Few, however, have focused on the health of West Indian immigrants in Great Britain, some 125,000 of whom have entered the country since that time (2, 12, 13, 20). This paper reports on the results of a six-month psychiatric morbidity survey of a group general practice in Brixton, the main purpose of which was to collect and compare data on the illness and consultation patterns of West Indian and English patients attending the same general practice.