Mental illness among immigrant minorities in the United Kingdom

Ethnic diversity and equality of access to specialist therapeutic community treatment for severe personality disorder

Aims and Method

All mental health services are expected to aim for equality of access to people from minority ethnic groups. Psychotherapy services typically have a low proportion of ethnic minority clients. Specialist services such as therapeutic communities are no exception. It is also possible that ethnic minority residents are more likely to leave group treatments early if they are clearly in the minority. The study examined records between 1996–2000 to ascertain whether ethnic minorities show a different pattern of exit from the process than people from other backgrounds.

Results

Just over 9% of referrals to Henderson Hospital were from ethnic minorities. Ethnic minority referrals were less likely to be invited to a selection interview. However, there was no difference in length of stay in treatment. There was a trend towards ethnic minority referrals having more severe symptomatology and histories than those from White backgrounds.

Clinical Implications

Ethnic background should be taken into account when considering referral for specialist psychotherapy. Routine monitoring of the processing of ethnic minority referrals should be conducted in all psychotherapy services.

Ethnic diversity and equality of access to specialist therapeutic community treatment for severe personality disorder

Aims and Method

All mental health services are expected to aim for equality of access to people from minority ethnic groups. Psychotherapy services typically have a low proportion of ethnic minority clients. Specialist services such as therapeutic communities are no exception. It is also possible that ethnic minority residents are more likely to leave group treatments early if they are clearly in the minority. The study examined records between 1996–2000 to ascertain whether ethnic minorities show a different pattern of exit from the process than people from other backgrounds.

Results

Just over 9% of referrals to Henderson Hospital were from ethnic minorities. Ethnic minority referrals were less likely to be invited to a selection interview. However, there was no difference in length of stay in treatment. There was a trend towards ethnic minority referrals having more severe symptomatology and histories than those from White backgrounds.

Clinical Implications

Ethnic background should be taken into account when considering referral for specialist psychotherapy. Routine monitoring of the processing of ethnic minority referrals should be conducted in all psychotherapy services.

A pilot investigation of the effects of stress on neuropsychological performance in Asian-Indians in the United States

The present study evaluated the effects of stress and the ethnicity of the examiner on neuropsychological performance in a sample of Asian-Indian males in the United States. Participants were 60 Asian-Indian college students randomly assigned to one of four conditions in a 2 x 2 factorial design. The first factor was level of stress induction and the second was ethnicity of examiners. Results suggested that both stress inducing instructions and examiner ethnicity impacted highly demanding tasks, while moderately difficult tasks were less sensitive to ethnicity of the examiner. Results also indicate that examiners should recognize the potential impact of ethnicity and heightened level of stress when administering and interpreting neuropsychological measures.

Migration and mental health in Europe (the state of the mental health in Europe working group: appendix 1)

BACKGROUND

This paper is a part of the work of the group that carried out the report "The state of the mental health in Europe" (European Commission, DG Health and Consumer Protection, 2004) and deals with the mental health issues related to the migration in Europe.

METHODS

The paper tries to describe the social, demographical and political context of the emigration in Europe and tries to indicate the needs and (mental) health problems of immigrants. A review of the literature concerning mental health risk in immigrant is also carried out. The work also faces the problem of the health policy toward immigrants and the access to health care services in Europe.

RESULTS

Migration during the 1990s has been high and characterised by new migrations. Some countries in Europe, that have been traditionally exporters of migrants have shifted to become importers. Migration has been a key force in the demographic changes of the European population. The policy of closed borders do not stop migration, but rather seems to set up a new underclass of so-called "illegals" who are suppressed and highly exploited. In 2000 there were also 392,200 asylum applications. The reviewed literature among mental health risk in some immigrant groups in Europe concerns: 1) highest rate of schizophrenia; suicide; alcohol and drug abuse; access of psychiatric facilities; risk of anxiety and depression; mental health of EU immigrants once they returned to their country; early EU immigrants in today disadvantaged countries; refugees and mental health. Due to the different condition of migration concerning variables as: motivation to migrations (e.g. settler, refugees, gastarbeiters); distance for the host culture; ability to develop mediating structures; legal residential status it is impossible to consider "migrants" as a homogeneous group concerning the risk for mental illness. In this sense, psychosocial studies should be undertaken to identify those factors which may under given conditions, imply an increased risk of psychiatric disorders and influence seeking for psychiatric care. COMMENTS AND REMARKS: Despite in the migrants some vulnerable groups were identified with respect to health problems, in many European countries there are migrants who fall outside the existing health and social services, something which is particularly true for asylum seekers and undocumented immigrants. In order to address these deficiencies, it is necessary to provide with an adequate financing and a continuity of the grants for research into the multicultural health demand. Finally, there is to highlight the importance of adopting an integrated approach to mental health care that moves away from psychiatric care only.

Perceptions of schizophrenia in multi-cultural Britain

OBJECTIVES

The importance of perceptions of mental health problems from the perspectives of different ethnic populations is especially pertinent within a society such as Britain, which is culturally diverse, but employs a classification of psychopathology which is based upon western models. This study aimed to investigate differences in the lay perceptions of mental health problems, particularly schizophrenia, across different ethnic populations living in Britain. Further it aimed to look at the influence ethnic background had in relation to other variables such as age, gender, religion and contact with people with mental health problems.

DESIGN

190 participants from five broad ethnic groups (Afro-Caribbean, Bangladeshi, Indian, Sub-Saharan African and White British) reported their perceptions of schizophrenia symptoms using the Perceptions of Mental Health Problems Questionnaire.

RESULTS

Differences were found across ethnic groups in participants' perceptions of schizophrenia symptoms. Differences were consistently shown across the specific symptoms of hallucinatory behaviour, suspiciousness, unusual thought content and alogia. In particular, in comparison with the white British group, Bangladeshi participants were less likely to view suspiciousness or hallucinatory behaviour as indicative of mental health problems, and the Afro-Caribbean participants were less likely to view unusual thought content as a symptom. As expected, differences in perceptions were also associated with religion, education, gender and contact with people with mental health problems. However, ethnicity was the best predictor of perceptions of schizophrenia symptoms.

CONCLUSION

Ethnicity was found to be an important factor in influencing perceptions of schizophrenia. The specific differences found across ethnic groups are useful in beginning to understand more fully public perceptions of mental health problems in Britain today. The findings raise interesting discussion in relation to ethnic and cultural factors in planning services for people from ethnic minorities, and considering in more detail issues concerning diagnosis and engagement.

Migration and health in the European Union

The paper gives a brief overview of a wide spectrum of health issues and problems, ranging from communicable disease to mental health and family formation, which affect migrants and host countries.

Aspects of psychiatric admissions of migrants to hospitals in Perth, Western Australia

OBJECTIVE

Recent Australian Government initiatives have emphasised problems with service provision to the ethnic mentally ill. This study aims to address the paucity of contemporary data describing the disposition of the ethnic mentally ill in hospital settings.

METHOD

Patterns of admissions for psychiatric disorders to all hospitals in Perth, Western Australia, for the 3 years from 1990 to 1992, of migrants and the Australian born were compared using data from the Western Australian Mental Health Information System.

RESULTS

The overall rates for European migrants showed a 'normalisation' towards those of the Australian-born. There were high rates for the schizophrenic spectrum disorders in Polish and Yugoslavian (old terminology) migrants. There were low admission rates for South-East Asian migrants, predominantly those from Vietnam and Malaysia. Rates for alcoholism were low in Italian and all Asian migrants. There were high rates of organic psychosis, especially in those older than 75 years, among the Italian and Dutch migrants. The relative risk of a first admission in the 3 years being an involuntary admission to a mental hospital was almost twice that of the Australian-born for migrants from Poland, Yugoslavia, Malaysia and Vietnam.

CONCLUSIONS

The results imply the possibility of significant untreated and/or undiagnosed psychiatric morbidity in the South-East Asian-born. They also indicate a need for further exploration of the unexpectedly high levels of psychiatric morbidity among some ethnic elderly groups, specifically the Dutch- and Italian-born. The findings demonstrate the persistence of high rates of presentation for psychotic disorders among Eastern European-born populations, many years post migration.

Integration between primary and secondary services in the care of the severely mentally ill: patients' and general practitioners' views

BACKGROUND

Communication between secondary and primary care is an important aspect of continuity of care. We investigated communication between general practitioners (GPs) and psychiatric teams about a representative group of patients with severe mental illness (SMI). We also sought views on GP involvement in care from the patients and their GPs.

METHODS

One hundred patients with SMI were randomly selected from those under the care of two psychiatric sector teams in inner London. The patients and their GPs were interviewed.

RESULTS

GPs' knowledge about the care their patients received was limited. Most GPs perceived their role as providing physical care and prescribing. Few patients consulted GPs for mental health care. GPs perceived themselves as less involved in the care of Black Caribbean or Black African patients.

CONCLUSIONS

Considerable discontinuities of care between secondary and primary care were identified. GP involvement in the care of patients with SMI appears limited. Better communication is necessary if care is to be shared.

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.

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

There is convincing evidence that in the UK, various ethnic minorities are over-represented in psychiatric hospitals, prisons and special hospitals. Various explanations have been put forward for this picture. The expanding emphasis on community care means that models for looking after ethnic communities should be innovative and work from a bottom-up approach. Psychiatric emphasis on clinical diagnoses means that services are developed according to the diagnoses rather than needs.

Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London

OBJECTIVE

To compare the risk of detention under the Mental Health Act 1983 in a representative group of people with psychotic disorders from different ethnic groups.

SETTING

Two defined geographical areas in south London.

DESIGN

Annual period prevalent cases of psychosis were identified in 1993 in the study areas from hospital and community data. Standardised criteria were applied to case notes to establish diagnosis and detention under the act.

SUBJECTS

535 patients were identified, of whom 439 fulfilled ICD-10 criteria for psychosis.

MAIN OUTCOME MEASURES

Risk of ever having been detained under the Mental Health Act 1983, risk of detention under specific sections of the act during the study year, and risk of contact with forensic services for the different ethnic groups.

RESULTS

439 patients with a psychotic illness were identified. Nearly half of the white patients had been detained under the act compared with 70% and 69% of black Caribbean and black African patients, respectively. Black Caribbean and black African patients were more likely than white patients to have been involuntarily detained (adjusted odds ratio 3.67; 95% confidence interval 2.07 to 6.50 and 2.88; 1.04 to 7.95, respectively). Rates of use of sections 2, 3 and 136 in the study year were higher for black than for white patients, and black patients were more likely than white patients to have been admitted to a psychiatric intensive care facility or prison.

CONCLUSION

Independent of psychiatric diagnosis and sociodemographic differences, black African and black Caribbean patients with psychosis in south London were more likely than white patients to have ever been detained under the Mental Health Act 1983.

Immigrant child and adolescent psychiatric referrals: a five-year retrospective study of Asian and Caucasian families

OBJECTIVE

Referrals to the Bradford (England) Child and Family Psychiatric Clinic were studied over a five-year period with the purpose of comparing native Caucasian and immigrant groups. Punjabi Moslems of Pakistani descent formed a majority of immigrant referrals.

METHOD

This immigrant sample was compared with native Caucasians matched for age and sex.

RESULTS

Differences between these groups were found in the rates and sources of referral, together with family composition, diagnosis and adherence to treatment.

CONCLUSION

These results are discussed in terms of the influence of cultural background and gender socialization. This report makes suggestions with respect to service provision and the assessment of individuals from linguistically unassimilated ethnic minorities.

Retesting the validity of the Arabic version of the Hospital Anxiety and Depression (HAD) scale in primary health care

The Arabic version of the Hospital Anxiety and Depression (HAD) scale was retested and cut-off points determined in a sample of 217 patients attending a primary health care centre in Al Ain, United Arab Emirates (U.A.E.). Subjects were screened using the HAD scale and all patients were then interviewed by a single consultant psychiatrist. The scale scores were assessed against the psychiatrist's clinical evaluations. The study furnished evidence that the Arabic version of the HAD scale is a valid instrument for detecting anxiety and depressive disorders in primary health care settings. Spearman rank correlations of all items of the scale were significantly above zero. The butterflies item of the anxiety subscale had the lowest correlation coefficients. The overall Cronbach alpha measures of internal consistency were 0.7836 and 0.8760 for anxiety and depression, respectively. The cut-off points that produced a balanced combination of sensitivity and specificity appropriate for referral to a psychiatric facility by the general practitioner were 6/7 for anxiety and 3/4 for depression. Almost all other similar studies have determined a single cut-off point for both subscales of the HAD. This study also indicated that the HAD depression subscale is more consistent and more predictive than the HAD anxiety subscale. Moreover some of the problems arising from applying psychiatric research instruments across cultures are highlighted by this study.

Relationship of migrant status (refugee or immigrant) to mental health

This study investigated and compared mental health levels among refugees and immigrants living in New Zealand. One hundred and twenty-nine Indochinese refugees, 57 Pacific Island immigrants and 63 British immigrants to New Zealand were surveyed. A questionnaire and the Hopkins Symptom Checklist-25 (HSCL-25) in English and in three Indochinese translations, were administered face-to-face. The hypothesis that migrant status (being a refugee or immigrant) affects mental health and that refugees experience more emotional distress than immigrants was only supported by the comparison with British immigrants. Both Indochinese refugees and Pacific Island immigrants experienced relatively low levels of mental health. However, the incidence of clinical depression and clinical total emotional distress tended to be higher among Indochinese refugees than in either immigrant group. In contrast clinical anxiety occurred most often among Pacific Islanders.

Asian inpatients in a district psychiatric unit: an examination of presenting features and routes into care

The case notes of one hundred consecutive Asian admissions at first presentation to a distric psychiatric unit were examined. Asian admissions to Greenwich Hospital comprise a young, well educated group of predominantly Punjabi Sikhs. They present mostly through crisis services often following a domiciliary visit. General practitioners (GPs) were involved in only 34% of referrals although 54% of patients had Asian GPs. They are less likely to be compulsorily admitted than has previously been reported and very infrequently came into contact with police services. Alcoholism was found mostly in male married Sikhs. Psychotic illness accounted for 51% of presentations and neurotic depression for 18%, the latter being the largest single diagnostic category. This study raises questions regarding preferred routes into care for Asians and has service implications when considering establishment of accessible community services.

Mental health, race and ethnicity: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit

A retrospective case-note study of 152 discharged psychiatric patients (77 subjects of ethnic minority origin and 75 whites) examined for details of follow-up arrangements on discharge, compliance rate with out-patient appointments and details on length of stay, status on admission, employment status, record of illicit drug taking and diagnosis. The results show that in the areas of diagnosis, possible illicit drug involvement, status on admission and length of stay, there are significant differences between Afro-Caribbean subjects and others.

Suicide and self-burning among Indians and West Indians in England and Wales

Suicide levels in England and Wales during 1979-83 were low among males from the Indian subcontinent (SMR 73) and significantly high in young Indian women (age-specific ratios 273 and 160 at ages 15-24 and 25-34 respectively). Suicide levels were low in Caribbeans (SMRs 81 and 62 in men and women respectively) and high in East Africans (SMRs 128 and 148 in men and women respectively). The excess in East Africans (most of whom are of Indian origin) was largely confined to younger ages. Immigrant groups had significantly higher rates of suicide by burning, with a ninefold excess among women of Indian origin. The pressures leading to higher suicide levels among young women of Indian origin highlight the need for making appropriate forms of support and counselling available to this community.

'Mentally disordered persons found in public places'. Diagnostic and social aspects of police referrals (Section 136)

A survey over 2 years of all Police Referrals (Section 136 of the Mental Health Act 1983) in an inner-city health district identified 163 cases, with a core group of repeat referrals. Previous psychiatric admissions, a diagnosis of schizophrenia, social deprivation, and a bias towards young men of Afro-Caribbean ethnicity were key features. The difficulty of obtaining clear data and uncertainties within the law rebound unfairly on patients, police and psychiatrists. Section 136, while not inappropriate diagnostically, can be seen as highlighting unmet social and medical needs in the context of community care. The requirement for coordinated resources, including acute in-patient services sufficient for deprived populations and legal provision for treatment beyond a hospital's boundaries, seems paramount.

The relationship between schizophrenia and immigration. Are there alternatives to psychosocial hypotheses?

Several recent studies have found markedly increased rates of schizophrenia among West Indian immigrants to the UK. Almost exclusively, authors have sought psychosocial explanations for these findings. This paper hypothesises that environmental causes, notably obstetric complications and perinatal infections, provide more plausible aetiological models, especially for the raised rates of schizophrenia among second-generation West Indian immigrants.

Psychiatric hospital admission rates in Jamaica, 1971 and 1988

The overall psychiatric hospital admission rates in Jamaica were 136 per 100,000 in 1971 and 69 per 100,000 in 1988. The admission rate for schizophrenia was 69 per 100,000 in 1971 and 35 per 100,000 in 1988. The 49% reduction in admission rates over these 17 years is attributed to the introduction of an island-wide community mental health service with psychiatric admission to general parish hospitals in 1972. This admission rate for schizophrenia is five to six times lower than the rate reported for Afro-Caribbeans in the UK by a number of studies, and is more in keeping with the admission rate for schizophrenia reported for the general population in England.

Schizophrenia in migrants living in the western region of Melbourne

Comparison is made between migrant (n = 332) and Australian-born (n = 242) schizophrenic outpatients attending a regional psychiatric hospital. Age-corrected rates show that migrants are over-represented. The migrant patient-group was older, developed the illness later, and had a higher proportion of females. More female migrant patients had developed the illness before arrival and in the first five years after migration compared to males whose peak incidence was between 11 and 15 years after arrival. Migrant patients showed greater family cohesion. On broad socio-economic indices, illness characteristics and treatment received, no significant differences emerged. In many respects patients born in U.K. and Ireland resembled the Australian-born.

Psychosis in migrants from the Indian subcontinent and English-born controls. A preliminary study on the use of psychiatric services

A cohort of first-generation Asian immigrants who received a diagnosis of a functional psychosis at the Bethlem Royal and Maudsley Hospitals were compared with an English-born control group. The Asians were found to have spent a lower total percentage of time in the two hospitals, had fewer in-patient admissions per year, and had a shorter average duration of stay in hospital than the matched controls.

Management of first episode psychotic illness in Afro-Caribbean patients

We studied retrospectively a consecutive series of 40 Afro-Caribbean patients and compared them with 40 non-Caribbean patients matched for age, sex, and diagnosis. There was no overall difference in initial or cumulative doses of neuroleptic medication in the early treatment of psychosis. However, a small subgroup of Afro-Caribbean patients received higher peak dosages. Clearly recorded episodes of behavioural disturbances were more frequent in Afro-Caribbean patients generally. They were more likely to be admitted compulsorily, discharged earlier, and prescribed depot medication.

Social deprivation and rates of treated mental disorder. Developing statistical models to predict psychiatric service utilisation

A review of the literature shows that there are strong associations of treated prevalence rates of psychiatric disorder with social class, sex, marital status, ethnic group and living alone; and moderate associations with living in inner-city areas and a high degree of residential mobility. The Jarman-8 index of social deprivation correlates with psychiatric admission rates for patients aged less than 65 years (R2 = 0.38). Individual census variables can themselves account for up to 0.71 of the variance in the admission rates, while combined in a stepwise multiple regression the census variables will account for over 0.95 of this variation. Multiple regression models using individual census variables and derived indices should be applied next on a wider geographical basis, and to narrower age, sex and diagnosis-specific psychiatric morbidity rates.

A survey of psychiatrically ill Asian children

This case-note survey compares a group of Asian children referred to child psychiatry and guidance clinics in Bolton with a control group of white children referred to the same clinics. The proportion of Asian children was less than the proportion of Asian people in the general population. The proportion of Asian children coming from a broken home or a single-parent family was significantly lower than in the control group. Conduct disorders were more common in the control group and somatoform disorders were more common in the Asian group.

Double jeopardy: psychopathology of black mentally ill returned migrants to Jamaica

The psychopathology of 126 black Jamaican migrants who had spent an average of 12 years in North America and the United Kingdom and had subsequently returned to Jamaica, was established and compared to that of a matched control group of Jamaicans who had never migrated. There was a statistically significant difference in the pattern of diagnosis between the two groups (p less than 0.0001), and although the existence of a past history of mental illness between the groups was not statistically significant (p less than 0.1), the returned migrants had a significantly higher frequency of mental hospitalisation (p less than 0.0001) than the controls, with 94% of the previous hospitalisations of the returned migrants being for schizophrenic illnesses. Case studies are presented to illustrate the social stresses experienced by the returned migrant group in the countries to which they migrated and on the return to their home country, and thus to underscore the double jeopardy faced by these patients experiencing return migration.

Addressing racism in psychiatry: is the therapeutic community model applicable?

Several reports have documented the failure of statutory psychiatric services in Britain to provide for the needs of clients from minority ethnic groups. Black clients are particularly underrepresented in Psychotherapy for reasons which are complex and varied, but include the institutionalised racism which pervades British society. We argue that the Therapeutic Community (TC) model of treatment (or aspects of it deployed in other mental health situations) provides a potential for a less racist service. Using the Henderson Hospital TC as a case in point, we argue that the TC is an approach which can meet the needs of black peoples. However, it is acknowledged that despite the ideological suitability of the TC model for black clients, in practice the Henderson Hospital is not fulfilling its role in providing therapy to this group. We discuss possible explanations and suggest the practical changes necessary, so that Henderson Hospital can meet the needs of clients in a multi-cultural Britain.

The use of inpatient psychiatric care by immigrants in a London Borough

The prevalence of admission to psychiatric inpatient care in the major immigrant groups in the London Borough of Newham in 1982 is surveyed and results discussed with reference to relevant published literature. High admission rates were found among young West Indian men and older West Indian women, Pakistani men, older Indian women, Irish women and women from the West African new commonwealth. Women from the East African new commonwealth had a low admission rate. The diagnostic mixture found in patients from the various groups is discussed.

Eating behaviour and attitudes to weight and shape in British women from three ethnic groups

Attitudes towards eating, weight and shape were examined in 479 Caucasian, Afro-Caribbean and Asian British women. The Asian women were found to have significantly more disordered eating attitudes than the Caucasian women, but no difference was found between the three groups in their concern with their body weight and shape. However, while in the Caucasian group disordered eating attitudes were significantly positively correlated with feelings of anxiety and depression, this was not true in the other two groups. Although the concerns of British Afro-Caribbean and Asian women are similar to those of the Caucasian women, there may be ethnic differences in the relationship between feelings about eating, weight and shape and mood.

Folie à trois among two Soviet-Jewish immigrant families to Israel

In two cases of folie à trois, affecting two Soviet-Jewish families who emigrated to Israel, both elderly parents in both cases shared the paranoid delusional beliefs of an only child. Severe trauma in the past and social maladjustment in the present may be among the precipitating factors for the development of the shared paranoid disorder.

Psychiatric morbidity among Punjabi medical patients in England measured by General Health Questionnaire

The 28-item GHQ was administered to 282 Punjabi and white British patients visiting two Health Centres in Bedford. We discovered that ethnicity is not significantly correlated with GHQ 'caseness', but that differences exist in somatic and depressive symptomatology. The discussion relates these findings to debates about the psychiatric morbidity of Asian immigrants and somatization.

The mortality of first and second generation Irish immigrants in the U.K

The Irish have generally been ignored in studies of the health needs of ethnic groups in the U.K. despite being the largest immigrant group and having the highest Standardised Mortality Ratio of all first generation immigrants. Using the OPCS Longitudinal Study, the present paper shows that this excess mortality persists into the second generation Irish in the U.K., regardless of the part of Ireland from which their parents originated or whether one or both parents were Irish. The effects of social class, age, sex, year of entry to the U.K. and period of death are explored, and variations with these factors are found to be complex.

The evaluation of psychiatric illness in Asian patients by the Hospital Anxiety Depression Scale

Twenty Asian psychiatric patients suffering from neurotic illness completed the Urdu version of the HAD Scale. The results were compared with the Clinical Interview Schedule. Somatic symptoms were significantly related to various measures of anxiety but not to those of depression. This finding contradicts the previously held view of linking somatic symptoms with the presentation of depression.

Transcultural patterns of somatization in primary care: a preliminary report

The ethnic origins of patients consulting their general practitioners (GP) were determined using criteria of country of birth, religion and preferred language. Three samples with preferred languages of English, Gujarati or Urdu were compared on a standardized interview with regard to symptom complaint, perception and attribution and also completed the General Health Questionnaire and Illness Behaviour Questionnaire. Their GPs provided diagnoses and ratings of physical and mental disorders. Compared with the English group, the Gujaratis had fewer psychosocial complaints, perceived less anxiety and were more likely to attribute their complaints to physical causes. They had higher scores on the Hypochondriasis and Denial scales. Their GPs rated them as less likely to have relevant physical or mental disorders. The Urdu group was intermediate in most respects. Thus somatization was commoner in these two Asian groups with different ethnic origins. However, overall levels of somatization appear to be high even in the English group. No significant differences were found between groups for complaints or ratings of depression, and the differences found in the somatization process appear to be related only to anxiety.

Bulimia in British blacks and Asians. A catchment area study

This paper describes the demographic and clinical features of five non-white, normal body weight bulimics, all from the same catchment area. Comparisons with white bulimic referrals from the same area showed clinical similarities, but the non-white bulimics gave an account of gross emotional deprivation: all came from broken homes; four had been separated for long periods from their mothers; two had been subjected to incestuous abuse; and four had been cared for by white women. Response to treatment was poor. The ratio of non-white referral to white was at most one tenth of the ratio of non-white to white women in the catchment area.