The compulsory detention of males of different ethnic groups, with special reference to offender patients

Social Defeat, Psychotic Symptoms, and Crime in Young Caribbean Immigrants to Rotterdam

Background: The negative experience of being excluded from the majority group (social defeat) may be associated with psychosis in immigrants. The social defeat hypothesis is supported by the high frequency of perceived discrimination and acculturation problems in psychotic immigrants. In addition, social defeat may lead to crime through social problems such as unemployment, school dropout, a broken family structure, or psychotic symptoms. Methods: We assessed the association between social defeat and acculturation on the one hand and broadly defined psychotic symptoms and crime on the other in Caribbean immigrants to Rotterdam who are aged 18-24 years. The municipality of Rotterdam provided data about Caribbean immigrants to Rotterdam. Acculturation, social defeat (perceived discrimination, sense of control, and evaluation of self and others), psychotic symptoms, and crime were assessed using online questionnaires. Results: Social defeat was associated with psychotic symptoms in women (β = 0.614, p < 0.001). This relation applied particularly to the negative self-perception domain of social defeat. Acculturation was associated with neither social defeat nor psychotic symptoms or crime and did not mediate the association between social defeat and psychosis. Conclusion: The social defeat hypothesis of psychosis may be gender-specific valid but does not extend to crime.

Psychiatry on Tobago in 1989

An unstructured observation concerning low rates of observed psychological disturbance was explored by estimating rates of suicide, and psychotropic drug use. Recorded suicide, overdose, and ‘minor’ tranquilliser and antidepressant use were strikingly low on Tobago, when compared with the United Kingdom. Tobagonians were unlikely to medicalise distress by presenting with overt psychological symptoms. Most local doctors felt that patients preferred spiritual support, e.g. from charismatic religious groups and traditional healers (some using obeah). A rich network of social and recreational groups may also give important support, as may ‘liming’ (a local conversational pastime). Tabanka (a local culture specific syndrome) may also be a non-medical outlet.

Socio-economic deprivation and admission rates to secure forensic psychiatry services

Annual admission rates from the North-East Thames Region to maximum- and medium-secure forensic psychiatry services demonstrated a highly significant correlation with social deprivation measured at district health authority level using the Jarman UPA 8. There were specific associations with the number of unemployed persons, overcrowded households, and persons from ethnic minorities in the districts studied. There was a 10-fold difference in treated prevalence rates across the region, indicating that certain purchasing authorities may be seriously underfunded to meet the needs of their catchment area populations for secure forensic psychiatry services. Further research is required into the nature of the association between admissions to these services and social deprivation. It is readily apparent that a new formula is required for the allocation of resources in the face of such wide disparities in demand from different geographical locations.

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?"

Psychotic disorders are more common in ethnic minority than in Dutch native defendants

PURPOSE

The prevalence of psychotic disorders among prisoners from racial or ethnic minority groups remains uncertain. We therefore compared the frequency of psychotic disorder in ethnic minority and Dutch native defendants using the nationwide database of elaborate pre-trial reports.

METHODS

Analysis of a nationwide database of pre-trial reported defendants in the Netherlands between 2000 and 2006 (n = 12,752).

RESULTS

A diagnosis of a psychotic disorder was more common in ethnic minority than in Dutch native defendants (21.1 vs. 10.2%). The odds ratio of this diagnosis, adjusted for age, gender, IQ below 85 and abuse of cannabis or hard drugs, was 2.6 (95% CI 2.2-3.0). This odds ratio was highest for African defendants (OR = 5.2; 95% CI 3.7-7.4).

CONCLUSIONS

Psychotic disorders were more common among pre-trial reported defendants from ethnic minorities than among their Dutch native counterparts.

Ethnicity and access to an inner city home treatment service: a case-control study

There is strong evidence suggesting ethnic variations in mental health service use and disproportionate numbers of people of black ethnic origin being admitted to hospital. The objective of this study was to establish whether people of black ethnic origin had equal access to home treatment in a mental health crisis. Using a case-control design, we selected a random sample of 240 inpatient episodes and compared them with a sample of 77 home treatment episodes over a 12-month period (1 April 2008-31 March 2009). We found no difference in the proportion of people of black ethnic origin being home treated in comparison to receiving an inpatient admission, although they experienced longer hospital admissions than people of other ethnic origin. Diagnosis, housing status and source of referral were found to be significant in influencing the choice of intervention in our multivariate analysis. People of black ethnic origin were found to use home treatment to the same extent as other ethnic groups in a mental health crisis, but further research is required for the early discharge function of home treatment teams to evaluate whether this aspect of care is experienced differently by different ethnic groups.

Mental health care and resistance to fascism

Mental health nurses have a critical stake in resisting the right-wing ideology of British fascism. Particularly concerning is the contemporary effort of the British National Party (BNP) to gain credibility and electoral support by the strategic re-packaging of a racist and divisive political manifesto. Evidence that some public sector workers are affiliated with the BNP has relevance for nursing at a series of levels, not least the incompatibility of party membership with a requirement of the Professional Code to avoid discrimination. Progressive advances, though, need to account for deep rooted institutionalized racism in the discourse and practice of healthcare services. The anomalous treatment of black people within mental health services, alongside racial abuse experienced by ethnic minority staff, is discussed in relation to the concept of race as a powerful social category and construction. The murder of the mentally ill and learning disabled in Nazi Germany, as an adjunct of racial genocide, is presented as an extreme example where professional ethics was undermined by dominant political ideology. Finally, the complicity of medical and nursing staff in the state sanctioned, bureaucratic, killing that characterized the Holocaust is revisited in the context of ethical repositioning for contemporary practice and praxis.

Ethnicity and dangerousness criteria for court ordered admission to a psychiatric hospital

BACKGROUND

Black and minority ethnic (BME) populations are disproportionately detained in psychiatric hospitals.

AIM

To examine the dangerousness criteria for compulsory court ordered admission to a psychiatric hospital in White and BME persons.

METHOD

We examined the psychiatric examinations for court ordered compulsory admissions in 506 White and 299 BME persons from October 2004 until January 2008 in Rotterdam, the Netherlands. The White and BME groups are compared using Chi-square tests and in case of significant differences with logistic regression models adjusted for age, gender, mental disorders and socio-economic background.

RESULTS

In BME persons, violence towards others and neglect of relatives were more often reasons to request court order admission as compared with Whites (39.8 vs. 25.3%, P < 0.001, respectively, 6.4 vs. 2.4%, P = 0.01). This remained true after adjustment for age, gender, mental disorders and socio-economic background [OR 1.56 (95% CI 1.12-2.18), P = 0.01, respectively; OR 3.08 (95% CI 1.31-7.26), P = 0.01]. The other reasons for a request of court order admission had a similar prevalence in both groups (suicide or self-harm, social decline, severe self-neglect, arousal of aggression of others, danger to the mental health of others, and the general safety of persons and goods).

CONCLUSION

Violence towards others and neglect of relatives are more often a reason to request court ordered admission in BME than in White persons. BME patients are more often perceived as potentially dangerous to others.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Multicultural mental health services: projects for minority ethnic communities in England

Black and minority ethnic (BME) communities form 7.8% of the total population of the U.K. Many of these communities face a variety of disadvantages when they access, or are forced to access, statutory mental health services under the National Health Service. Efforts have been made to address these problems by developing projects both within statutory mental health services and in the non-governmental ('voluntary') sector. This article describes some of these projects located in England, drawing out the themes and models that underlie their approaches, and discusses the lessons that can be learned from the U.K. experience.

The role of engagement with services in compulsory admission of African/Caribbean patients

BACKGROUND

High rates of compulsory admission of African/Caribbean patients have been reported. Several factors have been associated with this finding. The roles of some factors related to engagement with services have not been empirically evaluated.

AIMS

The aim of this study was to assess the role of engagement factors in compulsory admission of African/Caribbean patients.

METHOD

A systematic case-note review was made of the admission process of 100 compulsorily and 100 voluntarily admitted patients; each group containing 50 randomly selected African/Caribbean and White British patients. Information about socio-demographic and engagement factors was collected and the findings compared.

RESULTS

Compulsorily admitted African/Caribbean patients had more factors indicative of poor engagement with services than patients in the other groups. Prior to admission, they were less likely to keep their appointments, comply with their medication, contact their GPs and were more likely to present late. Furthermore, they had more history of multiple compulsory admissions. The compulsorily admitted patients, irrespective of ethnicity, also engaged poorly with services.

CONCLUSIONS

Poor engagement with primary care and secondary mental health services of African/Caribbean patients appears to be contributing to their high rates of compulsory admission. This aspect of ethnic factors and compulsory admission requires further studies.

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.

Ethnic differences in prisoners. 1: criminality and psychiatric morbidity

BACKGROUND

In England and Wales, persons of African-Caribbean origin are more likely to be both imprisoned and admitted to secure hospitals.

AIMS

To estimate population-based rates of imprisonment in different ethnic groups, and compare criminal behaviour and psychiatric morbidity.

METHOD

We examined Home Office data on all persons in prison, and carried out a two-stage cross-sectional survey of 3142 remanded and sentenced, male and female, prisoners in all penal establishments in England and Wales in 1997.

RESULTS

We confirmed high rates of imprisonment for Black people and lower rates for South Asians. Different patterns of offending and lower prevalence of psychiatric morbidity were observed in Black prisoners.

CONCLUSIONS

Despite increased risks of imprisonment, African-Caribbeans show less psychiatric morbidity than White prisoners. This contrasts with the excess of African-Caribbeans in secure hospitals, an inconsistency possibly in part due to the effects of ethnic groups on admission procedures.

Mental impairment in the West Midlands: 10 years on

In 1989, a survey was undertaken to describe the learning disabled population, originating from the West Midlands, classified as mentally impaired or severely mentally impaired under the Mental Health Act 1983. The results obtained were then used to help guide future service development within the region. Given the marked changes in service provision over the subsequent decade, the study was repeated in 1998-1999, looking at the same population on 1st December 1997 (prior to the Bournewood Ruling). Attempts were made to identify all people residing within the West Midlands region, or originating from it, and classified as mentally impaired or severely mentally impaired under the Mental Health Act (1983). This was achieved by contacting medical records departments, learning disability consultants and Health Authorities. The same data set as the original study was then collected from case notes to allow comparison. The current study however, collected extra information, relating to diagnosis, treatment and outcome. Ninety-three people were identified for the study. Over the 10 years, there has been approximately a 100% increase in the numbers of people detained under these categories of the Mental Health Act (1983). There has been a marked increase in the use of the private sector, as well as out-of-region placements. Sexual offending seemed a common reason for detention. The authors attempt to explain this phenomenon. They also highlight the need for future developments and greater systematic data collection.

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.

Ethnic differences in admissions to secure forensic psychiatry services

BACKGROUND

Persons of African-Caribbean origin are more frequently imprisoned, and increasing evidence suggests they are detained more frequently in psychiatric hospitals, following offending behaviour.

AIMS

To estimate population-based prevalence rates of treated mental disorder in different ethnic groups compulsorily admitted to secure forensic psychiatry services.

METHOD

A survey was recorded of 3155 first admissions, from 1988 to 1994, from half of England and Wales, with 1991 census data as the denominator adjusted for under-enumeration.

RESULTS

Compulsory admissions for Black males were 5.6 (CI 5.1-6.3) times as high as, and for Asian males were half, those for White males; for Black females, 2.9 (CI 2.4-4.6) times as high and for Asian females one-third of those for White females. Admissions of non-Whites rose over the study period. Patterns of offending and diagnoses differed between ethnic groups.

CONCLUSIONS

Variations in compulsory hospitalisation cannot be entirely attributed to racial bias. Community-based services may be less effective in preventing escalating criminal and dangerous behaviour associated with mental illness in African-Caribbeans.

Relationship between psychotic disorders in adolescence and criminally violent behaviour. A retrospective examination

BACKGROUND

The interaction between psychosis and violence in adults is an important area of research receiving attention. To date there is little available data examining this relationship in adolescence.

AIMS

To investigate the possible relationships between criminally violent types of behaviour, and psychopathology and social factors, among adolescents suffering from a psychotic disorder.

METHOD

A retrospective case note study of 39 in-patients diagnosed as having a psychotic disorder and admitted to one of two adolescent psychiatry units (one secure, one open). Cases were divided into a 'violent' and a 'non-violent' group, and these two groups were then compared for social and psychopathological variables.

RESULTS

There was no association between recorded psychopathology and criminally violent behaviour. Criminally violent behaviour was associated with a history of emotional or physical abuse, contact with social or mental health services, and previous criminal behaviour.

CONCLUSIONS

These findings fail to echo results of studies in adult schizophrenia; they suggest that violent behaviour in psychosis is associated more closely with social factors than with specific symptoms of the psychotic illness. Potential explanations are discussed.

Ethnic differences in satisfaction with mental health services among representative people with psychosis in south London: PRiSM study 4

BACKGROUND

Previous studies show that among Black Caribbeans there is a higher prevalence of schizophrenia and higher levels of both voluntary and compulsory admissions. These suggest that Black Caribbean patients may find psychiatric services less appropriate to their needs. The aim of this study was to establish the satisfaction with mental health services of representative psychosis patients in South London, especially in relation to ethnic group.

METHOD

A random sample of all cases of psychotic disorder identified in the two sectors was interviewed using the Verona Service Satisfaction Schedule. Questionnaires from 50 Black Caribbean patients and 134 White patients were analysed.

RESULTS

Black Caribbean patients, particularly those of second generation born in the UK, were significantly less satisfied with almost every aspect of the services that they received than either older Black Caribbean patients born in the Caribbean or White patients. Using multiple regression analysis it was found that among the younger Black Caribbean patients, unlike the other patients, the number of previous admissions was a significant predictor of dissatisfaction.

CONCLUSION

Patients' ratings of satisfaction with mental health services are significantly worse for UK-born Black Caribbean than other patients with psychotic disorder in South London.

Ethnic differences in substance use and alcohol-use-related mortality among first generation migrants to England and Wales

Epidemiological studies among migrant ethnic groups are potentially important as a way to provide insight into the relative importance of genetic, cultural, and socioeconomic factors in the etiology of substance use disorders. This paper summarizes prior United Kingdom studies of the prevalence of substance-use-associated problems in different ethnic groups before analyzing trends in recent mortality data by country of birth. On this evidence, rates of alcohol-related mortality may be marginally higher for those born in the Caribbean than for the native British, but are substantially raised for those born in Ireland and the Indian subcontinent. There is some indication that rates for the Caribbean and possibly the Irish groups have risen more rapidly than for the national population over a 12-year period. These differences in mortality rates seem to have arisen for complex reasons.

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.

Male Afro-Caribbean patients admitted to Rampton Hospital between 1977 and 1986--a control study

All Afro-Caribbean patients admitted to the Mental Illness Division of Rampton Hospital (a Special Hospital) between 1977 and 1986 and a randomly selected control cohort of Non Afro-Caribbean patients admitted in the same period, were compared on a variety of sociodemographic, psychiatric, criminological, treatment and outcome variables. Significantly, fewer of the Afro-Caribbean patients attracted the legal classification of Psychopathic Disorder. Detailed analysis was thus restricted to mentally ill patients in the two ethnic groupings. Similarities outweighed differences. There was no difference between the groups in terms of index offence, previous custodial sentence, in-patient psychiatric admission (including previous Special Hospital admission), admission source, Mental Health Act section, length of admission (including readmission) to Special Hospitals, likelihood of discharge or place to which discharged. Medication history in Special Hospitals was similar at one year and three years after admission. Afro-Caribbean patients had a lower incidence of childhood institutional care, a decreased likelihood of a previous supervision order, an increased likelihood of a previous Court appearance and received higher doses of antipsychotic medication four weeks after admission to Special Hospital.

Inner london collaborative audit of admission in two health districts. III: Reasons for acute admission to psychiatric wards

BACKGROUND

In this series, rates of admission and daily bed use in south Southwark were 30% higher than in Hammersmith & Fulham, principally because of a higher rate of admission for affective disorders. Factors associated with compulsory admission did not differ between the districts. This final paper examines the severity of symptoms, the reasons given for admission and factors relevant to the judgement to admit, in order to test the hypothesis that more resources mean better service.

METHOD

Sampling and data collection methods were described in the first paper.

RESULTS

In both districts, major reasons for admission were self-neglect and risk of self-harm, poor adaptive functioning, and poor acceptance of medication. In south Southwark, a group of patients had affective disorders and less severe symptoms but a stated risk of suicide. Rates for, and severity of, schizophrenia were similar in the two districts. Social and preventive reasons for admission were given more frequently in south Southwark, where patients had more often been in contact with services before admission. Staff there, but not in Hammersmith & Fulham, suggested that many could have benefited from alternative forms of residential care.

CONCLUSIONS

A 'buffer' of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.

Cannabis and acute psychosis

The Present State Examination was used to assess the psychopathology of 23 psychotic patients who were cannabis positive on urinary screening, and 46 matched drug-free controls. Cases and controls were indistinguishable in terms of psychopathology, DSMIII diagnoses, onset of recent illness, the proportion of first admissions, ethnicity, and socio-economic class, differing only in their histories of substance use. These data suggest that psychosis which develops or recurs in the context of cannabis use does not have a characteristic psychopathology or mode of onset, and is not restricted to a particular ethnic or socio-demographic group. There is thus little evidence to support the validity of 'cannabis psychosis' as a diagnostic entity.

1,000 forensic outpatients: a descriptive study

The case notes and court reports of 1,000 consecutive outpatient referrals to a regional forensic outpatient service were studied retrospectively. Socio-demographic, psychiatric and forensic information was collected. The sample was predominantly male, Caucasian and relatively young in comparison with a general psychiatric population. The commonest source of referral was from defense solicitors and the commonest reason for referral was for a court report. A wide range of diagnoses and offences were noted. A number of differences were found in the frequency of gender, ethnicity and diagnosis according to the source of, and reason for, referral.

Long-term follow-up of young Afro-Caribbean Britons and white Britons with a first admission diagnosis of schizophrenia

In this follow-up study, a group of black and white patients were followed up between 4 years 9 months and 10 years after a first admission with a clinical diagnosis of schizophrenia. It was possible to trace 98% of the sample, and historical, clinical and social data were obtained from case notes and interviews with patients and informants. There was no evidence of greater misdiagnosis in black patients, but their outcome was poorer in terms of readmissions and allocation to schizophrenic catego classes on follow-up (almost significant at 5% level). On follow-up, no differences were found in physical treatments and after-care arrangements or contacts with services. However, more black patients were readmitted on forensic sections and from prison, and more were treated in secure units. Explanations for the increased contact with penal and forensic services are discussed. The poorer clinical outcome found in black patients was associated with four factors apparent before first admission; living alone, unemployment, conviction and imprisonment.

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 morbidity and compulsory admission among UK-born Europeans, Afro-Caribbeans and Asians in central Manchester

Psychiatric admissions in Central Manchester of Europeans, Afro-Caribbeans, and Asians (within three age-bands) were studied over four years. Among the Afro-Caribbean group there were more single or unemployed persons than in either the Asian or European groups, which suggested greater socio-economic disadvantage. Rates for first admissions and readmissions among Afro-Caribbeans were greater; among Asians they were similar except for the 16-29-year age-group, who tended to have lower rates than Europeans. A higher proportion of Afro-Caribbeans and Asians were psychotic. In the Afro-Caribbean group, the raised rates of admission were largely attributable to increased rates of schizophrenia. The highest rate occurred in second-generation (UK-born) Afro-Caribbeans and was nine times that among Europeans. The police were more frequently involved in the admissions of Afro-Caribbeans compared with Europeans or Asians. Higher proportions of Afro-Caribbeans and Asians who were readmitted were detained under the Mental Health Act 1983, when compared with Europeans.

Dangerous behaviour preceding first admissions for schizophrenia

Of 253 patients in their first schizophrenic episode, 52 behaved in a way threatening to the lives of others before their admission to hospital. These 52 patients were studied from data collected at the time of their initial presentation. Despite a history of illness in excess of 1 year in 24 cases, and evidence that violence was motivated by psychotic symptoms in 23 cases, fewer than half of the patients were admitted to hospital as a direct result of their dangerous behaviour. Life-threatening behaviour was more common where the patient had been ill for longer, and where there were delusions of being poisoned.

'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.

Psychotropic medication and ethnicity: an inpatient survey

A survey of the catchment area psychiatric inpatient population of the Bethlem and Maudsley Hospitals showed that more black (Afro Caribbean) than non-black (white British) patients received anti-psychotic medication. This finding ceased to be significant after adjustment for diagnosis because a larger proportion of black than non black patients received a diagnosis of schizophrenia. However, after adjustment for diagnosis, black patients were significantly more likely to be receiving depot anti-psychotic medication, to be detained under a section and to have been involved in a violent incident during the present admission. There were no significant ethnic differences in total dose equivalents of anti-psychotic medication but doses of the depot form were significantly higher for black patients.

Attitudes of relatives of Afro-Caribbean patients: do they affect admission?

This pilot study explored suggestions made in the literature that high rates of Afro-Caribbean patients compulsorily admitted to hospital can be explained by the attitudes of relatives. In particular relatives who hold negative attitudes towards psychiatric services and adopt non-medical explanations for the onset of illness might delay in contacting hospital services. This could delay the process of admission and make a compulsory admission more likely. The attitudes and experiences of relatives of 15 patients admitted compulsorily and 10 admitted informally were compared. The relatives' attitudes did not differ between the two groups. There was also no difference in the severity of current symptoms or the relative's assessment of dangerousness. Neither group was characterised by the sorts of attitudes to illness that had been hypothesised. In fact the group were very similar to the relatives of white psychiatric patients. The data suggest that future research should concentrate on the interaction between families and the services. In particular attention needs to be paid to the possibility that compulsory admissions are occurring because relatives' need for help is not being met and because there is an over-expectation of dangerousness on the part of the services.

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.

Ethnic factors in voluntary and compulsory admissions

Socio-demographic and clinical aspects of compulsory and informal admissions to general adult psychiatry wards over a two-year period are compared. In addition, Afro-Caribbean patients are compared with white UK-born patients. Relative rates of admission are examined. The study confirms other reports of greater than expected compulsory admissions of Afro-Caribbean patients and pays particular attention to the circumstances preceding compulsory entry to hospital and the persons and agencies involved in that process.

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.

Section 136 and African/Afro-Caribbean minorities

Social, demographic and clinical information was collected retrospectively on all 99 people referred to a South London hospital in 1986 under Section 136 of the Mental Health Act (1983), this being the last complete year before local changes in the procedure for assessment of Section 136 cases were initiated. An over-representation of Afro-Caribbeans was confirmed and this seemed to be accounted for largely by young men under the age of 30 who with Africans had very high rates of previous Section 136 referral, were more likely to be perceived as threatening, incoherent and disturbed but less clearly diagnosed with a mental illness, and were more likely than the Caucasian sample to be living in stable accommodation. The implications of these results are discussed.

Are British psychiatrists racist?

Out of a sample of 220 British psychiatrists, 139 completed a questionnaire regarding a case vignette of psychotic illness. The sex and 'race' of the vignette were varied and the responses compared. The Afro-Caribbean case was regarded as that of an illness of shorter duration, and requiring less neuroleptics than the white case. Respondents judged the Afro-Caribbean case as potentially more violent and thought criminal proceedings were more appropriate. The female vignette was perceived as less violent, less criminal, and less likely to need neuroleptics. Cannabis psychosis and acute reactive psychosis tended to be diagnosed more often and schizophrenia less often in Afro-Caribbean cases, refuting the claim that psychiatrists tend to overdiagnose schizophrenia in this group. Such 'race thinking' (a form of stereotyping which is distinct from ideological racism) could lead to inappropriate management.

Police admissions to a psychiatric hospital. Demographic and clinical differences between ethnic groups

Between October 1983 and December 1985, 268 patients were brought by police to a psychiatric hospital in south London under section 136 of the Mental Health Act 1983. Comparisons were made between 'blacks' and 'whites' on several clinical and demographic variables. The vast majority of admissions received a psychiatric diagnosis. An excess of black admissions was recorded. Black men were younger, were more likely than whites to be given neuroleptics, to be put on compulsory orders, and to be given an out-patient appointment when discharged from hospital. More black men were given a case-note diagnosis of schizophrenia or drug-induced psychosis. The differences in clinical management between ethnic groups could be at least partly accounted for by these differences in diagnosis. Treatment did not appear to be independent of diagnosis among the black admissions.

Violence by psychiatric in-patients

A register of violence incidents showed a progressive increase in in-patient violence from 1976 to 1984, followed by a slight decline to 1987. The case notes of all 137 in-patients committing assaults during 1982 were analysed and compared with those of matched controls. Violence was often repetitive. The most common victims were nurses and then patients. The violent patients were more likely to be schizophrenic, deluded and hallucinated, and to have been repeatedly admitted. The violent and control groups had similar backgrounds, and both showed high levels of social isolation and unemployment. Violence tended to be repetitive, and the violent patients were usually identifiable from previous aggressive and disturbed behaviour. There was a high proportion of Afro-Caribbean patients who tended to be younger, more psychotic, and more seriously violent. Afro-Caribbeans were particularly likely to be detained compulsorily and treated in a locked ward.

Severe mental disorder in Afro-Caribbean patients: some social, demographic and service factors

Forty-two consecutively identified Afro-Caribbean patients with a first episode of psychosis were compared with a similar group of non-Caribbean patients. A number of differences emerged, although the same proportion of patients in each group had symptoms for 6 months or more prior to psychiatric contact. Afro-Caribbean patients showed greater delay in seeking help, more 'disturbance' later in the course of their illness and were more likely to be admitted compulsorily. The social geography of the two groups suggests that the high rates of schizophrenia and related psychoses that we previously reported cannot be explained simply by differences in area of residence at the time of presentation.

Community care and the difficult and offender patient

Concern has been growing about a cyclical pattern or ‘periodicity’ in mental health care over the past 300 years, in which large-scale policy decisions have been made, and then reversed, paying little attention to the particular needs of differing patient groups. Turner (1985) drew attention to the reckless course followed by psychiatry, and how the “discipline that has lost its way” (Lancet,1985) may have done so owing to a poor grasp of its past history. In the movement towards community care, ‘difficult’ or the so-called ‘unrewarding’ (to use Scott's (1970) term) patients are a particularly vulnerable group (Aviram & Segal, 1973; Bachrach, 1980). Increasingly, community services are compelled to cater for less disturbed patients through being selective about whom they will accept. To a degree, forensic services on both sides of the Atlantic have partially filled the gap so created in service provision. For this and other reasons, it is difficult to make a general statement about the effectiveness of deinstitutionalisation and community care. To be more specific, there are basic conceptual difficulties in defining continuity of care and identifying subgroups for which it has different implications (Bachrach, 1981), and there are major methodological difficulties impeding an analysis of such a diffuse and fragmented provision. Scull's (1984) description of the overnight abolition of state facilities for juvenile offenders in Massachusetts in the US between 1969 and 1973 points to the impossibility of making a comparison ‘before and after’, when so much dissolution and decentralisation of services has occurred (see also Jones, 1982). A few model alternatives were described soon after the closures, and Bachrach (1980) has written about the dangers of generalising from model programmes, highlighting the differences between demonstration efforts and reality. It is proposed here that the difficult and offender population might act as a ‘litmus paper’ for the efficiency, or otherwise, of community care in general.

A prospective study of severe mental disorder in Afro-Caribbean patients

Several previous studies have reported increased rates of schizophrenia among Afro-Caribbean immigrants, although doubt has been cast upon the value of case-note diagnoses and retrospective case-finding. A prospective study was therefore undertaken, including all patients of Afro-Caribbean ethnic origin with a first onset psychosis presenting to the psychiatric services from a defined catchment area. Utilizing several diagnostic classifications, rates for schizophrenia were found to be substantially increased in the Afro-Caribbean community, and especially in the 'second generation' British born. Mode of onset and symptom profiles of psychoses suggest that atypical syndromes, and by implication 'misdiagnoses', do not account for reported higher rates of schizophrenic illness in these patients.