"Dem sey mi mad": a scoping review of the attitudes and beliefs of English-speaking Afro-Caribbeans about psychosis

Introduction

The mental health disparities suffered by the English-speaking Afro-Caribbean diaspora living with psychosis in North America and the United Kingdom have been well described for decades, but the root causes of these disparities remain poorly understood. Part of the problem may be that the attitudes and beliefs of Caribbean communities regarding psychosis have never been systematically assessed. Such an inquiry could lay the foundation for changes to how psychiatric services for psychosis are implemented with migrant Caribbean communities. The ideal would be a re-design of services, or cultural adaptation of care, based on input from community members, patients, and their families, with the hope that disparities of care would be reduced or eliminated as clinicians co-create interventions that are more appropriate and acceptable to Caribbean people. To lay the groundwork of such an important endeavor, we investigated the shared attitudes, beliefs, experiences, practices, and traditions of English-speaking Afro-Caribbean people in relation to psychosis and psychiatric care.

Methods

We conducted a scoping review by searching Medline, PsychINFO and Scopus, reviewing 764 articles, and selecting 220 for thematic content analysis.

Results

We highlighted the heterogeneity in the Caribbean diaspora living in North America and the UK. Five principal themes emerged: (1) The enduring effects of colonialism on the psychiatric care of Afro-Caribbean migrants; (2) The effects of adaptation to migration on the experience of psychosis; (3) Pervasive cultural mistrust of psychiatry and mental health institutions; (4) A collective approach to life; and (5) The role of religion and spirituality in the understanding of psychosis.

Conclusion

Historical, sociocultural, and geopolitical themes characterize the English Afro-Caribbean experience of psychosis and inform culturally adapted clinical interventions for patients with psychosis and their families. Careful attention to these adaptations will reduce clinical bias and misdiagnosis, optimize adherence to treatment, engage patients and families in recovery, and ultimately, reduce treatment disparities while empowering Afro-Caribbean people and their communities. By bringing forward the themes in this chapter, individual clinicians will be given tools to change how they work with Caribbean people with psychosis in addition to laying the foundation for higher order changes in the mental health professions and society as a whole.

‘It Just Feels Like an Invasion’: Black First-Episode Psychosis Patients’ Experiences With Coercive Intervention and Its Influence on Help-Seeking Behaviours

Studies from the United States and United Kingdom show that Black patients are disproportionately diagnosed with psychosis and receive excess coercive medical intervention. There has been little discussion of this topic in Canada, and of how coercive interventions may have influenced Black patient attitudes towards mental health services. To address these issues, semi-structured interviews were administered to five Black men with first-episode psychosis (FEP) to (a) explore their experiences with coercive interventions and (b) describe how these experiences may have influenced help-seeking behaviours. Interpretative phenomenological analysis (IPA) was used to analyze the data. Four core themes and four additional themes emerged from the interviews. Patients described loneliness, not being heard, police contact and forced medication as influencing their attitudes towards mental health care. Further research is needed to develop reparative strategies to encourage reflection about and awareness of coercive intervention among Black FEP patients.

Structural Racism and Inequities in Incidence, Course of Illness, and Treatment of Psychotic Disorders Among Black Americans

Psychotic disorders (e.g., schizophrenia, schizoaffective disorder) are a leading cause of morbidity and premature mortality and an overlooked health inequity in the United States. European data indicate inequities in incidence, severity, and treatment of psychotic disorders, particularly for Black communities, that appear to be primarily attributable to social adversities. The dominant US narrative is that any observed differences are primarily a result of clinician bias and misdiagnosis. We propose that employing the framework of structural racism will prompt European and US research to converge and consider the multifaceted drivers of inequities in psychotic disorders among Black Americans. In particular, we describe how historical and contemporary practices of (1) racialized policing and incarceration, and (2) economic exploitation and disinvestment, which are already linked to other psychiatric disorders, likely contribute to risks and experiences of psychotic disorders among Black Americans. This framework can inform new strategies to (1) document the role of racism in the incidence, severity, and treatment of psychotic disorders; and (2) dismantle how racism operates in the United States, including defunding the police, abolishing carceral systems, and redirecting funds to invest in neighborhoods, housing, and community-based crisis response and mental health care. (Am J Public Health. 2022;112(4):624-632. https://doi.org/10.2105/AJPH.2021.306631).

Ethnoracial Differences in Coercive Referral and Intervention Among Patients With First-Episode Psychosis

OBJECTIVE

Using a retrospective sample, the authors sought to determine whether Black patients with first-episode psychosis (FEP) in Canada were at a higher risk for coercive referral and coercive intervention than non-Black patients with FEP.

METHODS

Retrospective data from patients referred to an FEP program in 2008-2018 were collected via chart review (N=208). The authors used chi-square and logistic regression analyses to explore the relationships among race-ethnicity, diagnosis of psychosis, and coercive referral and intervention.

RESULTS

Results showed that Black persons of Caribbean or African descent with FEP were significantly more likely to be coercively referred (χ²=9.24, df=2, p=0.010) and coercively treated (χ²=9.21, df=2, p=0.010) than were non-Black individuals with FEP. Age and violent or threatening behavior were predictors of coercive referral. Ethnoracial status, age, and violent or threatening behavior were predictors of coercive intervention.

CONCLUSIONS

This study contributes to the dearth of research on Black Canadians and offers insight into factors that may place patients with FEP at risk for coercive treatment. More research is needed to explore the role that ethnoracial status may play in hospital admissions and to uncover the role of racial prejudices in the assessment of danger.

"Insanity Is the Price of Modern Civilization": The Discourse of Civilization and the Asian Insane in Modern America

Examining debates on the link between civilization and insanity in the late nineteenth and early twentieth-century United States, this essay engages the discourse of civilization to discuss the ways in which insanity among Asian immigrants, in particular Chinese and Japanese, was understood, defined and debated. During the period, insanity was regarded as a disease of civilization, which had been increasing due to the struggles of modern life. While Americans witnessed insanity among the "colored" and Asians, they argued that these groups had lower rates of insanity than white Americans and European immigrants because they belonged to lower positions on the civilization scale. Though not explicitly racialist or even racist, the discourse of civilization ordered the international world and drew a clear color line between white westerners and non-white others. At the same time, American missionaries and medical professionals stationed in China and Japan, who were there to see and learn about insanity in Asia, reaffirmed the existing medical understandings of insanity and offered a knowledge base for American psychiatrists who would encounter the Asian insane at their mental institutions. The alleged rarity of mental troubles for Chinese and Japanese was not considered an asset; the insanity debates confirmed the non-white, non-American status of Asian immigrants, rendering them forever foreign. Moreover, their very distance from western civilization explained why Asians in America seemed to have suffered less from mental disturbances and how they could resist the debilitating effects of civilization and migration.

Effects of a culturally sensitive assessment on symptom profiles in native Dutch and Moroccan patients with a first psychosis referral

Previous studies have reported a higher incidence of psychosis in Moroccan immigrants in the Netherlands than among native-born residents. However, this disparity was substantially attenuated when cultural differences in symptom presentation were taken into account. To better understand the impact of different diagnostic procedures on incidence rates, we examined the effects of the use of a culturally sensitive diagnostic interview, compared to a standard semi-structured diagnostic interview, on symptom profiles among Moroccan immigrant and native Dutch patients in the Netherlands. A total of 26 Dutch and 26 Moroccan patients referred with a possible first psychosis diagnosis were interviewed twice: once with the standard version and once with a culturally adapted version of the Comprehensive Assessment of Symptoms and History questionnaire (CASH and CASH-CS, respectively). Among native Dutch patients, symptoms profiles based on CASH and CASH-CS interviews were very similar. By contrast, among Moroccan immigrant patients, symptom profiles based on CASH and CASH-CS interviews differed substantially, with more mania symptoms (+30%; p < .05) and fewer delusions (-31%; p < .05) reported when using the CASH-CS. These results suggest that the over-diagnosis of schizophrenia in Moroccan immigrants with a first psychosis referral may be related to a tendency to under-detect mood symptoms and over-detect positive psychotic symptoms when a standard diagnostic procedure is used. This bias may be corrected, at least in part, by the use of a culturally sensitive interview instrument such as the CASH- CS.

Transatlantic variation in the attributed etiology of psychosis

BACKGROUND

Differences in transatlantic perception of psychosis have been reported in the historical psychiatric literature.

AIMS

This study aims to determine if articles in the American Journal of Psychiatry (AJP) are more likely to attribute biological factors to the etiology of psychosis than those of the British Journal of Psychiatry (BJP).

METHODS

A systematic MEDLINE search for articles in the AJP and BJP from 2005 to 2007 identified 360 abstracts with psychosis and etiology-related words. Chi-square analyses were used to test differences in the proportion of attributed biological or psychosocial etiology of psychosis in each journal.

RESULTS

A greater proportion of abstracts (83/87) in the AJP attributed biological etiology of psychosis (χ(2) = 12.33, df = 1, p < 0.001), while a greater proportion in the BJP (16/44 abstracts) attributed psychosocial etiology (χ(2) = 19.76, df = 1, p < 0.001).

CONCLUSIONS

The AJP tends to publish biomedical explanations of psychosis, while the BJP shows a relative preference for psychosocial theories.

Clinician reasoning in the use of cultural formulation to resolve uncertainty in the diagnosis of psychosis

We examined how the process of cultural formulation contributes to diagnostic assessment of patients with psychotic disorders at a specialized Cultural Consultation Service (CCS). Specifically, we investigated the reasoning process used to resolve uncertainty of psychotic disorder diagnosis in African immigrant patients referred to the CCS for assessment of possible psychotic disorder. Qualitative thematic analysis of 23 clinical case conference transcripts was used to identify clinicians' reasoning styles. Use of the CF appears to facilitate the emergence of a rule-governed reasoning process that involved three steps: (i) problematize the diagnosis of the intake 'psychosis' symptoms or behavior; (ii) elaborate explanations as to why the symptoms or behavior may or may not be psychosis; and (iii) confirm the diagnosis of psychosis or re-interpret as non-psychosis. Prototypes and exemplars drawn from previous experience in intercultural work featured prominently in clinicians' reasoning. Prototypes were crucial in diagnostic decision-making and appear to be important sources of both clinician expertise and bias, and may need to be targeted specifically in cultural competence training.

Changing psychiatric perception of African-Americans with affective disorders

This article explored the origins and implications of the underdiagnosis of affective disorders in African-Americans. MEDLINE and old collections were searched using relevant key words. Reference lists from the articles that were gathered from this procedure were reviewed. The historical record indicated that the psychiatric perception of African-Americans with affective disorders changed significantly during the last 200 years. In the antebellum period, the mental disorders of slaves mostly went unnoticed. By the early 20th century, African-Americans were reported to have high rates of manic-depressive disorder compared with whites. By the mid-century, rates of manic-depressive disorder in African-Americans plummeted, whereas depression remained virtually nonexistent. In recent decades, diagnosed depression and bipolar disorder, whether in clinical or research settings, were inexplicably low in African-Americans compared with whites. Given these findings, American psychiatry needs to appraise the deep-seated effects of historical stereotypes on the diagnosis and treatment of African-Americans.

Insanity and ethnicity in New Zealand: Māori encounters with the Auckland Mental Hospital, 1860-1900

This article examines Māori patients at the Auckland Mental Hospital between 1860 and 1900.We argue that the patient case notes reveal 'European' categories in which Māori were situated, and demonstrate the extent to which the authorities at the hospital grappled with their appearance, their language and their culture, all of which were elements of their ethnicity. We argue that the use of institutional case records is highly suggestive of some of the historical meanings of insanity for Māori, including the lack of detailed or sustained collection of information about patients' tribal affiliations, the interest shown in their rights to land in maintenance payment inquiries, the experiences of cultural alienation or mate Māori, and the sad outcomes for Māori.

Cultural neuroscience and psychopathology: prospects for cultural psychiatry

There is a long tradition that seeks to understand the impact of culture on the causes, form, treatment, and outcome of psychiatric disorders. An early, colonialist literature attributed cultural characteristics and variations in psychopathology and behavior to deficiencies in the brains of colonized peoples. Contemporary research in social and cultural neuroscience holds the promise of moving beyond these invidious comparisons to a more sophisticated understanding of cultural variations in brain function relevant to psychiatry. To achieve this, however, we need better models of the nature of psychopathology and of culture itself. Culture is not simply a set of traits or characteristics shared by people with a common geographic, historical, or ethnic background. Current anthropology understands culture as fluid, flexible systems of discourse, institutions, and practices, which individuals actively use for self-fashioning and social positioning. Globalization introduces new cultural dynamics and demands that we rethink culture in relation to a wider domain of evolving identities, knowledge, and practice. Psychopathology is not reducible to brain dysfunction in either its causes, mechanisms, or expression. In addition to neuropsychiatric disorders, the problems that people bring to psychiatrists may result from disorders in cognition, the personal and social meanings of experience, and the dynamics of interpersonal interactions or social systems and institutions. The shifting meanings of culture and psychopathology have implications for efforts to apply cultural neuroscience to psychiatry. We consider how cultural neuroscience can refine use of culture and its role in psychopathology using the example of adolescent aggression as a symptom of conduct disorder.