To Di World: Jamaican soccer, poiesis and post-colonial transformation

This article presents a case study of an innovative culturally based therapeutic approach using collective poiesis to improve the functioning of a youth sports team in Jamaica. In recent decades, Jamaica has endured high levels of violence and corruption, and has been ranked among the top four countries in the world in terms of murder rate per capita. We conjecture that a high prevalence of personality disorder linked to the legacy of slavery and colonialism often impedes Jamaicans from achieving success in diverse fields, including sports. Psychological interventions in the preparation of football teams are a novelty, and have been used mainly to enhance global team performance or individual player skill. The use of psychological interventions to address personality disorder psychopathology on the soccer pitch has not been reported. Psychohistoriographic cultural therapy (PCT) integrates psychological perspectives with a dialectic method of historical analysis and uses collective poiesis as a vehicle to translate insights through an embodied cognitive restructuring process. Two workshops were carried out with a high school football team using PCT techniques. The process of dialectic reasoning engaged their collective ideas and insights to establish a psychic centrality that was expressed in poetic form to illustrate the pathologies of the group in an emotionally safe and psychologically acceptable narrative. This poetic narrative of the group's psychic centrality counters the personality disorder psychopathology caused by the lingering intergenerational wounds of slavery, colonial oppression and collective trauma.

Community Engagement Mental Health Model for Home Treatment of Psychosis in Jamaica

Economic constraints in low- and middle-income countries like Jamaica challenge health care services to identify efficient methods of mental health care. This column describes the community engagement mental health (CEMH) model in Kingston, Jamaica, for patients with mental disorders, including psychosis. The CEMH uses a task sharing methodology to deliver acute psychiatric treatment within a community setting. Preliminary results suggest high service user and provider satisfaction and good clinical outcomes. The authors discuss challenges and benefits of the CEMH in terms of its potential as a cost-effective service innovation.

Owning our madness: Contributions of Jamaican psychiatry to decolonizing Global Mental Health

The contentious debate on evidence-based Global Mental Health care is challenged by the primary mental health program of Jamaica. Political independence in 1962 ushered in the postcolonial Jamaican Government and the deinstitutionalization of the country's only mental hospital along with a plethora of mental health public policy innovations. The training locally of mental health professionals catalyzed institutional change. The mental health challenge for descendants of African people enslaved in Jamaica is to reverse the psychological impact of 500 years of European racism and colonial oppression and create a blueprint for the decolonization of GMH. The core innovations were the gradual downsizing and dismantling of the colonial mental hospital and the establishment of a novel community mental health initiative. The successful management of acute psychosis in open medical wards of general hospitals and a Diversion at the Point of Arrest Programme (DAPA) resulted in the reduction of stigma and the assimilation of mental health care into medicine in Jamaica. Successful decentralization has led to unmasking underlying social psychopathology and the subsequent development of primary prevention therapeutic programs based on psychohistoriographic cultural therapy and the Dream-A-World Cultural Therapy interventions. The Jamaican experience suggests that diversity in GMH must be approached not simply as a demographic fact but with postcolonial strategies that counter the historical legacy of structural violence.

The high cost of poverty: mental health perspectives from the Caribbean Diaspora

A Caribbean Diaspora has emerged worldwide after 500 years of European colonial exploitation of the Caribbean geopolitical region. This exploitation has a two-tiered social legacy: the ‘haves'; and the ‘have-nots', characterised by poor educational achievement, underdevelopment and unemployability of the many. The Caribbean Diaspora is a product of ever-increasing fantasies of escape from poverty by migration to greener ‘First World’ pastures. The complex, contradictory Caribbean society generates a crucible of misery and violence amid opulent wealth and luxury, which requires a burgeoning private and public police and military apparatus for its containment, and an ever-increasing health, mental health and penal correctional system to buttress the casualties of this conflict that is spiralling out of organisational and economic control. This two-tiered society was inherited from the hierarchical legacy of European colonialism. The colonisers existed in a system of high productivity and order, which imposed its will on the colonised, who lived in relative disorganisation and need. The resultant vector of this unequal yoke is the virtual anarchy of present-day Jamaica and other Caribbean territories, characterised by a subculture of violence and increasingly violent crime. The physical, psychological and economic costs of this seeming conundrum are bewildering and unaffordable.

Post-colonialism and mental health

We were encouraged by the many, varied, responses to our paper on the roast breadfruit psychosis (Hickling & Hutchinson, 1999). We have no intention of defining or creating a new nosological entity. We are proposing the centrality of identity negotiation as a psychological process occurring when one is faced with the concrete reality of racism and social exclusion. This process of negotiation, if unsuccessful, is a mechanism through which psychopathology can result as defined within the rubric of psychiatry. Identity negotiation as a trigger for psychosis must not be confused with nosological definition. One of the by-products of empires has been the European propensity to believe that their nosological constructs are universal and can therefore be applied to the cultural behaviour of their former subjects. This becomes dangerous when nosological characterisation is synonymous with pathology and the need for treatment, again in ways that are determined and deemed appropriate by the colonial hegemony. The construction of semiotic equivalence of knowledge and cultural systems that are widely diverse is another demonstration of the moulding of otherness into terms and perceptions understandable to the European mind and is as such the sine qua non of the European colonial experience. The post-colonial challenge is to seek liberation from these mechanisms and so foster insight into the behaviour and thought processes of both the former colonisers and those people they colonised.

Psychiatry in the Commonwealth Caribbean

Treatment of the mentally ill by the Aboriginal Awaraks of Jamaica and the other Caribbean islands was first described by a Spanish monk in 1540: ‘Lunatics’ who were called ‘mind riven’ were treated in the community with salvent herbs, which were blended with food and left to hang on fruit trees for those who wandered, and by the administration of unguents and lavings while singing. This record indicates that the mentally ill were treated by the indigenous Indians without restraints, and with rudimentary attempts at pharmacology and cultural therapies. But this enlightened but primitive mental health system was destroyed with the advent of the Spanish conquerors who, according to Las Casas, “in about eight to forty years have unjustly put to death about twelve million Indians without distinction of quality, sex or age”.

Current research on transcultural psychiatry in the Anglophone Caribbean: epistemological, public policy, and epidemiological challenges

In this article, we review recent research on mental health in the Caribbean. Three major themes emerge: (a) the effects of colonialism on the Caribbean psyche; (b) decolonization of psychiatric public policy, including innovative treatment approaches, deinstitutionalization, and community and policy responses to mental health issues; and (c) the nature and epidemiology of psychiatric pathology among contemporary Caribbean people, with particular focus on migration, genetic versus social causation of psychosis and personality disorders, and mechanisms of resilience and social capital. Caribbean transcultural psychiatry illustrates the principles of equipoise unique to developing countries that protect the wellness and continued survival of postcolonial Caribbean people.

Promoting Resilience in High-risk Children in Jamaica: A Pilot Study of a Multimodal Intervention

OBJECTIVE

To assess the effectiveness of a multimodal afterschool and summer intervention called the Dream-A-World (DAW) Project for a cohort of school-aged Jamaican children from an impoverished, disadvantaged inner-city community in Kingston, Jamaica. Children were selected by their teachers based on severe disruptive disorders and academic underachievement and compared with a matched control group. The pilot was a child focused therapeutic modality without parental intervention for disruptive conduct and academic failure.

METHOD

A group psychotherapeutic intervention of creative arts therapies and remedial academic support adapted for the Jamaican context was implemented with 30 children from an inner-city primary school. The intervention was implemented over 2½ years spanning grade three to six with evaluation of outcomes using the ASEBA Teacher Report Form (TRF) and end of term grades for the intervention group versus matched controls who were offered usual school supports.

RESULTS

The intervention group made significant improvements in school social and behavior adjustment measured by the TRF, with more successful outcome amongst boys for behavioral gains. No significant improvements were made by the girls. Limitations of cohort size, lack of parent data and questions of gender disparities in outcome were unresolved interpretative issues.

CONCLUSION

This multi-modal mental health and academic intervention for high-risk children living in an impoverished, violent neighbourhood, improved global functioning of boys more than girls, and raised questions for design of further preventive planning.

Issues of clinical and cultural competence in Caribbean migrants

The level of out-migration from the Caribbean is very high, with migration of tertiary-level educated populations from Caribbean countries being the highest in the world. Many clinicians in receiving countries have had limited diagnostic and therapeutic experience with Caribbean migrants, resulting in diagnostic and therapeutic controversies. There is an urgent need for better understanding of these cultural differences. The paper explores issues of clinical and cultural competence relevant to assessing, diagnosing, and treating Caribbean migrants with a focus on three areas: cultural influences on illness phenomenology; the role of language differences in clinical misunderstandings; and the complexities of culture and migration. Clinical issues are illustrated with case studies culled from four decades of clinical experience of the first author, an African Jamaican psychiatrist who has worked in the Caribbean, North America, Europe, and New Zealand.

Understanding patients in multicultural settings: a personal reflection on ethnicity and culture in clinical practice

OBJECTIVE

To identify and discourse on the complexities of ethnicity and culture, their role in the social and psychological functioning of patients and their potential impact on clinical assessment and treatment of these patients in diverse cultural contexts.

DESIGN

Description of aspects of the cultural competence required by clinicians in mental health service provisions in therapeutic interactions involving the therapist and patient and also in the encounter between practitioners.

RESULTS

The four-decade clinical experience of the author, an African Jamaican psychiatrist, encompasses clinical experience in the Caribbean, North America, Europe and New Zealand. From this wealth of multicultural clinical practice the author uses personal examples of four experiences with patients and professionals of African Caribbean, British and Maori ethnicities to discuss issues of ethnicity, ethnic identity and stereotyping, culture, cultural competency and alterity in the exchanges between the therapist and patient, and between therapists and the difficulties encountered in effective assessment and treatment of patients in multicultural settings. The author highlights the importance of historical experience in the psychological constitution of patients, which is the basis of a novel analytic model called psychohistoriography. This insight-oriented individual or group-focused intervention was created with the intention of attempting to heal the wounds of history; an aim that is absent from existing psychoanalytic treatment modalities.

CONCLUSION

Psychohistoriography may be a viable therapeutic option in the negotiation of cross-cultural clinical interactions.

Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study

OBJECTIVE

To consider whether or not deinstitutionalization and the integration of community mental health care with primary health care services have reduced stigma toward mental illness in Jamaica.

METHODS

A qualitative study of 20 focus groups, with a total of 159 participants grouped by shared sociodemographic traits. Results were analyzed using ATLAS.ti software.

RESULTS

Participant narratives showed that stigma had transitioned from negative to positive, from avoidance and fear of violent behavior during the period of deinstitutionalization to feelings of compassion and kindness as community mental health services were integrated with Jamaica's primary health care system. The Bellevue Mental Hospital and homelessness were identified as major causes of stigma.

CONCLUSIONS

Attitudes toward the mentally ill have improved and stigma has decreased since the increase of community involvement with the mentally ill. This reduction in stigma seems to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica.

"Mad, sick, head nuh good": mental illness stigma in Jamaican communities

Stigma may be an important factor in mental health service seeking and utilization. However, little work on stigma has been conducted in developing nations in the Caribbean, including Jamaica. We explored mental illness stigma in Jamaica by conducting focus groups with 16 community samples. Four overarching conceptual themes are discussed: (1) community members' definitions of stigma; (2) emotional responses towards those with mental illness, such as fear and love; (3) behavioral responses towards those with mental illness, including avoidance and cautious approach; and (4) perceptions of and beliefs about mental illness, including a distinction between "madness" and "mental illness."

Psychic centrality: reflections on two psychohistoriographic cultural therapy workshops in Montreal

The use of psychohistoriographic cultural therapy (PCT) developed in Jamaica is described in the context of two workshops in Montreal. PCT is a form of group intervention that seeks to elicit and clarify the "psychic centrality" of a group. Psychic centrality refers to a sense of psychological containment or organization of diverse individual points of view through creating a historical map of collective experience. In PCT, this collective map is constructed and techniques borrowed from creative arts therapies are used to develop a performance. This performance provides additional containment and fosters a group process that can contain collective conflicts. The performance can also be used to engage an audience, working to contain conflict while representing diverse perspectives within the group. Factors that may contribute to the effectiveness of PCT and those that may derail the process are identified through the systematic comparison of the two workshops. PCT was demonstrated to cross successfully from a Third to a First World culture, and established potential as a method to facilitate group conflict resolution and for the promotion of pluralistic civil societies.

Psychiatry in Jamaica

The intense historical relationship linking Jamaica and Britain to 300 years of the transatlantic slave trade and 200 years of colonialism has left 2.7 million souls living in Jamaica, 80% of African origin, 15% of mixed Creole background and 5% of Asian Indian, Chinese and European ancestry. With a per capita gross domestic product of US$4104 in 2007, one-third of the population is impoverished, the majority struggling for economic survival. The prevailing religion is Protestant, although the presence of African retentions such as Obeah and Pocomania are still widely and profoundly experienced, and the powerful Rastafarian movement emerged as a countercultural religious force after 1930. The paradox and contradictions of five centuries of Jamaican resistance to slavery and colonial oppression have spawned a tiny, resilient, creative, multicultural island people, who have achieved a worldwide philosophical, political and religious impact, phenomenal sporting prowess, astonishing musical and performing creativity, and a criminal underworld that has stunned by its propensity for violence.

Psychiatry in Jamaica

The intense historical relationship linking Jamaica and Britain to 300 years of the transatlantic slave trade and 200 years of colonialism has left 2.7 million souls living in Jamaica, 80% of African origin, 15% of mixed Creole background and 5% of Asian Indian, Chinese and European ancestry. With a per capita gross domestic product of US$4104 in 2007, one-third of the population is impoverished, the majority struggling for economic survival. The prevailing religion is Protestant, although the presence of African retentions such as Obeah and Pocomania are still widely and profoundly experienced, and the powerful Rastafarian movement emerged as a countercultural religious force after 1930. The paradox and contradictions of five centuries of Jamaican resistance to slavery and colonial oppression have spawned a tiny, resilient, creative, multicultural island people, who have achieved a worldwide philosophical, political and religious impact, phenomenal sporting prowess, astonishing musical and performing creativity, and a criminal underworld that has stunned by its propensity for violence.

A public health and suicide risk in Jamaica from 2002 to 2006

BACKGROUND

Globally, suicide is the third leading cause of mortality among persons aged 15-44 years. However in Jamaica it is not among the leading cause of mortality; but its importance cannot be ignored because of this fact.

AIMS

This study seeks to 1) update the prevalence of suicide in Jamaica, 2) make comparisons with international data, 3) provide an understanding of age-sex composition of those who are committing suicides, and 4) provide public health practitioners with valuable information which will be used to inform policy decisions.

MATERIALS AND METHODS

Secondary data published by the Jamaica Constabulary Force was used for this study. Data were summarized using percentages and associations were examined by Kruskal-Wallis or Analysis of Variance.

RESULTS

The suicide rate averaged 2.26 per 100,000 over the last six years. In 2006, the suicide rate for males was 9 times higher than that of females. The group of 65-74 age, among the male population, recorded the highest suicide rate (11.3 per 100,000) and the 5-14 age group recorded the lowest (0.3 per 100,000). The highest rate for the female population (3.4 per 100,000) was recorded in the 65-74 age group. The 30-39 age group showed an overall higher rate of suicide over the study period, this was followed by the 40-49 age group.

CONCLUSIONS

Jamaica's suicide rate is among the lowest in the world and in spite of this, there is a need to formulate a suicide policy for the nation in particular males and young adults.

Open papers, open minds? Media representations of psychiatric de-institutionalization in Jamaica

Little research has been conducted on media representations of psychiatric de-institutionalization in low-income countries. We set out to examine whether the Jamaican media takes a positive or negative orientation to psychiatric de-institutionalization, and which arguments and rhetorical devices are employed to support the media's position. This was done by the collection, review, and analysis of all stories related to psychiatric de-institutionalization published over a 26-month period from 2003 to 2005 by Jamaica's principal broadsheet newspaper. All of the stories were positive in orientation. Articles alluded to the therapeutic and economic benefits of de-institutionalization. To allay public fears, articles gave prominence to the views of senior psychiatric experts, quoted supporting statistics and international trends, and translated relevant research findings into lay language. Our results are contrary to most studies in high-income countries indicating negative media portrayals of mental illness and the mentally ill.

Open general medical wards versus specialist psychiatric units for acute psychoses

BACKGROUND

As international healthcare policy has moved away from treating people with severe mental illness in large inpatient psychiatric institutions, beds for people with acute psychiatric disorders are being established in specialised psychiatric units in general hospitals. In developing countries, however, limited resources mean that it is not always possible to provide discrete psychiatric units, either in general hospitals or in the community. An alternative model of admission, used in the Caribbean, is to treat the person with acute psychosis in a general hospital ward.

OBJECTIVES

To compare the outcomes for people with acute psychosis who have been admitted to open medical wards with those admitted to conventional psychiatric units.

SEARCH STRATEGY

We searched The Cochrane Schizophrenia Group's study-based register (April 2007). This register is compiled from searches of BIOSIS, CINAHL, The Cochrane Library, EMBASE, LILACS, MEDLINE, PsycINFO, PSYNDEX, Sociofile, and many conference proceedings.

SELECTION CRITERIA

We would have included all relevant randomised or quasi-randomised trials, allocating anyone thought to be suffering from an acute psychotic episode to either acute management on general medical wards, or acute management in a specialist psychiatric unit. The primary outcomes of interest were length of stay in hospital and relapse.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we would have calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based using a fixed effects model.

MAIN RESULTS

We didnt identify any relevant randomised trials.

AUTHORS' CONCLUSIONS

The Caribbean practice of treating people with severe mental illness on general medical wards has been influenced by socio-economic factors rather than evidence from randomised trials. This practice affords an opportunity for a well designed, well conducted and reported randomised trial, now impossible in many other settings.

Changing the research culture at the section of psychiatry, the University of the West Indies, Mona

OBJECTIVE

To compare the medical research output of the Section of Psychiatry, The University of the West Indies (UWI), Mona, before and after the implementation of strategies aimed at stimulating research.

METHOD

Specific strategies such as weekly research and journal club meetings, with an emphasis on team activities and the establishment of bi-annual targets for submission of research papers were instituted in 2000. All research outputs from the Section of Psychiatry over the period 1995 to 2005 were identified from the Departmental Reports of the University of the West Indies and the published abstracts of the UWI Faculty of Medical Sciences and the Caribbean Health Research Council annual research conferences. A number of variables were extracted from each paper and comparisons made between the five-year period before and the five-year period after the implementation of the research enhancing strategies. Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS; version 11.5) and included chi-squared and Mann Whitney U tests.

RESULTS

One-hundred and sixty-two items of research output were identified for the entire period under study. In the period after the implementation of the research enhancing strategies, there were significant increases in the total research output (p = 0.008) and refereed publications (p = 0.016).

CONCLUSIONS

There were considerable increases in the overall research output of the department as well as in many sub-categories of output. These strategies are presented as a model to other departments seeking to augment their output of research.

The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean

OBJECTIVE

To report on the epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean.

METHODS

The MEDLINE, MEDCARIB and West Indiana electronic databases were searched with the phrases Caribbean AND psychiatry OR mental OR suicide, and items with specific reference to epidemiology were culled and reviewed.

RESULTS

The age-corrected incidence rate for schizophrenia per 10,000 is 2.09 in Jamaica, 2.2 per 1000 in Trinidad, and 2.92 in Barbados. These rates are lower than the incidence rates reported for white British people, and significantly lower that the 6- to 18-fold higher risk ratio incidence reported for African Caribbeans living in Britain. A comparative diagnostic study carried out in the United Kingdom (UK) suggests that misdiagnosis plays a significant role in this difference. Relatively low incidence figures for affective disorders, anxiety states, suicide and attempted suicide have been reported for Jamaica, Trinidad, and Barbados.

DISCUSSION

Most published epidemiological studies of Caribbean populations center on schizophrenia, because of the startling findings of a large increase in risk ratios for African Caribbean people living in England compared to the white native British people. The etiological evidence is shifting toward factors of racism and social alienation experienced by black people in the UK, and to misdiagnosis by white British psychiatrists. Studies of the role of colonial enslavement and social engineering raise the etiological possibility of a role for social and structural community organization in the genesis of schizophrenia. The Caribbean thus represents a rich crucible for research in the epidemiology and etiology of mental health disorders.

A comparison of the objective structured clinical examination results across campuses of the University of the West Indies (2001 and 2002)

OBJECTIVE

To compare the performance of medical students in the Objective Structured Clinical Examination (OSCE) of thefinal MBBS Examination across the four campuses of The University of the West Indies, over a two-year period

DESIGN AND METHODS

All final examination results of the Medicine and Therapeutics OSCE were collectedfrom the Faculty of Medical Science at the four campuses of The University of the West Indies and analyzed using both parametric (t-tests and ANOVAs) and non-parametric tests (chi-squared tests).

RESULTS

Results indicated that students achieved significantly higher mean scores in the 2002 examination than in 2001 (t = 3.85, df = 415, p = 0.000). There were no significant differences between campuses with regards to the mean corrected score in 2001. Also in 2001, in adult stations, all campuses achieved significantly higher scores than Jamaica. However, in Jamaica, mean child health station scores were significantly higher than all other campuses and, the mean score in Trinidad and Tobago was higher than the Bahamas and Barbados. In 2002, all other campuses achieved significantly higher scores than Trinidad and Tobago and females performed significantly better than males with regards to overall mean scores (t = 2.814, df = 189, p = 0.005). Also in 2002, Barbados achieved significantly higher mean corrected scores than Trinidad and Tobago (F = 4.649, df = 3191; p = 0.004) and Barbados and Trinidad and Tobago both obtained significantly higher mean child health station scores than Jamaica.

CONCLUSIONS

The important conclusion from this study is that the OSCE scores in Medicine and Therapeutics are generally uniform across the four campuses of the University, thereby confirming the consistency of the approach to teaching and helping to validate the efficacy and veracity of the medical graduate being produced by The University of the West Indies.

Open general medical wards versus specialist psychiatric units for acute psychoses

BACKGROUND

As international healthcare policy has moved away from treating people with severe mental illness in large inpatient psychiatric institutions, beds for people with acute psychiatric disorders are being established in specialised psychiatric units in general hospitals. In developing countries, however, limited resources mean that it is not always possible to provide discrete psychiatric units, either in general hospitals or in the community. An alternative model of admission, used in the Caribbean, is to treat the person with acute psychosis in a general hospital ward.

OBJECTIVES

To compare the outcomes for people with acute psychoses who have been admitted to open medical wards with those admitted to conventional psychiatric units.

SEARCH STRATEGY

The Cochrane Schizophrenia Group's study-based register was searched (November 2001). This register is compiled from searches of BIOSIS, CINAHL, The Cochrane Library, EMBASE, LILACS, MEDLINE, PsycINFO, PSYNDEX, Sociofile, and many conference proceedings.

SELECTION CRITERIA

All relevant randomised or quasi-randomised trials, allocating anyone thought to be suffering from an acute psychotic episode to either acute management on general medical wards, or acute management in a specialist psychiatric unit. The primary outcomes of interest were length of stay in hospital and relapse.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, assessed for quality, and their data would have been extracted. Homogeneous data were to have been synthesised. For binary data, the risk ratios (RR) and 95% confidence intervals (CI) were to have been calculated on an-intention-to-treat basis. If possible, the number needed to treat/harm statistic (NNT/H) was to have been calculated. For continuous data, weighted mean differences (WMD) were to have been calculated and only data from valid scales would have been reported in this review.

MAIN RESULTS

We identified no relevant randomised trials.

REVIEWER'S CONCLUSIONS

The Caribbean practice of treating people with severe mental illness on general medical wards has been influenced by socio-economic factors rather than evidence from randomised trials. This practice affords an opportunity for a well designed, well conducted and reported randomised trial, now impossible in many other settings.

Outcome of first contact schizophrenia in Jamaica

Several previous studies have identified high incidence rates, high relapse rates and poor short-term outcome for schizophrenia in African-Caribbeans in the United Kingdom (UK). Studies in the Caribbean have found the incidence of schizophrenia to be within worldwide levels, and one-year outcome to be much lower than that reported for African Caribbean patients in the UK. First contact patients with schizophrenia identified prospectively by the Present Status Examination were followed prospectively for one year. The main outcome measures which were collected from case notes included: clinical status and medication usage at contact with clinical service, employment status, outpatient clinic compliance, relapse rate and in-patient hospital status, after 12 months. Three hundred and seventeen patients between ages 15 and 55 years who had made first contact with the psychiatric service in Jamaica in 1992 received a computer diagnostic programme for the present status examination (CATEGO) diagnosis of schizophrenia. The majority 197 (62%) were treated at home, and 120 (38%) were admitted to hospital for treatment. Two hundred and sixty-four (83%) were still being seen after one year. The relapse rate was 13% (41 patients), higher for admissions (24, 20%) than for those treated at home (17, 9%; p < 0.001). The relapse rate was higher for patients brought into care by the police and mental health officers (p < 0.005). One hundred and thirty-five (43%) were in gainful employment within the 12-month period of follow-up, contrasted with the 40% unemployment rate for the 2.4 million population of the island (chi square = 39.322, p < 0.001). There was a self-reported use of medication in 213 (67%) patients, with 142 (45%) on monthly intramuscular depot medication. The low relapse rates and good outcome measures after 12 months of first service contact with schizophrenia are related to high levels of gainful employment and good intramuscular medication compliance. The favourable short-term outcome in Jamaica does not correspond to the high relapse rate for this condition found in African Caribbeans in the UK.

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE

The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals.

METHODS

The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status.

RESULTS

More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment.

CONCLUSIONS

While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.

Medical research at the Faculty of Medical Sciences, UWI, Mona Campus 1960-1990

The objective of this study was to evaluate research output in relation to undergraduate teaching output of the Faculty of Medical Sciences, Mona Campus, University of the West Indies between 1960 and 1990. The Departmental Reports published by the University of the West Indies were examined using a successive independent sample design with sentinel years at ten-year intervals for the 30-year period under review. The numbers of reported peer-reviewed publications for each department were disaggregated and analysed. Ten of the fourteen departments (10/14, 72%) of the Mona Faculty showed a decline in output of peer-reviewed publications of up to 100% between 1960 and 1990 (p < 0.001). The number of academic staff had risen from 41 in 1960 to 143 in 1990 (249%) while the publication/staff ratio had fallen from 1.73 in 1960 to 0.48 in 1990 (p < 0.0001). Student/staff ratios had declined significantly over the 30-year period (p < 0.005) as had the graduate/staff ratio (p < 0.01). The Faculty reports indicated that the research-in-progress reported far exceeded the actual publication rate in 1990, whereas the opposite was the case in 1960. There was a statistically significant decline in the number of international conference abstracts published and an increase in the number of regional conference abstracts (p < 0.01) and also a significant decrease in the number of papers presented at conferences compared with the number of conferences attended without a paper being presented (p < 0.0001). The research publication record and the medical graduate/staff ratio of the Mona Faculty had declined significantly over the 30 years under review. There was also a significant decline in the graduate/staff ratio in the same period. Some of the conventional reasons given for this decline such as staff shortages and increased clinical service or teaching load are discussed.

A Jamaican psychiatrist evaluates diagnoses at a London psychiatric hospital

BACKGROUND

Authors have suggested that the high rate of schizophrenia reported for African-Caribbeans living in the UK is due to misdiagnosis by British psychiatrists.

AIMS

To compare the diagnoses made by a Black Jamaican psychiatrist with those of White British psychiatrists.

METHOD

All in-patients on four wards at the Maudsley hospital were approached for the study; 66 participated: 24 White, 29 Black African-Caribbeans and 13 Blacks from other countries of origin. F.W.H., a Black Jamaican psychiatrist, conducted his standard clinical assessment and performed the Present State Examination (PSE) on these patients. His diagnoses were compared with the case note diagnoses made by British psychiatrists, and with the PSE CATEGO diagnoses.

RESULTS

Of 29 African and African-Caribbean patients diagnosed with schizophrenia, the diagnoses of the British and the Jamaican psychiatrists agreed in 16 instances (55%) and disagreed in 13 (45%). Hence, interrater reliability was poor (kappa = 0.45). PSE CATEGO diagnosed a higher proportion of subjects as having schizophrenia than the Jamaican psychiatrist did (chi 2 = 3.74, P = 0.052).

CONCLUSIONS

Agreement between the Jamaican psychiatrist and his UK counterparts about which patients had schizophrenia was poor. PSE CATEGO may overestimate rates of schizophrenia.

Retroviruses and schizophrenia in Jamaica

Reports of an 18-fold higher incidence of schizophrenia among second-generation Afro-Caribbeans, and especially Jamaican migrants in the United Kingdom were soon called "an epidemic of schizophrenia," with the inference that a novel virus, likely to be perinatally transmitted, was a possible etiological agent. This intriguing observation led us to explore a possible link with human T-cell lymphotropic virus type one (HTLV-I), because it is a virus that is endemic in the Caribbean Island, is perinatally transmitted, known to be neuropathogenic, and the cause of a chronic myelopathy (tropical spastic paraparesis/HTLV-I associated myelopathy. We therefore examined inpatients as the Bellevue Mental Hospital, Kingston, Jamaica and did standard serological tests for retroviruses HTLV-I and HTLV-II and HIV-I and HIV-II on 201 inpatients who fulfilled ICD-9 and DSM III-R criteria for schizophrenia. Our results produced important negative data, since the seropositivity rates for HTLV-I, the most likely pathogen, were no greater than the seropositivity range for HTLV-I carriers in this island population, indicating the HTLV-1 and the other retroviruses tested do not play a primary etiological role in Jamaican schizophrenics.

Psychopathology of white mentally ill immigrants to Jamaica

OBJECT

To test the hypothesis that white immigrants to a predominantly black country have a different pattern of psychopathology from the native population.

METHOD

The psychopathology (DSM III-R) of white immigrants to Jamaica seen in the author's private practice between 1979 and 1990 was compared with the psychopathology of a control sample of native Jamaicans matched with the immigrant sample for age, sex, and social class.

RESULTS

There was no statistical difference in the major diagnoses mood disorder (35%), anxiety states (27%), and schizophrenia (20%) between the immigrant and control groups. White immigrants to this black country did not develop schizophrenia at higher rates than the native born. White mentally ill immigrants to Jamaica move into social class positions at a significantly higher level (p < 0.005) than those of their parents with whom they grew up in their home country. This was significantly different (p < 0.005) from their Jamaican controls. Two case studies are presented to illustrate these findings.

CONCLUSIONS

The political/economic situation which exists in black postcolonial countries like Jamaica provides a protective social environment for white immigrants, which buffers them from the etiological conditions that engender schizophrenia in immigrants to other countries with predominantly white populations.

The incidence of first contact schizophrenia in Jamaica

BACKGROUND

Afro-Caribbean immigrants are reported to have a high rate of schizophrenia compared with other population groups.

METHOD

In a prospective first contact study of schizophrenia in Jamaica in 1992, 335 patients were examined using the Present State Examination.

RESULTS

285 patients were evaluated as having a PSE 'restrictive' S+ diagnosis of schizophrenia, and 32 as having a 'broad' S?, P, or O diagnosis of schizophrenia. With a population of 2.46 million, this represents a first-contact incidence rate for 'restrictive' schizophrenia of 1.16 per 10,000 population, and an age-corrected (15-54) incidence rate of 2.09 per 10,000.

CONCLUSION

Incidence rates for schizophrenia in Jamaica are lower than those reported in Afro-Caribbean immigrants in the UK and Holland, and within the reported range for other population groups worldwide.

Community psychiatry and deinstitutionalization in Jamaica

Between 1960 and 1990, the population of Jamaica's single mental hospital was reduced by 58 percent, from more than 3,000 to less than 1,300. Services were reoriented from mental-hospital-based custodial care to rehabilitative, community-based care with no appreciable increase in the mental health budget. Despite several changes in government over the past 30 years, continuity of public policy and fiscal support has allowed ongoing development of the island's community mental health services. The national community mental health service, which had a case-load of about 14,000 patients in 1990, relies on specially trained psychiatric nurse practitioners who provide crisis management, medication management, and supportive psychotherapy; make home visits; and carry out treatment plans developed by the community psychiatrist. Community acceptance of mentally ill persons has been enhanced by public education programs and media coverage of advances in treatment.

Clinical perspectives on the Rastafari movement

Members of the Rastafari movement, which originated in Jamaica, are found in the Caribbean and in parts of the United States and Europe with a large Afro-Caribbean population. To help mental health professionals serve members of this group more effectively, the authors review literature on the movement and present clinical case examples with analyses and recommendations for interventions. The Rastafari movement is both a political and a religious group with a life-style that includes the wearing of dreadlock hairstyles and the sacramental use of marijuana. The group also advocates opposition to traditional government and support members' repatriation to Africa. Clinicians involved in caring for Rastafari are encouraged to make diagnoses based on phenomenological grounds rather than on social behavior. Many blacks who became engaged in the antithetical transformation to membership in the Rastafari movement may be attempting to resolve racial, religious, class, and gender conflicts. The Rastafari movement may provide an affirmation of black identity and a moral framework for black people emerging from centuries of slavery, colonization, and oppression.

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.

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.

Sociodrama in the rehabilitation of chronic mentally ill patients

Sociodrama, a synthesis of group psychotherapy and theatrical presentation, was used from 1978 to 1981 to promote rehabilitation of chronic mentally ill patients at Bellevue Mental Hospital in Jamaica. Staff and patients collectively analyzed their recollections of the hospital's history, then wrote and staged dramatic productions based on the insights derived from those analyses. Changes in the major themes that emerged from the process reflected improvement in therapeutic attitudes and practices and in patient-staff communication over the four-year period. Patients who participated in the sociodramas had greater decreases in medication dosage and psychosocial disability scores and higher rates of improvement and discharge than a matched group of patients who did not participate.