Race and mental health: there is more to race than racism

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Abstract
Rates of mental illness in minority groups High rates of mental illness in migrant groups have been recognised and speculated on throughout the past century. A scientific approach to understanding the issue originated with Odegaard's observation of raised rates in Norwegian immigrants in Chicago,7 and various theories have been proposed to explain this excess.8 In the United Kingdom the argument is at its most intense around the enduring epidemiological finding of high rates of psychosis in second generation African-Caribbean patients. Lee Jasper, chair of African and Caribbean Mental Health, says mental health services are institutionally racist Credit: IAN McLLGORM/REX FEATURES These higher rates have been proposed as evidence of racism on two main grounds. Firstly, that the diagnoses are mistaken, stemming from “Eurocentric” diagnostic practices; Western psychiatrists are proposed to be more likely to misinterpret behaviour and distress that is culturally alien to them as psychosis. It is unfamiliarity with culturally alien ideas and practices that leads psychiatrists to label some black and ethnic minority people's behaviour as “bizarre” or illogical (characteristics of psychotic psychopathology). In short, the patients neither have the illness nor the symptoms attributed to them but are simply misunderstood by intellectually rigid and inattentive professionals. The second argument is that even if the diagnosis is not that amiss the clinical response is powerfully influenced by racial stereotypes. It is argued that the compulsory detention of black patients, by itself, reflects entrenched discriminatory value judgments. Contrary to the view that “there has been little debate” and “little inclination to address” racism within mental health services,9 psychiatry is not complacent about these issues. Indeed, an impressive body of high quality research focuses explicitly on them. To date, no population group or culture has been identified in which psychotic disorders do not occur.10 There are some variations in incidence and course of psychotic disorders across cultures, but what is striking is the similarity of phenomenology.11–13 A diagnosis of psychosis is therefore not made because ethnic minority groups “deviate from white norms” or on “Eurocentric” theories or even in a “futile search for ‘black schizophrenia.’”9 14 15 A series of UK studies has been conducted specifically to test the theory that culturally derived misdiagnosis explains excess rates of psychosis in ethnic minority patients. Using highly structured and validated research diagnostic assessments by independent raters, these studies have consistently confirmed high rates of psychosis in the African-Caribbean population (particularly second generation immigrants) and also not found any raised rate of misdiagnosis.16–18 The excess of psychosis in the African-Caribbean community in the UK is real and well accepted by epidemiologists and researchers.8 19 Rates of psychotic disorder are high not just among the African-Caribbean community in the UK, they are high for all immigrant groups globally.20 The excess is also not restricted to non-Western minorities. Rates of schizophrenia are high in migrants to Denmark from Australia and Greenland,20 in Finnish migrants to Sweden,21 and in Britons, Germans, Poles, and Italians who migrated to Australia.20 Increased rates of psychosis in all migrants, irrespective of ethnicity, therefore suggests an explanation that is not ethnic specific and is environmental rather than genetic. Shared experiences of discrimination, social exclusion, and urbanicity may all contribute to this increased risk and also explain a greater increase in communities exposed to higher levels of such experiences, such as black and ethnic minority communities in the UK.20–22 Ethnicity and psychosis is simply not a black and white issue.