Ethnicity and Mental Ill Health Shulamit Ramon Anglia Ruskin University, Cambridge

Ethnicity is introduced in the study of mental ill health around: Ethnicity is introduced in the study of mental ill health around: The social selection vs social causation etiological positions. The social selection vs social causation etiological positions. The significance of this distinction: The significance of this distinction: dominance of biological explanations vs. the beliefs of sociologists and social workers dominance of biological explanations vs. the beliefs of sociologists and social workers leading our choices of policies and interventions leading our choices of policies and interventions

Conceptual approaches A.Through the anthropolgical perspective A.Through the anthropolgical perspective B.Through Current Epidemiology B.Through Current Epidemiology Seeing themselves as scientists responsible for mapping illness and health in Seeing themselves as scientists responsible for mapping illness and health in large populations, through the application of reliable methods to the collection large populations, through the application of reliable methods to the collection of valid data, analysed through parametric statistical packages. of valid data, analysed through parametric statistical packages. Little attention is being paid to subjective and inter-subjective variables and their indicators. Little attention is being paid to subjective and inter-subjective variables and their indicators. Lack of own explanatory framework; Lack of own explanatory framework; Unlike the work of some leading general health epidemiologists who are ready Unlike the work of some leading general health epidemiologists who are ready to accept the primacy of social factors in health (e.g. Muntaner, 2000 Wilkinson, 2005); the latter illustrate a revived trend within a globalised approach to epidemiology of health. to accept the primacy of social factors in health (e.g. Muntaner, 2000 Wilkinson, 2005); the latter illustrate a revived trend within a globalised approach to epidemiology of health.

Table 1 Diagram of the potential influences on prevalence rates of the common mental disorders Diagram of the potential influences on prevalence rates of the common mental disorders Source: Melzer, D et all (2004), Social Inequalities and the Distribution of the Common Mental Disorders, Psychology Press Ltd Source: Melzer, D et all (2004), Social Inequalities and the Distribution of the Common Mental Disorders, Psychology Press Ltd

The framework does not look at issues such as poverty, stigma and The framework does not look at issues such as poverty, stigma and discrimination due to age, ethnicity and gender, while preferring individualised psychosocial experiences which may be the result of these issues. discrimination due to age, ethnicity and gender, while preferring individualised psychosocial experiences which may be the result of these issues. (Bywaters and McLeod, 1996) (Bywaters and McLeod, 1996) Likewise, although victimisation, personal attacks, and racial Likewise, although victimisation, personal attacks, and racial discrimination are specifically mentioned as risk factors for common mental discrimination are specifically mentioned as risk factors for common mental disorders in ethnic minority groups (table 2, below, Meltzer et al, 2004, p. disorders in ethnic minority groups (table 2, below, Meltzer et al, 2004, p. 207) they are left out of the more comprehensive framework 207) they are left out of the more comprehensive framework presumably because they can be subsumed under the presumably because they can be subsumed under the stressful life events category, even if the latter is thus rendered meaningless stressful life events category, even if the latter is thus rendered meaningless of a central and irreducible risk factor. of a central and irreducible risk factor.

Table 2 Risk factors for common mental disorders in ethnic minority groups Risk factors for common mental disorders in ethnic minority groups Source: Melzer, D Et. All (2004), Social Inequalities and the Distribution of the Common Mental Disorders, Psychology Press Ltd Source: Melzer, D Et. All (2004), Social Inequalities and the Distribution of the Common Mental Disorders, Psychology Press Ltd

Table 2b 1.Absence of full-time worker in the household 1.Absence of full-time worker in the household 2.Unemployed 2.Unemployed 3.Lower standard of living 3.Lower standard of living 4.Financial difficulties 4.Financial difficulties 5.Migration before the age of 11 years 5.Migration before the age of 11 years 6.Older age- group 6.Older age- group 7.Lone parents 7.Lone parents 8.Victimisation 8.Victimisation 9.Personal attacks 9.Personal attacks 10.Racial discrimination 10.Racial discrimination 11.Problems with the police 11.Problems with the police 12.Discrimination in housing and employment 12.Discrimination in housing and employment 13.Absence of confident 13.Absence of confident 14.Absence of parent in laws 14.Absence of parent in laws 15.Social isolation 15.Social isolation 16.Small primary group 16.Small primary group 17.Perceived lack of social support 17.Perceived lack of social support

C. Through sociological research C. Through sociological research D.Through the issue of inequality in mental illness (Busfield, 2000). D.Through the issue of inequality in mental illness (Busfield, 2000). In particular through the focus on life events within a context of deprivation (Dohrewend and Dohrenwend 1981) In particular through the focus on life events within a context of deprivation (Dohrewend and Dohrenwend 1981)

All of the above perspectives add a useful dimension – though some more than others, hence it could be argued that they are necessary but insufficient All of the above perspectives add a useful dimension – though some more than others, hence it could be argued that they are necessary but insufficient

The main empirical evidence I will focus on British findings, (Meltzer et al, 2004) (Pilgrim and Rogers 2003) I will focus on British findings, (Meltzer et al, 2004) (Pilgrim and Rogers 2003) With some comparisons with continental Europe (Stakes, 2004, Eurobarometer 2003), With some comparisons with continental Europe (Stakes, 2004, Eurobarometer 2003), Australia (Andrews, 2001) and the US (Kessler, 1995, 2005) mainly due to similarities in social structure, psychiatric diagnosis and attitudes towards mental ill health. Australia (Andrews, 2001) and the US (Kessler, 1995, 2005) mainly due to similarities in social structure, psychiatric diagnosis and attitudes towards mental ill health. The need for looking at findings from non First World countries The need for looking at findings from non First World countries

Ethnicity A number of studies in the past have found that members of ethnic A number of studies in the past have found that members of ethnic minorities had a higher rate of mental illness, and have under-utilised psychiatric minorities had a higher rate of mental illness, and have under-utilised psychiatric services. services. This is true for some ethnic minorities, but not for others, and the dividing This is true for some ethnic minorities, but not for others, and the dividing line is neither colour nor race. line is neither colour nor race. Thus Irish people in the US and the UK tend to have higher rates of psychosis Thus Irish people in the US and the UK tend to have higher rates of psychosis than any group of black people (Greenslade, 1993); and people of Pakistani origin in the UK have the highest rate of neurosis. than any group of black people (Greenslade, 1993); and people of Pakistani origin in the UK have the highest rate of neurosis. How do we explain these findings? How do we explain these findings? The significance of the history of migration, expectations, economic, political and cultural realities of being members of an ethnic minority in the UK at present. The significance of the history of migration, expectations, economic, political and cultural realities of being members of an ethnic minority in the UK at present.

common mental disorders? Gender and ethnicity feedback relationships: Asian women, Afro-Caribbean men Gender and ethnicity feedback relationships: Asian women, Afro-Caribbean men Within the neuroses, there is greater similarity in terms of prevalence among all groups, with some variations Within the neuroses, there is greater similarity in terms of prevalence among all groups, with some variations e.g. depression is higher in Afro-Caribbeans and Africans; e.g. depression is higher in Afro-Caribbeans and Africans; Anxiety is higher among Irish-born and non-British white groups, Anxiety is higher among Irish-born and non-British white groups, Phobias more prevalent among Asian and Oriental people Phobias more prevalent among Asian and Oriental people ( Meltzer et al, 2004, p.208). ( Meltzer et al, 2004, p.208). However, within the psychoses there is a greater prevalence for Afro-Caribbean and Africans than all other groups in the UK, while this is not the case in their countries of origin (Jabelnsky et al, 1992). However, within the psychoses there is a greater prevalence for Afro-Caribbean and Africans than all other groups in the UK, while this is not the case in their countries of origin (Jabelnsky et al, 1992). If any, research on recovery from Schizophrenia highlights higher rate of recovery in developing countries (Warner, 1994). If any, research on recovery from Schizophrenia highlights higher rate of recovery in developing countries (Warner, 1994). People from ethnic minorities in the UK are less likely to be offered talking therapies (Fernando, 1993, Pilgrim and Rogers, 2003) People from ethnic minorities in the UK are less likely to be offered talking therapies (Fernando, 1993, Pilgrim and Rogers, 2003) The centrality of poverty is retained when looking at ethnicity; poorer people in ethnic minorities are more likely to experience mental ill health than those who are not. The centrality of poverty is retained when looking at ethnicity; poorer people in ethnic minorities are more likely to experience mental ill health than those who are not.

A case study The most famous, or infamous, empirical finding is that Afro-Caribbean men have the highest rate of schizophrenia (Harrison et al, 1989); The most famous, or infamous, empirical finding is that Afro-Caribbean men have the highest rate of schizophrenia (Harrison et al, 1989); They also have the highest rate of complusory admissions to hospital (Mercer, 1986, Morgan et al, 2005); They also have the highest rate of complusory admissions to hospital (Mercer, 1986, Morgan et al, 2005); and the highest rate of offences and violence in their background (Bhui et al, 2003) and the highest rate of offences and violence in their background (Bhui et al, 2003)

Fewer of them are referred through the GP (the family doctor) than is the case for other groups; Fewer of them are referred through the GP (the family doctor) than is the case for other groups; More of them are referred via the police or through their families More of them are referred via the police or through their families They come to the notice of psychiatric services later in the onset of their illness then people from other groups They come to the notice of psychiatric services later in the onset of their illness then people from other groups

Likely explanations The genetic assumption: The genetic assumption: Research on the prevalence of Schizophrenia in the countries of origin of their parents demonstrated a much lower rate than of the 2 nd generation of migrants from the Caribbean islands, born in the UK, thus putting to rest the genetic assumption per se Research on the prevalence of Schizophrenia in the countries of origin of their parents demonstrated a much lower rate than of the 2 nd generation of migrants from the Caribbean islands, born in the UK, thus putting to rest the genetic assumption per se Research on physical vulnerability continues inconclusively Research on physical vulnerability continues inconclusively

The level of poor educational achievements is higher than in the case of other groups; The level of poor educational achievements is higher than in the case of other groups; The same applies to the level of unemployment and overall poverty; The same applies to the level of unemployment and overall poverty; The experience of social exclusion and racism is high too. The experience of social exclusion and racism is high too. The reported experience of using mental health services by members of this group is poor and negative, especially in forensic psychiatry. The reported experience of using mental health services by members of this group is poor and negative, especially in forensic psychiatry.

What can be concluded from these attempts at explanations? What can be concluded from these attempts at explanations? While it is impossible to rule out the existence of physical vulnerabilities, the case for social causation is much more compelling. While it is impossible to rule out the existence of physical vulnerabilities, the case for social causation is much more compelling. This is a case of the cummulative effect of different deprivation factors, including social and psychological such factors (e.g. children in care, being a male in a largely female-dominated ethnic group, use of violence and being abused from early age). This is a case of the cummulative effect of different deprivation factors, including social and psychological such factors (e.g. children in care, being a male in a largely female-dominated ethnic group, use of violence and being abused from early age).

Implications If the main issue is the cummulative effect of deprivation, how can this be tackled? If the main issue is the cummulative effect of deprivation, how can this be tackled? At the level of mental health services: At the level of mental health services: Attention to ethnicity and its psychosocial significance; Attention to ethnicity and its psychosocial significance; Attention to experiences of abuse and violence; Attention to experiences of abuse and violence; Attention to gender issues Attention to gender issues Attention to the social inclusion of the person (in social networks, in education, in suitable employment) Attention to the social inclusion of the person (in social networks, in education, in suitable employment) Providing appropriate pschological interventions and reducing the use of medication; Providing appropriate pschological interventions and reducing the use of medication; Moving away from the over-use of forensic and institutionalised services Moving away from the over-use of forensic and institutionalised services The place – and risk – of establishing ethnically focused services The place – and risk – of establishing ethnically focused services The Cabinet BME programme The Cabinet BME programme At the structural level: education opportunities, fighting racism, improving employment opportunities At the structural level: education opportunities, fighting racism, improving employment opportunities The place of collective action by service providers, users and carers The place of collective action by service providers, users and carers