Against the backdrop of continued policy failures, the time has come to do something that fundamentally changes the way African Caribbean people come into contact with mental health services, says Dr Dawn Edge.
Decades of research consistently report that African Caribbean people in the UK are at significantly greater risk of being diagnosed with psychoses such as schizophrenia than any other ethnic group.
According to the multi-centre AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study, the odds of African Caribbeans being diagnosed with psychosis is nine times that of white British people. Yet, intriguingly, rates of psychosis in the Caribbean are actually similar to those of white British people, thus raising interesting questions about the relationship between ethnicity and diagnosis with mental illness.
This picture is reflected in Manchester where the minority represent just 1.7% of the population yet 17% of patients in psychiatric wards. Meanwhile, for African Caribbean people (including ‘black British’ and ‘mixed ethnicity’), their whole experience of mental health services has also been shown to be more negative than for white British people. For instance, they are much more likely to be admitted under the Mental Health Act (commonly referred to as ‘sectioning’), often with the involvement of police or the courts, rather than via a GP.
Once in psychiatric services, African Caribbean people then receive higher doses of medication, are more likely to be held in seclusion, and are less likely to be offered psychological therapies,such as family therapy. On average, African Caribbean patients stay two-and-a-half times longer in hospital than their white British peers.
Not surprisingly, these factors generate concerns that mental health services may be institutionally racist, and causes people from this community to be particularly fearful of engaging with services. However, delayed engagement increases the length of time without treatment so people are more severely ill when they come into contact with mental health services, thus increasing the likelihood of more medication and a longer inpatient stay.
In turn, this increases fear and mistrust of services. A vicious cycle of delayed engagement, negative access to services, poorer experiences and more fear and mistrust ensures.
The consequences for patients and their families are considerable. For example, the ‘burden of care’ that families experience as a result of long periods of untreated illness can be tremendously stressful, creating conflict and hostile home environments, which can lead to family breakdown. This can cause patients to become socially isolated, which increases the risk of relapse and readmission.
Sadly, the record of public policy in this area has not been successful, most notably the failure of the Delivering Race Equality (DRE) in Mental Health (2005) agenda which was a government response to the David ‘Rocky’ Bennett inquiry, held after the death of the 38-year-old in 1998 in a psychiatric unit in Norwich.
The inquiry found that black men were five times more likely to be detained by the authorities under mental health legislation than white men, concluding that this was due to institutional racism within mental health services. The inquiry recommended cultural competence training for all mental health staff, stating that it was time to take action and that there could be “no excuses for delay”.
A decade on there has been little improvement. In fact, the Care Quality Commission recently concluded that the situation had got worse despite major investment by the previous government. It would appear that the issue of black and minority ethnic mental health, and specifically that of African Caribbeans, has once again been put into the ‘too difficult to do’ box. But it needs to come out of that box. Now really is the time for asking the right people what needs to be done.
As part of my ongoing work into health inequalities I responded to a call from the National Institute for Health Research (NIHR) for more research into this difficult and challenging subject area. My starting point was that I wanted to do something both to create more culturally appropriate and accessible treatments, and to improve the interaction between African Caribbean people and mental health services.
The NIHR is funding a three-year Health Services and Delivery Research study in conjunction with Manchester Mental Health and Social Care Trust to begin to address the problem. The study has two key aims. Firstly, to assess the feasibility of working together with African Caribbean patients diagnosed with schizophrenia, their families and professionals to create a more culturally-appropriate form of family therapy. Secondly to then try to implement and evaluate the work in the Trust’s acute and rehabilitation wards and Community Mental Health Teams (CMHTs).
Mindful that some patients might have lost touch with their families, we also plan to test the feasibility and acceptability of delivering our novel culturally-adapted family intervention (CaFI) via ‘proxy families’ where biological families are not available.
Ultimately, we anticipate that the research will not only improve relationships between families and patients but also reduce stigma in the community because of the engagement work we have been doing. We will also be working with staff to improve their confidence in working with African Caribbean people via ‘cultural competence’ workshops and seminars.