MENTAL HEALTH AND ETHNIC MINORITIES:
A REVIEW OF THE LITERATURE AND
IMPLICATIONS FOR SERVICES
R. Cochrane and S. P. Sashidharan
University of Birmingham
Northern Birmingham Mental Health Trust
The Mental Health of ethnic minorities has been the subject of much research and, over the years, a substantial body of research evidence has been accumulated. Although there remains much controversy concerning the methodology of ethnic health research, and the generalisability of individual studies to minority groups at large, it is still possible to draw some general conclusions pertaining to the mental health needs of ethnic minorities in this country and their implications for service provision.
Perhaps more than in any other area of health care and health service related research. psychiatry has to be understood in a broader socio-political context and nowhere is this more important than when considering issues relating to ethnicity and culture. Unlike many other medical specialities psychiatry has problems of definition, of meaning and of relationship with service users. It is not the intention to present an exhaustive review of these issues here, but some mention of key topics is unavoidable in any discussion of psychiatric services for ethnic minorities.
By and large the raw materials of psychiatry are peoples' behaviour (often received via second-hand accounts) and self reports of emotional state and cognitive processes. There are very few objective, scientific tests that can be carried out to help with diagnosis or to monitor treatment effectiveness. Although a medical model is usually adopted there is no real distinction between the symptoms and the hypothesised underlying disease in many cases. Yet the process of diagnosis purports to go beyond a mere description of symptoms and attempts to identify a (hidden) disease entity which is producing these symptoms, but without any method of accessing the disease other than through the symptoms. This would make the process problematic (and unreliable) at the best of times, but when cultural overlays are placed on the very material upon which diagnosis is based then the problems are multiplied many times.
Psychiatry and the disciplines which support it, like psychology are basically Eurocentric even when practised elsewhere in the world or by doctors from non-European cultural backgrounds. Ethnic minority patients in Britain, by definition, come from cultural backgrounds which differ from those of European origin. This gives rise to several potential problems. On a superficial, but non-trivial, level there may be language barriers between psychiatrist and patient. Even if this is overcome satisfactorily through professional translating services it is the case that many psychological problems are described by analogies or in local idiom (nervous breakdown, broken hearted, low spirits etc.) which are culturally or linguistically specific. There are also well documented cultural differences in the way psychological problems may be presented e.g. via somatic symptoms, such as backache or thinness of semen, which may seem remote from the 'real' problem identified by clinicians trained on cases where 'psychological' presentation maybe common-place.
The problem goes even deeper than this however. The whole nosological system employed by psychiatry is shot through with a Eurocentric bias and almost forces practitioners to assume that the mental illnesses commonly found in European patients (schizophrenia, depression, neuroses etc.) are also to be found in non-European patients and the system does not easily allow for other disorders to be identified which do not conform to those that are recognised in white patients. There is some academic discussion of so-called 'culture-bound syndromes' but it is doubtful if this influences clinical practices in busy hospitals or GP surgeries. Little wonder then that Loring and Powell (1988) found that the ethnic background of both the psychiatrist and the patient had a significant effect on the diagnostic decision.
Ethno-semantic and cultural issues extend beyond diagnosis of course. A recent report by Jayasuriya et al (1992) points out "...psychiatric treatment practices such as psychotherapy and counselling are heavily laden with Western beliefs and value systems, stemming from the Judeo-Christian tradition, which places a premium on the philosophy of individualism, the right to self-determination and the desirability of independence and assertiveness. Systems of treatment based on these cultural tenets are hardly likely to be universally appropriate..."
In parenthesis it should be noted that the dangers of cultural and Eurocentric bias are just as great in research on ethnicity and mental health as in the practice of psychiatry. There is a long history of research comparing European and non-European behaviour and mental processes which has often come to conclusions which now seem blatantly racist (Littlewood and Lipsedge, 1982), but which were accepted as valid at the time. Although crude racist conclusions are no longer apparent in transcultural psychiatry research, implicit or subtle racism still pervades the discipline. This kind of research still tends to be undertaken by white people and to focus on areas where non-whites appear to have more problems. As shown below there are dozens of studies on the apparently high rate of schizophrenia in Britain’s black population but only one study on the apparently low rate of alcohol-related problems in this population. It is also a common assumption that the behaviours (and problems) of the white population are normative and that deviation from the white pattern shown by another ethnic group in either direction reveals some cultural or racial pathology: higher rates of schizophrenia among black than whites - must be produced by genetic factors or cultural disintegration or abnormal family structures; lower treated prevalence of depression among Pakistani women - must be because they cannot express their psychological problems clearly to doctors, or because their relatives keep them locked away from services for fear of bringing shame on the family.
Psychiatry is distinguished from most other medical specialities in another important way which has very significant implications for its interaction with minority group clients - its practice is not always seen as benign. There has been a long history of reinterpreting psychiatry as a way legitimising the suppression of non-normative and subversive behaviour by applying labels of madness to activities which threaten the status quo or even just embarrass the respectable white middle classes. Whereas in most areas of medicine, wealth, power and influence facilitate access to health care services and poorer and less powerful groups have more difficulties in accessing these valued services - the opposite is the case with psychiatry. Here the poor, the ill educated, and unemployed and the otherwise disadvantaged populate our mental hospitals. Psychiatry also has a unique privilege - the ability to forcibly detain and treat people against their will. The powers conferred on psychiatrists (and others) by the 1983 Mental Health Act exceed even those available to police officers or virtually anyone else in our society. Add the ethnic dimension to this and a very potent brew of racial suspicion and distrust is created. What are we, and more significantly the community concerned, to make of the fact young black men are twice or three times as likely to be brought to a mental hospital by the police and doctors and detained there compulsorily than are white men? The very same group are also more likely to be detained in prison. At least one large mental hospital where a high proportion of patients are both black and are detained under the Mental Health Act shares a site with a notorious local jail. Is it surprising if some of the more politically aware black groups view psychiatry as just another arm of the state apparatus of oppression and social control?
The relevance of all this for this paper lies in the way in which certain data on treated prevalence rates may be interpreted. If, for example, it was discovered that 10 times as many black people as white people were admitted to hospital for heart bypass operations then it would be a reasonable conclusion that there was a greater level of cardiovascular morbidity in the black population. The same relative risk of being admitted to a mental hospital for treatment for schizophrenia is often attributed to other, more sinister interpretations.
One final methodological point has to be considered before embarking on a review of research on ethnicity and mental health. This concerns the definition and composition of minority ethnic groups in Britain. The largest single foreign born group in Britain consists of those people who have migrated from Ireland and who, together with their descendants are over twice as numerous as any other minority group. Despite the fact that the distribution of psychopathology in the Irish in Britain is quite different from that of the native born (Cochrane, 1977; Cochrane and Bal, 1989) very few research projects include the Irish as a distinct ethnic group (see Cochrane and Stopes-Roe, 1979 for an exception). The absence of current data means that the Irish will not be considered in this paper either.
With regard to the other commonly recognised ethnic minority groups in Britain (South Asian, African-Caribbean, Chinese etc.), there is a major element in the composition of these populations which confounds attempts to relate ethnicity to mental health and illness-migration. A very substantial (but declining) proportion of ethnic minorities in Britain are first generation immigrants. In any discussion of "ethnicity” as a variable one has to be aware of the fact that many members (until recently a majority of adults) of these populations have characteristics and experiences which distinguish them from the white majority in addition to their ethnic origin. For example its clear that migrants are far from representative of the population from which they are drawn. At times it has been argued that they are either strongly predisposed to mental illness (e.g. Odegaard, 1932) or they are exceptionally psychologically stable (e.g. Cochrane. 1983). Many first generation immigrants from the 'New Commonwealth' to Britain have had to make a transition from a stable, traditional, rural, collective culture to a western. urban, individualistic society in a state of flux (Furnham and Bochner, 1990). In addition it is a common feature of economically motivated migration from third world to first world countries that the social class distribution of the first generation of migrants is skewed downwards so the incomers are likely to be exposed to harsh working conditions. economic uncertainty, substandard and overcrowded housing and other forms of social deprivation. Depending upon context, these experiences will, themselves, have mental health implications which may mistakenly be attributed to ethnicity. These potential confounds will reduce, but not disappear entirely, as a greater and greater proportion of minority ethnic groups are born in this country.
One factor which all generations of non-white ethnic minorities in Britain have in common is exposure to racism. Racism, in so far as it is manifested in discrimination and economic disadvantage, may well have an effect on physical as well as mental health as poverty and low socioeconomic status are among the best predictors of risk for many forms of morbidity. But unlike for physical conditions the other manifestation of racism, prejudice, will also impact upon psychological well-being. It would come as no surprise to discover that the experience of stereotyping and denial of humanity, jokes and other verbal disparagement, the easy assumption that skin colour is associated with a whole range of assumed problems from academic underachievement to serious criminal activity, as well as explicit social rejection, had very significant influences on self-esteem and mental health.
In this paper, we will provide a selective review of relevant findings from research in the area of mental health of ethnic minorities. From the outset it will be clear that most of the research in this field has followed the conventional epidemiological or medical paradigm by focusing on mental ill health as the dependent variable. It is, therefore, not surprising that there is a lack of empirically grounded research on mental well-being or the psychological resilience and survival of minority groups in this country.
An additional problem is that most of what we know about the mental health of minority ethnic groups in this country is based on service usage at the specialist or secondary care level and there is a lack of research pertaining to common mental health experiences in the communities at large. This is reflected in the health needs assessment of minority groups where the usual premise is that observations from institutional or specialist care settings will inform us of morbidity patterns within the population as a whole. This is particularly problematic in psychiatry where utilisation of specialist care alone cannot be taken as an index of health care need given the need for maintaining social order that is implicit in much of institutional psychiatric practice (see above). We have set out this review within the conventional paradigm of pathway into care. Using such a model of different levels of care (from the general population through primary care into specialist settings), as postulated by Goldberg and Huxley (1980), we will outline salient research findings pertaining to both south Asians and African-Caribbeans in this country. Given the remit of this review, i.e.; to draw out health service implications of studies to date, such an approach will help in delineating the implications of available knowledge for public health and psychiatric practice in a multiethnic setting.
2. Treatment Patterns in Specialist Services
The use of mental hospital in-patient admissions statistics to examine ethnic variations in the pattern of mental illness offers both advantages and disadvantages. On the plus side they have been available on a national scale (Cochrane, 1977; Cochrane and Bal, 1989) and are ‘non-reactive' - that is they are not likely to be influenced by the research process itself. On the other hand these data suffer from several severe problems which means that findings based on them exclusively can be considered only as a starting point in the research process - a good basis for constructing interesting research questions - rather than as a basis for drawing conclusions. The four main methodological problems inherent is the way NHS statistics relating to ethnicity are gathered are: 1) only data based on 'Country of Birth', not ethnicity, have been available; while this was not a significant problem while most members of ethnic minorities in Britain (as defined earlier) were born abroad, now that substantial proportions, even majorities, of these groups are born in Britain the data become increasingly confounded; 2) Record keeping and statistical returns in the NHS have been of an appallingly low standard and this situation is only now being addressed. For example in 1981 fully 30% of mental hospital in-patient record returns failed to provide information on country of birth, even though this was asked for explicitly. Virtually no statistics at all are available for out-patients or other forms of psychiatric care; 3) There is no standardised scheme for diagnosis - each clinician who has to make a return operationalises the diagnosis employed in their own way. Not only can this give rise to regional variations in case definition but also make the interpretation of trends over time difficult as diagnostic criteria change. 4) Although there is a body of research data on factors other than severity of illness which are related to risk of in-patient admission (gender, social class, marital status etc.), there is no research on the relationship between these factors, ethnicity and admission rates. If in-patient admissions represent the proverbial tip of the iceberg of psychiatric morbidity in the community, what is not at all clear is whether or not the tip represents a constant fraction of the total across all ethnic groups - indeed what evidence there is tends to suggest that it is not constant.
Bearing in mind these caveats, what does research using in-patient statistics show? The most comprehensive surveys are those carried out for the years 1971 (Cochrane, 1977) and 1981 (Cochrane and Bal, 1989) which covered all countries of birth represented in the returns for those years (172,000 and 186,000 admissions respectively). Rates were calculated based upon population data drawn from the Censuses which occurred in those years. All diagnostic categories and readmissions as well as first admissions were included. The most obvious and important patterns evident from the 1981 data are:
1. Excess of diagnosed schizophrenia in people born in the Caribbean. Males have 4.3X the native English born rate, females 3.9X the native rate of first admissions for this diagnosis. Further analyses of these data showed that young (<35 years) Caribbean born men were admitted to mental hospitals with a diagnosis of schizophrenia at 6X the rate of native born men of the same age.
2. For all other diagnoses combined (excluding schizophrenia) the admission rates of the Caribbean born were substantially below those of the native born - especially for neurotic conditions, personality disorders and alcohol abuse.
3. For migrants from South Asia (India, Pakistan, Bangladesh, Hong Kong) overall admission rates were lower, and in the case of Hong Kong very much lower, than those for people born in England. While rates of admission for schizophrenia in these groups are roughly comparable to the native born, rates for less severe disorders are substantially below those of the native born. The major exception to this generalisation is that the rate for alcohol related admissions among Indian born men is twice that of the native born and has increased very substantially since the comparable analysis performed on 1971 data.
4. For women born in India and Pakistan the ratio of re-admissions to first admissions is below that of the native born. In the case of Pakistani born women there were 1.2 readmissions for every first admission compared to 2.8:1 for native born women.
Further evidence bearing on each of these observations drawn from other studies using data of the same sort, and from studies which do not rely exclusively on in-patient admission statistics will be reviewed.
A. African-Caribbeans and schizophrenia. The very high treated prevalence rate of schizophrenia in men and women of African-Caribbean origin is the most well researched and thoroughly debated issue in transcultural psychiatry in Britain. Virtually all studies show an excess of diagnosed schizophrenia in Britain S black population - the excess ranges from 2X to 7X the white rate depending on methodology. There has been a long running, but inconclusive debate, on whether these figures are entirely accurate (Sashidharan, 1993) and on the possible causes of the excess (Cochrane and Bal, 1987). It has not been possible entirely to explain away the excess of diagnosed schizophrenia in black people in Britain as being a result of 1) an artefact produced by inaccuracies in either the numerator or the denominator used in calculating rates, 2) high rates of schizophrenia in the Caribbean population as a whole, 3) social class and other demographic characteristics which distinguish the black and white population of England and which are known to be related to risk of schizophrenia, or 4) selective migration of those predisposed to schizophrenia.
Two hypotheses which remained tenable for the longest time have also recently been shown to be unable to explain the increased levels of diagnosis of schizophrenia in the black population of Britain. The deeply ingrained and widespread racism in British society may well have serious psychological consequences for those who are the target of the prejudice and discrimination it breeds, but it is difficult to sustain this by itself as a credible explanation in the face of the evidence that a similar set of experiences does not produce the same effect in other prejudiced-against groups (e.g. South Asians). Second, the treated prevalence rates of other psychiatric conditions which might be considered to be even more susceptible to racism induced elevation (depression, neuroses etc.) are no higher, indeed often lower, in blacks than whites. Third, the same phenomenon (high treated prevalence of schizophrenia) is not shown by African-Americans who are also exposed to pervasive racism. Similarly the suggestion that the misdiagnosis as schizophrenia of acute, stress-induced psychotic reactions in black people could account for the elevated rates found among them has been challenged by several well-designed and well-executed studies which appear to show that misdiagnosis is no more common with black patients than white patients (e.g. Harvey et al, 1990; Harrison et al, 1988).
What has emerged positively from the welter of research on this topic can be summarised as follows:
1. There is an elevated rate of schizophrenia in Britain’s' black (African-Caribbean) population compared to whites of the order of 3 - 5 times.
2. At present this appears to be unique to Britain - there is no evidence of black rates of schizophrenia being elevated to this extent anywhere else in the world.
3. The increased risk of schizophrenia is not confined to first generation immigrants. Recent studies have shown that, if anything, the relative risk is greater in the second generation than the first (Harrison et al, 1988: McGovern and Cope, 1987; Littlewood and Lipsedge, 1988; Thomas et al, 1993). This contradicts the usual pattern of the distribution of disease found in migrant populations where the incomers' rates, whether initially higher or lower than the host population rates, approach those of the host population in the second and subsequent generations.
4. African-Caribbean patients with diagnosed schizophrenia are significantly more likely to be detained under a Section of the Mental Health Act and to have had a 'non-standard' pathway into care (i.e. police involvement more likely, direct referral from a GP less likely) than are whites (Harrison et al, 1989; Thomas et al, 1993; McGovern and Cope, 1987, 1991; Owens et al, 1991).
5. There is some evidence to suggest that the phenomenon under consideration here is either confined to, or most exaggerated in, a cohort of African- Caribbean men born in 1950s and early 1960s either in the Caribbean or in Britain (Glover, 1989). Possibly the excess vulnerability in this cohort might be linked to mothers' exposure to influenza while pregnant with the eventual patient in a population which has not developed any immunity to the influenza virus. While the evidence for this suggestion is not strong it would, if correct, have important implications for how services would need to respond to the phenomenon both in terms of the cost effectiveness of adapting services to what may be a transitory phenomenon and in terms of prevention of 'epidemics' of schizophrenia.
6. As well as increased risk of schizophrenia there is growing evidence of a poorer course and outcome of the disorder in Britain's black population than among whites (McGovern and Cope, 1991; McGovern et al 1994; Birchwood et al, 1992). After a first episode, black patients are more likely to be readmitted, spend longer in hospital, have more residual symptoms and poorer social outcomes that' white patients. Although there is no evidence that black patients are less likely to remain in contact with services after discharge from hospital, the fact that significantly more of their readmissions are compulsory under the Mental health Act may indicate either reduced medication compliance and/or disinclination to accept close supervision by doctors.
B. Lower rates of inpatient admissions of black people with diagnoses other than schizophrenia. If we accept that the high rate of diagnosed schizophrenia in black people is not attributable to psychiatrists mistaking other psychiatric conditions for schizophrenia then the suspicion must exist that black people with less severe disorders are not accessing in-patient services as easily as white people (whether this is a good or bad thing depends upon point of view - see Section 1). Certainly it is surprising, given the association between ethnicity and indices of deprivation (unemployment, social class distribution, housing conditions etc.) that are known to be associated with increased risk of mental illnesses such as depression and anxiety, that black people are under-represented in mental hospitals once admissions for schizophrenia are set aside. Obviously three possibilities exist: 1) black people are actually less likely to suffer from non-psychotic conditions; 2) black people suffer these disorders at a similar rate to white people but receive alternative forms of care; 3) black people suffer these disorders at a similar rate to white people but do not gain access to care because, either they find existing services aversive and/or they are blocked off from receiving services. In the absence of any reliable data on other forms of contact with psychiatric services (e.g. out-patients) or the rate at which GPs treat black and white people with less severe psychological problems, and no data at all on the prevalence of these disorders in the community, no firm conclusions can be drawn.
The only exception to this paucity of data is the study by Cochrane and Howell (in press) of the extent of alcohol problems among African-Caribbean men in the West Midlands. Noting the low treated prevalence rate for alcohol problems revealed by in-patient data, they screened for alcohol problems in a random sample of black men. The data showed conclusively that black men were less likely to engage in excessive drinking, less likely to exceed safe drinking limits, less likely to get drunk, less likely to have social or personal problems related to alcohol and scored lower on a Alcohol Problems Scale than a random sample of white men. Thus for this particular diagnosis the relative inpatient rates of blacks and whites seem to be an accurate reflection of morbidity in the respective communities.
C. Low treated prevalence rates of South Asian population. This observation has been confirmed in many, but not all, studies using in-patient statistics. Few if any studies have found Asian rates exceeding the white rates (the exception being for alcohol related disorders - this is discussed below). Again it appears that the patterns differ for schizophrenia and all other illnesses. In the case of schizophrenia rates, of first admission for South Asian populations are comparable to those for the white population after appropriate adjustments to make allowance for demographic differences between the populations are made (Cochrane and Bal, 1987 - but see King et al, 1994 for an exception to this pattern). For most other diagnostic categories however, rates of admission and readmission are conspicuously lower for South Asians than whites.
To take schizophrenia first, the data to hand show a pattern diametrically opposed to that found for black people. Not only is the incidence of the disorder no higher than the incidence in the white population, but evidence is accumulating that Asian patients have a superior course and outcome pattern following first admission. Birchwood et al, (1992) in a retrospective case note study in Birmingham showed that South Asian patients had fewer readmissions, fewer residual symptoms and better social adjustment than did whites two years after a first admission for schizophrenia. They tentatively attributed this to family factors. Gupta (1991) in a study employing a similar design in Camberwell, also showed that Asian patients had fewer readmissions, spent less time as in-patients and were more likely to be rated as "well" or "much improved" than were white patients two years after an admission with a diagnosis of a 'functional adult psychosis'. However, Gupta (1992) also reported that a significantly higher proportion of the Asian cohort of patients (40%) than white patients (21 %) could not be located via GPs at follow-up 5 - 20 years after the index admission. He expressed concern that many Asian clients may lose contact with both specialist and primary services after discharge from hospital. Other explanations are, of course, also available.
Turning to other disorders, there is more evidence against which to evaluate the extent to which mental hospital in-patient statistics reflect true levels of morbidity than is the case for the African-Caribbean population. Unfortunately the same gap exists in our knowledge of utilization rates for forms of specialist care other than in-patient admissions. Based on a community survey of a random sample of the Indian-born population of England, Cochrane and Stopes-Roe (1981) found a lower incidence of self reported minor psychological illness which is consistent with a lower rate of admissions for non-psychotic disorders. One discordant note in this optimistic pattern is the much higher than expected rate of suicide among women from the Indian subcontinent, especially young married women (see below).
Similarly the exceptionally low treated prevalence rates manifested by the Hong Kong Chinese population of Britain (less than 50% of the white rate) is congruent with the findings of two local community surveys of the incidence of psychological morbidity among the Chinese (Furnham and Li, 1993; Wong and Cochrane, 1989) which also showed very low rates to exist.
The limited data to hand on the Pakistani/Bangladeshi population gives more cause for concern. Cochrane (1981) found equivalent levels of morbidity in random samples of the Pakistani-born and white population of England, but a treated prevalence rate of less than half the white rate for non-psychotic disorders (Cochrane 1977). This is clear prima facie evidence for “underutilisation" of mental health facilities by the Pakistani/Bangladeshi community. It is worth noting that this population is significantly less well educated, more deprived and less “acculturated” than is the Indian (Sikh or Hindu) population of Britain (Cochrane, 1983). There must be genuine concern that significant morbidity, especially among Pakistani/Bangladeshi women is going untreated and unnoticed by specialist services and, possibly, also by primary services. There is no evidence that recourse is being made to traditional healers instead of formal services as it appears that where help is sought from these source it is usually in addition to western medicine not instead of it (Bal, 1989). Attention has already been drawn to the unusually low readmission rate of Pakistani women (compared to white women). It would be convenient to believe that this was because they had no further need for in-patient services, but there is no evidence for this.
The data seem to show a very different pattern with respect to alcohol related disorders for Indian (Sikh) men. This group showed a very high treated prevalence rate for alcohol related disorders (twice the white rate and accounting for 25% of all mental hospital admissions in this group in 1981 compared to less than 10% of white male admissions), but a community survey of drinking patterns and alcohol related problems in the West Midlands (Cochrane and Bal, 1990) showed Sikh and white men to abuse alcohol to approximately the same extent (Hindu men drank less than either of these groups on average, and Moslem men drank scarcely at all). The best available explanation for the elevated in-patient treatment rate of Sikh men appears to depend on a mixture of two factors. First Sikh (and other Asian) men do not access voluntary sector alcohol services with the same ease as white men so are more reliant on the statutory sector. The reason for this is believed to be a preference for seeing the problem in medical rather than psychological terms and the lower level of stigmatisation this orientation brings. Second, there is evidence that people from the Indian subcontinent are more likely to suffer liver damage at a lower level of alcohol consumption than are white men because of previous exposure to hepatitis. The most positive feature of these findings is that heavy drinking, exposure to hepatitis and avoidance of the voluntary sector are all more common in the first generation of Sikh men and are very much less evident in the second generation. Thus the high rate of alcohol-related problems in this particular group may literally die out in the next two decades.
3. Primary care
There is, then, concern that there may be considerable unmet need for psychological support among minority ethnic groups. In contrast to the considerable research emphasis on ethnic factors in relation to hospital or secondary care, relatively little is known about access to primary care and the management of psychological disorders in ethnic minorities at this level (Lloyd, 1992). The limited literature in this area shows a further discrepancy in its focus on Asians and the apparent neglect of other ethnic minorities, particularly African-Caribbeans.
Although there appears to be no substantial ethnic variation in G.P. registration (Johnson et al 1983), there are important differences in overall consultation rates, with men and women of Pakistani origin consulting G.Ps more often than other groups. Men of Asian and African-Caribbean origin in the age group of 16 to 65 years are also more likely to consult their G.Ps than the general population (Balarajan et al., 1989). Other studies have largely confirmed these findings (Gillam et al, 1989), with no evidence to suggest that ethnic minorities consult their G.Ps any less frequently than do their white counterparts. However, when it comes to consultation rates for psycho-social problems, the picture is almost reversed; the group that is most likely to be diagnosed by the G.P. as having psychological disorders is white women,. with women of African-Caribbean and Asian origin least likely to be identified as having significant psychological problems (Gillam et al 1989). The data relate to conspicuous morbidity i.e.; that identified by the G.Ps as significant psychological problems and do not take into account the extent of morbidity hidden from G.Ps.
Whether such ethnic differences in primary care morbidity as identified by G.Ps are due to lower prevalence of minor psychological problems in ethnic minorities or if such observations are artifactual, possibly as a result of misattribution by the G.Ps (Brewin 1980) remains unclear. There is evidence to suggest that the psychological presentation of minority groups in general practice settings does not fit in with conventional diagnostic categories familiar to British G.Ps, for example, the apparent excess of 'somatisation' symptoms in Asian patients (Bal & Cochrane, 1990; Goldberg & Bridges, 1988) although such symptoms are often associated with concomitant symptoms of depression and anxiety (Simon & Von Korif, 1991) and are not uncommon among white British patients (Helman, 1990). It is also not clear if ethnic minority groups are less willing to declare psychological problems to their G.Ps compared to white consulters. Mumford et al (1991) have reported that when Asian patients are questioned in their own language they are usually able to describe psychological symptoms of a mood disturbance. It has also been argued that ethnic minorities are reluctant to consult their G.Ps with psychological problems and instead make use of 'alternative healers' (Bhopal, 1986; Ineichen, 1990) but there is little empirical evidence to support such a speculation.
The available evidence clearly points to significant ethnic differences in conspicuous psychiatric morbidity. It is worth noting that most of the studies in this area have been largely confined to first generation migrants and there are few data on British born black people and their access to primary care. There is no reason to assume that the discrepancies identified in consultation rates for psychological problems identified in the 'first generation' migrants will persist in their offspring in this country. However, there is a compelling case for appropriate training of General Practitioners in the detection of psychological problems in minority ethnic groups, especially where assessments are likely to be compromised by language difficulties.
4. General Population
There is a dearth of general population surveys of minority ethnic groups. The few studies among the general population indicate that for both African-Caribbeans and south Asians rates of psychiatric morbidity are lower then the indigenous population (Bebbington et al, 1991; Cochrane and Stopes-Roc, 1981; Williams. Bhopal and Hunt 1993), a surprising observation given the strong association between social and material adversity and prevalence rates for psychological distress in the population at large. For example, in one study examining the impact of unemployment on British Asians, the unemployed group was found to have lower levels of psychological well-being and self esteem compared to those in employment (Shams, 1993; Shams and Jackson, 1994). Most of the evidence would appear to confirm that minority ethnic groups experience considerably greater levels of social and material adversity compared to their white counterparts. Whether the reported low rates of psychological distress found in this community is a product of the inadequacy of case finding techniques, which have relied on culturally biased measures, or if such under-reporting is indicative of low prevalence remains unclear at present. Where studies have attempted to depart from conventional case definition, for example using culturally appropriate definitions of mental distress, (Krause, 1989; Beliappa, 1991, for example) greater levels of mental distress, consistent with the high levels of adversity found amongst minority ethnic groups have been identified. It is likely that much of this morbidity will remain hidden in the general population unless an attempt is made to go beyond conventional categorisation of psychological disorder derived from current psychiatric nosology.
There are much more clear cut data available on suicide and attempted suicide (parasuicide) rates in the minority ethnic groups. Differential levels of suicide among immigrant groups in general were identified in the first national analysis of immigrant mortality (Marmot et al, 1984). Subsequent studies (Soni Raleigh et al, 1990; Soni Raleigh and Balarajan, 1992) have confirmed the trend in the national mortality statistics which show a higher rate of suicide in women from the Indian subcontinent. This excess of suicide among women of Indian origin (including those from East Africa) is particularly marked in the age group 15 to 24 years where it is more than twice the national rate (SMR 273) while in the older group (25 to 34 years) it is still elevated (SMR 160). In contrast, the rate in Asian men and in African-Caribbean men and women the suicide rate appears to be lower the national average. Finding from local studies on attempted suicide are in keeping with these observations, with higher rates reported in young Asian women (Burke, 1976a; Merrill & Owens 1986) and lower than expected rates in African-Caribbeans (Burke, 1976b; Merrill & Owens 1987) although the latter observation has been contested by a study which examined the changing pattern of attempted suicide in a London borough in which African-Caribbeans were reported to have similar rates of self harm as in the catchment areas as a whole (Lockhart & Baron 1987).
What is clear from these studies is the pronounced risk of self-harm found in women of Indian origin, particularly in the younger age group. This association between ethnicity and suicidal behaviour does not appear to be mediated through an increased propensity to severe mental illness because there is no apparent excess risk for psychiatric illness, particularly severe depression in women of Indian origin within this age group. Therefore it is unlikely that the greater risk of deliberate self harm and suicide amongst young Asian women is a product of untreated mental illness which raises doubts about the usefulness of currently acceptable strategies for suicide prevention. Furthermore, unlike in the general population, where there is an increased risk of suicide with increasing age, in women of Indian origin at least the highest risk appears to be in the younger age group. This latter finding is more consistent with emerging trends in the indigenous population which show an increasing risk of suicide in young males often without a history of psychiatric illness. The fact that a disproportionate number of suicides among young Indian women are as a result of burning (a method virtually unknown in other groups) gives rise to other concerns.
5. Implications and Conclusions
1. It is very unfortunate that data on mental health service provision for the population of this country is so poor. A great deal of research effort, and not a little ingenuity, has had to be expended on finding out just who gets treated, how often and for what and there are still no definitive and widely accepted data on this issue. Papers are still appearing attempting to document accurately the number of black people being treated for schizophrenia (e.g. Bebbington et al, 1994). This should not be necessary. With modern systems and information technology any researcher, and more importantly, any service planner, should have access to definitive data to enable many of the questions raised in this review to be answered. A well though-out, comprehensive and reliable data capture and dissemination system covering in-patient, out-patient, day-patient, domiciliary and home treatment services and, ideally, services provided at primary care is an imperative if services at the appropriate level and of an appropriate configuration are to be provided.
2. A major use of such a database would be to evaluate Glover's (1989) hypothesis which suggests the existence of a cohort effect and the associated suggestion that levels of black schizophrenia will approach white levels for people born after about 1968. If this is indeed a trend then it should be discernible by now. Taking this with the evidence from studies by Eagles and others (e.g. Eagles and Whalley, 1985) that rates of schizophrenia are declining absolutely in Britain there are obvious implications for the planning of services for the 21st century.
3. There is hardly any research on the treatment of psychological disorders in minority groups at the primary care level. This is a major gap in the existing research and, this combined with the lack of detailed studies concerned with the interface between primary and secondary care, makes it very difficult to understand fully the processes which underlie the problems of access to specialist psychiatric care that have been identified in minority groups. Given the poor recognition of psychological morbidity in all minority groups at the primary care level and overall under-representation of such patients within counselling and psychotherapy settings across different levels of care (Kareem and Littlewood, 1989) it would be reasonable to expect that the cases identified by General Practitioners are more likely to be given pharmacological treatment and perhaps less likely to receive social or psychological interventions. Support for this hypothesis comes from the observation that ethnic minority patients are less likely to be referred to other agencies such as District Nurses within general practice and their problems more likely to be interpreted as restricted in range and therefore not requiring anything more than medical intervention. Detailed research around assessment and treatment of psychological disorders in primary care is urgently required. In particular, an evaluation of the clinical and social outcome of G.P. intervention is a high priority, given the variations between minority groups and others in referral to specialist care.
4. Given the suspicions that have been aroused concerning the accuracy of in-patient admission statistics as a measure of true incidence, a well planned epidemiologically sound survey of the incidence of schizophrenia in the African-Caribbean, South Asian and white communities of Britain to include those not receiving formal treatment as well as those in contact with services is long overdue. Such a project should be extended to a prospective, longitudinal study of the course and outcome of the disorder in those people reliably identified as having schizophrenia.
5. Notwithstanding the above, and for whatever reason, there are a lot of black people being treated for schizophrenia in Britain today, yet services seem to be failing them in significant ways. Black patients are often reluctant to come into care, or to remain in care once contacted by services (hence high rates of compulsory admissions); are more likely to receive higher doses of neuroleptics, more likely to receive their medication intramuscularly, and more likely to be given ECT (Moodley, 1993). Despite this high intensity treatment the prognosis is poor compared to that for white or Asian patients with similar clinical diagnoses and outpatient follow-up care is often "inadequate, inappropriate and lacking in quality" (Collins, 1994, p 64). Services need to be developed which are at the same time cognisant of the danger, on the one hand, of being stigmatising and heavy handed, while on the other being available and accessible (physically and psychologically) and on a continuing basis. It seems unlikely that the traditional large mental hospital with all the historical and political baggage it carries will ever be an appropriate environment in which services meeting these criteria can be delivered.
6. The alarmingly high proportion of black patients with a suspected psychotic disorder who are detained compulsorily under a section of the Mental Health Act must also be challenged. Those involved in this procedure (doctors, Approved Social Workers, the Police) must be made aware of the data and receive appropriate training designed to increase awareness of the dangers of invoking the provisions, of the Act unnecessarily possible because of a misperception of the 'dangerousness' of black patients.
7. The issue of the appropriateness of services is also relevant in other ways for people of South Asian origin. While we wish to avoid falling into the trap of assuming that there must be unmet need because the take up of formal care is relatively lower than among similar white populations, it does seem probable that some Asian people are not receiving services they require because of either inadequate referral and diagnostic practices and/or because of the perceived unattractiveness of these services. Minas (1990) draws useful distinctions between 'need' (the level of morbidity about which something could be done) , 'demand' (what potential clients of services would actually like to receive) and 'utilization' (what services people are actually receiving). Utilization of specialist services by different ethnic groups is not at present only, or even mainly, influenced by the relative prevalence of psychiatric disorder but also by patterns of help seeing behaviour, barriers to access to services (e.g. language), alternative coping strategies which may be available (family, friends, religious healers etc.), service provides' attitudes, and the acceptability of services. The "acceptability" of services is a key element in service planning which has largely been overlooked. Depending on the cultural background of potential uses it may involve issues such as single sex wards, the availability of religious advice and opportunities for religious observance, the presence of staff from similar back grounds (other than in menial roles), appropriate food choices, appropriate arrangements for personal hygiene, not addressing elders by their forenames and in a patronising fashion etc.
8. Undoubtedly young women of Indian origin are a high risk group for both attempted suicide and suicide. In the light of the Health of the Nation Targets (reduction of overall suicide rate by 15% within the next six years), there is an urgent need to identify the factors that contribute to this increased risk. Much of the current debate on why young women of Indian origin demonstrate such a risk (a risk that appears to be confined to Indian and not other Asian women) is highly speculative and perhaps not very helpful in identifying appropriate strategies for prevention. What is important in this context is to provide advice and support to such women specifically aimed at avoiding self-injurious behaviour although the effectiveness of such educational and counselling strategies in the primary prevention of self harm is largely untested. More importantly perhaps, women who come into contact with health service agencies, either in primary care with significant psychological symptoms or in the context of deliberate self harm must be ensured access to crisis services in the future aimed at dealing with personal adversities.
9. If it is also the case that the established voluntary sector is also less ‘acceptable’ to ethnic minorities than the white majority whose needs it has grown up to cater for, then similar issues are raised. Given that the voluntary sector may adopt a more psychotherapeutic orientation to clients' problems than the statutory sector it may be impossible for any single agency to make itself acceptable to people from several cultural backgrounds at the same time. It may well be almost impossible for existing institution based services, statutory or voluntary to become sufficiently ethnically sensitive for them to become acceptable to all potential users from minority ethnic backgrounds. It is clearly not enough for institutions to outlaw overt discrimination and become 'colour blind'. Designing and implementing truly ethnically sensitive services, like true equal opportunities, involves an enormous cost both materially and in terms of changing attitudes. It may be that a combination of lack of resources, lack of managerial ability, the weight of institutional inertia and the external imposition of other priorities frustrate attempts to create better and more responsive services.
10. This raises the issue of whether the only way to achieve fully acceptable services is to create new and ethnically separate services, staffed by members of the minority group to which the services are provided and with services customised to their own health belief models and cultural values. This has been tried to a limited extent in the voluntary sector and in some cases pressure has been applied to the statutory sector to follow suit. There is evidence from the United States that such services are better at engaging minority ethnic clients but do not necessarily produce better outcomes (Flaskerud and Hu, 1994). Superficially attractive as this idea might be, it is fraught with dangers. There are too many minority groups to provide serves exclusive to each at anything approaching a realistic cost; in many cases suitably qualified staff may not be available or may not wish to work in an ethnically separate unit; it is a real possibility that such services would become marginalised and separate but not equal; there would almost certainly be local and national political opposition especially if such services were thought to be more expensive. Finally, how would a service respond to a user pressure group which demanded a whites only service?
11. If this is not the way forward, how would an ideal service for ethnic minorities look? Parimala Moodley has made an attempt to define just such a service and we end this section this paper with her model:
"An ideal service for ethnic minorities is one which the majority will use voluntarily because it is a place they can trust to provide them with care when they need it. It will have racial and cultural mix of staff which will enable them to feel understood (not black staff in inferior positions). If the languages they speak are not spoken by the staff, interpreters will be easily available. Assessment of their difficulties will be carried out free of negative stereotypes and taking account of cultural variations in expressions of distress. As they express less satisfaction with explanations given to them about their conditions and the treatment offered to them, particular attention will be paid to providing information in language that is easily understood by all users. Goals of management will be set jointly with users, enabling them to take greater control of their lives. In this process there will be capitalisation of their strengths which may have become buried under feelings of inferiority in society and compounded by a mental illness label.” (Moodley, 1993 p. 498-499).
Balarajan, R., Yuen, P., & Soni Raleigh, V. (1989). Ethnic differences in general practitioner consultations. British Medical Journal, 299, 958-968.
Bal, S. S. (1989). The cross cultural symptomatology of psychological distress Unpublished doctoral dissertation, University of Birmingham,
Bal, S. S., & Cochrane, R. (1990). Why do more Asians at primary care present psychological problems physically? Health Psychology Papers, 2, 59-67.
Bebbington, P. E., Hurry, J., & Tennant, C. (1991). The Camberwell Community Survey - A summary of results. Social Psychiatry & Psychiatric Epidemiology, 26, (5), 195-201.
Bebbington, P., Feeney, S., Flannigan, C., Glover, G., Lewis, S., & Wing, J. (1994). Inner London collaborative audit of admissions II: Ethnicity and the use of the Mental Health Act. British Journal of Psychiatry, 165, 743-749.
Beliappa, J. (1991). Illness or Distress? London: Confederation of Indian Organisations (UK).
Bhopal, R. (1986). Asians' knowledge and behaviour on preventive health issues: smoking, alcohol, heart disease, pregnancy, rickets, malaria prophylaxis and surmia. Community Medicine, 8, 315-321.
Birchwood, M., Cochrane, R., McMillan, F., Copestake, S., Kucharka, J., & Carris, M. (1992). The influence of ethnicity and family structure on relapse in first episode schizophrenia: a comparison of Asian, Caribbean and white patients. British Journal of Psychiatry, 161, 783-790.
Brewin, C. (1980). Explaining the lower rates of psychiatric treatment among Asian immigrants to the UK. Social Psychiatry, 15, 17-20.
Burke, A. W. (1976a). Attempted suicide among Asian immigrants in Birmingham. British Journal of Psychiatry, 129, 528-533.
Burke, A. W. (1976b). Socio-cultural determinants of attempted suicide among West Indians in Birmingham. British Journal of Psychiatry, 129, 261-266.
Cochrane, R. (1977). Mental illness in immigrants to England and Wales: an analysis of mental hospital admissions, 1971. Social Psychiatry, 12, 25-35.
Cochrane, R. (1981). A survey of psychological morbidity in Pakistani immigrants in England. London: Paper Presented at Royal College of Psychiatrists.
Cochrane. R. (1983). The Social Creation of Mental Illness. London: Longmans.
Cochrane, R., & Bal, S.S. (1987). Migration and Schizophrenia: an examination of five hypotheses. Social Psychiatry, 22, 181-191.
Cochrane, R., & Bal, S. S. (1989). Mental hospital admission rates of immigrants to England: a comparison of 1971 and 1981. Social Psychiatry and Psychiatric Epidemiology, 24, 2-12.
Cochrane, R., & Bal, S.S. (1990). Patterns of alcohol consumption by Sikh, Hindu and Muslim men in the West Midlands. British Journal of Addiction, 85, 759-769.
Cochrane, R., & Howell, M. (In Press). Drinking patterns of black and white men in the West Midlands. Social Psychiatry and Psychiatric Epidemiology,
Cochrane, R., & Stopes-Roe, M. (1979). Psychiatric disturbance in Ireland, England and in Irish emigrants to England: a comparative study. Social and Economic Review, 10, 301-320.
Cochrane, R., & Stopes-Roe, M. (1981). Psychological symptom levels in Indian immigrants to England - a comparison with native English. Psychological Medicine, 11, 319-332.
Collins, B. (1994). Promoting equal care for all: mental health services for people from ethnic minorities. Psychiatric Care, May, 61-64.
Eagles, 3., & Whalley, L. (1985). Decline in the diagnosis of schizophrenia among first admissions to Scottish mental hospitals from 1969-78. British Journal of Psychiatry, 146,151-154.
Flaskerud, 3. H., & Hu, L. T. (1994). Participation in and outcome of treatment for major depression among low income Asian-Americans. Psychiatric Research, 53 (3), 289-300.
Furnham, A., & Bochner, S. (1990). Culture Shock. London: Routledge.
Furnham, A., & Li, Y. (1993). The psychological adjustment of the Chinese community in Britain - A study of 2 generations. British Journal of Psychiatry, 162, 109-113.
Gillam, S., Jarman, B., & White, P. L. ,. (1989). Ethnic differences in consultation rates in urban general practice. British Medical Journal, 229, 953-957.
Glover, G. (1989). The pattern of psychiatric admissions of Caribbean-born immigrants in London. Social Psychiatry and Psychiatric Epidemiology, 24, 49-56.
Goldberg, D., & Bridges, K. (1988). Somatic presentations of psychiatric illness in primary care settings. Journal of Psychosomatic Research, 32, 137-144.
Goldberg, D., & Huxley, P. (1980). Mental Illness in the Community: The Pathways into Psychiatric Care London: Tavistock.
Gupta, S. (1991). Psychosis in Migrants from the Indian Subcontinent and English-Born Controls - A preliminary study on the use of Psychiatric services. British Journal of Psychiatry, 159, 222-225.
Gupta, S. (1992). Psychosis in Asian immigrants from the Indian subcontinent-preliminary findings from a follow-up study. Social Psychiatry and Psychiatric Epidemiology, 27, (5), 242-244.
Harrison, G., Holton, A., Neilson, D., Owens, D., Boot, D., & Cooper, J. (1989). Severe mental disorder in Afro-Caribbean patients: some social, demographic and service factors, Psychological Medicine, 19, 683-696.
Harrison, G., Owens, D., Holton, A., Neilson, D., & Boot, D. (1988). A prospective study of severe mental disorder in Afro-Caribbean patients. Psychological Medicine, 18, 643~58.
Harvey, I., Williams, M., McGuffin, P., & Toone, B. (1990). The functional psychoses in Afro-Caribbeans. British Journal of Psychiatry, 157, 515-522.
Helman, C. G. (1990). Culture, Health and Illness. Bristol: Wright.
Ineichen, B. (1990). The mental health of Asians in Britain: little disease or underreporting? British Medical Journal, 300, 1669-1670.
Jayasuriya, L., Sang, D., & Fielding, A. (1992). Ethnicity, Immigration and Mental Illness: A Critical Review of Australian Research. Canberra: Australian Government Printing Service.
Johnson, M., Cross, M., & Caslew, S. (1983). Inner-city residents, ethnic minorities and primary health care. Postgraduate Medical Journal, 59, 664-667.
Kareem, J., & Littlewood, R. (1989). Intercultural Therapy: Theory and Practice. Oxford: Blackwell.
King, M., Coker, E., Leavey, G., Hoare, A.,, & Johnson-Sabine, E. (1994). Incidence of psychotic illness in London: comparison of ethnic groups. British Medical Journal, 309, 1115-1119.
Krause, I. (1989). Sinking heart: a Punjabi communication of distress. Social Science and Medicine, 29, (4) 565-575.
Littlewood, R., & Lipsedge, M. (1982). Aliens and Alienists: Ethnic Minorities and Psychiatry, Harmondsworth, Middlesex: Penguin.
Littlewood, R., & Lipsedge, M. (1988). Psychiatric illness among British Afro-Caribbeans. British Medical Journal, 296, 950~951.
Lloyd, K. (1992). Ethnicity, primary care and non-psychotic disorders. International Review of Psychiatry, 4, 257-266.
Lockhart, S. P., & Baron, J. H. (1987). Changing ethnic and social characteristics of patients admitted for self-poisoning in West London during 1971/2 and 1983/4. Journal of the Royal Society of Medicine, 80, 145-148.
Loring, M., & Powell, B. (1988). Gender race and DSM-III a study of the objectivity of psychiatric diagnostic behaviour. Journal of Health and Social Behaviour, 22, 1-22.
Marmot, M., Adelstein, A., & Bulusu, L. (1984). Immigrant mortality in England and Wales 1970~78: Causes of death by country of birth. Studies in Medical and Population Subjects, (47).
McGovern, D., & Cope, R. (1987). The compulsory detention of males of different ethnic groups, with special reference to offender patients. British Journal of Psychiatry, 150, 505-512.
McGovern, D., & Cope, R. (1987). First psychiatric admission rates of first and second generation Afro-Caribbeans. Social Psychiatry, 22, 139-149.
McGovern, D., & Cope, R. (1991). Second generation Afro-Caribbeans and young whites with a first admission diagnosis of schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 26, 95-99.
McGovern, D., Cope, R., Hemmings, P., & Lowerson, A. (1994). long term follow up of young Afro-Caribbean British and White British with a first admission diagnosis of schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 29, (1), 8-19.
Merrill, J., & Owens, J. (1986). Ethnic differences in self-poisoning - a comparison of Asian and White groups. British Journal of Psychiatry, 148, 708-712.
Merrill, J., & Owens, J. (1987). Ethnic differences in self-poisoning: a comparison of West Indian and white groups. British Journal of Psychiatry, 150, 765-768.
Minas, 1. (1990). Mental health in a culturally diverse society. In J. Reid and P. Tromf (eds). The health of immigrant Australia: A social perspective, Sydney: Harcourt, Brace Jovavanovich.
Moodley, P. (1993). Setting up services for ethnic minorities. In D. Bhugra and J. Leff (eds). Principles of Social Psychiatry, Oxford: Blackwell. ps. 490-501.
Mumford, D. B., Baington, J. T., Bhamagan, K. S., & Hussain, Y. (1991). The Bradford Somatic Inventory: a multi-ethnic inventory of somatic symptoms. British Journal Of Psychiatry, 158, 379-386.
Odegard, O. (1932). Immigration and insanity: a study of mental disease among the Norwegian-born population in Minnesota. Acta Psychiatrica Scandinavica, 4, 1-206.
Owens, D., Harrison, G., & Boot, D. (1991). Ethnic factors in voluntary and compulsory admissions. Psychological Medicine, 21, (1), 185-196.
Sashidharan, S. (1993). Afro-Caribbeans and schizophrenia: the ethnic vulnerability hypothesis re-examined. International Review of Psychiatry, 5, 129-144.
Shams, M, & Jackson, P. R. (1994). The impact of unemployment on the psychological well-being of British Asians. Psychological Medicine, 24, 347-355.
Shams, M. (1993). Social support and psychological well-being among unemployed British Asian Men. Social Behaviour and Personality, 21, 175-186.
Simon, G. E., & Von Korff, M. (1991). Somatization and psychiatric disorders in the NIMH epidemiology catchment area study. American Journal of Psychiatry, 148, (11), 1494-1500.
Soni Raleigh, V., & Balarajan, R. (1992). Suicide and self-burning among Indians and West Indians in England and Wales. British Journal of Psychiatry, 161, 365-368.
Soni Raleigh, V., Bulusu, L., & Balarajan, R. (1990). Suicides Among Immigrants from the Indian Subcontinent. British Journal of Psychiatry, 156, 46-50.
Thomas, C., Stone, K., Osborne, M., Thomas, P., & Fisher, M. (1993). Psychiatric morbidity and compulsory admission among UK-born Afro-Caribbeans and Asians in Central Manchester, British Journal of Psychiatry, 163, 91-99.
Williams, R., Bhopal, R., & Hunt, L (1993). Health of a Punjabi ethnic minority in Glasgow: a comparison with the general population. Journal of Epidemiology and Community Health, 47, 96-102.
Wong, G., & Cochrane, R. (1989) Generation and assimilation as predictors of psychological well-being in British Chinese. Social Behaviour, 4, 1-14.