Ethnicity and Mental Ill Health

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Ethnicity and Mental Ill Health

• Shulamit Ramon
• Anglia Ruskin University, Cambridge
• shula.ramon_at_anglia.ac.uk

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

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Conceptual approaches

• A.Through the anthropolgical perspective
• B.Through Current Epidemiology
• Seeing themselves as scientists responsible for
  mapping illness and health in
• large populations, through the application of
  reliable methods to the collection
• of valid data, analysed through parametric
  statistical packages.
• Little attention is being paid to subjective and
  inter-subjective variables and their indicators.
• Lack of own explanatory framework
• 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.

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Table 1

• 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

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• 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.
• (Bywaters and McLeod, 1996)
• Likewise, although victimisation, personal
  attacks, and racial
• discrimination are specifically mentioned as risk
  factors for common mental
• disorders in ethnic minority groups (table 2,
  below, Meltzer et al, 2004, p.
• 207) they are left out of the more comprehensive
  framework
• presumably because they can be subsumed under the
  
• stressful life events category, even if
  the latter is thus rendered meaningless
• of a central and irreducible risk factor.

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Table 2

• 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

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Table 2b

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

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• C. Through sociological research
• 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)

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• 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

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The main empirical evidence

• I will focus on British findings, (Meltzer et al,
  2004) (Pilgrim and Rogers 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.
• The need for looking at findings from non First
  World countries

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Ethnicity

• 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
• services.
• This is true for some ethnic minorities, but not
  for others, and the dividing
• line is neither colour nor race.
• 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.
• 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.

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common mental disorders?

• 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
• e.g. depression is higher in Afro-Caribbeans and
  Africans
• Anxiety is higher among Irish-born and
  non-British white groups,
• Phobias more prevalent among Asian and Oriental
  people
• ( 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).
• 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)
• 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.

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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)
• 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)

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• 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
• They come to the notice of psychiatric services
  later in the onset of their illness then people
  from other groups

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Likely explanations

• 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 2nd
  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

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• 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 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.

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• 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.
• 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).

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Implications

• If the main issue is the cummulative effect of
  deprivation, how can this be tackled?
• At the level of mental health services
• Attention to ethnicity and its psychosocial
  significance
• Attention to experiences of abuse and violence
• Attention to gender issues
• 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
• Moving away from the over-use of forensic and
  institutionalised services
• The place and risk of establishing ethnically
  focused services
• The Cabinet BME programme
• At the structural level education opportunities,
  fighting racism, improving employment
  opportunities
• The place of collective action by service
  providers, users and carers