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

Psychiatry services in England and Wales have been accused of being institutionally racist, but are these accusations justified?

In 2005, the "Count me in" census for England and Wales showed higher rates of admission for mental illness and more adverse pathways to care for some black and minority ethnic groups and led to accusations of institutional racism within psychiatry. Several reports and inquiries have also alleged that psychiatry is institutionally racist.

But Professors Swaran Singh and Tom Burns argue in this week's British Medical Journal that these accusations are erroneous, misleading, and ultimately counterproductive

Higher rates of mental illness in migrant groups have been proposed as evidence of racism within psychiatry, they write. Yet rates of psychiatric disorder are high for all migrants, irrespective of ethnicity. This suggests an explanation that is not ethnic specific and is environmental rather than genetic.

High rates of detention and adverse pathways to care for ethnic minority patients have also been attributed to racism. Yet a recent UK study suggested that the greater stigma of mental illness in the African-Caribbean community might act as a barrier to early help seeking until a crisis develops.

It also suggested that, over time, the relationship between ethnic minority patients and mental health services deteriorates, thereby creating a spiral of downwards engagement.

Hence, a legitimate question is whether some groups of patients are more likely to refuse help from psychiatric services. And if so, why?

These findings highlight that there are perfectly reasonable alternative explanations for why the rates and manner of admission vary between different ethnic groups, say the authors. Construing racism as the main explanation for the excess of detentions among ethnic minorities adds little to the debate and prevents the search for the real causes of these differences.

In psychiatry, accusations of racism simply feed into ethnic minority communities' alienation and mistrust of services. They create a self fulfilling prophecy whereby ethnic minority patients are primed to expect services to be poor and racist, decline all offers of voluntary admission, are detained, and disengage with services over time.

There is a serious risk to potential patient care if charges of institutional racism deter staff from taking clinically appropriate decisions and actions, they warn. Hence, any potential solutions must go beyond the health sector and involve statutory as well as voluntary and community agencies. The problem does not reside exclusively in psychiatry and hence the solutions cannot emerge from psychiatric services alone.

http://www.bmj.com