John J Crowley BA(Hons) RGN RMN. Formerly Charge Nurse, Mental Health Untt, Greenwich Dtstnct Hospttal and Susan Simmons RGN RMN BSc MSc CertEd.
Joumal of Advanced Nurstng, 1992,17,1078-1087
Mental health, race and ethnicity: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit John J Crowley BA(Hons) RGN RMN Formerly Charge Nurse, Mental Health Untt, Greenwich Dtstnct Hospttal
and Susan Simmons RGN RMN BSc MSc CertEd Pnnapal Lecturer, Department of Health Stttdies, Universtty of East London, London, England
Accepted for pubhcahon 13 January 1992
CROWLEY J J & SIMMONS S (1992) Joumal of Advanced Nursmg 17, 1078-1087 Mental health, race and etfmidty: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit A retrospective case-note study of 152 discharged psychiatnc patients {77 subjects of ethnic mmonty ongm and 75 wbites) examined for details of follow-up arrangements on discharge, compliance rate with out-pahent appomtments and details on length of stay, status on admission, employment status, record of llliat drug takmg and diagnosis The results show that m the areas of diagnosis, possible lUiat drug mvolvement, status on admission and length of stay, there are significant differences between Afro-Canbbean subjects and others INTRODUCTION This study was conducted in the psychiatnc unit of a distnct general hospital m South-East London The unit has two acute admission wards, each serving different catchment areas Each ward caters for male and female patients The age range of pahents admitted is 16-65 years Both wards are used in the study One ward has a two-bedded mother and baby umt The refjehhve re-admtssions to hospital of a core group of yoimg patients of West Indian ongm prompted queshons as to the type and suitability of the services offered on dischargefromhospital The aim of this paper is to review some of the literature relating to ethnic minonhes and mental health More speafically it is aimed at
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compiling a profile of the demographic data obtained, e g diagnosis, record of lUiat drug takmg, legal status on admission, length of stay and employment status on admission, comparmg these findings with those of a 'white' group
LITERATURE REVIEW
The term 'ethmc mmonty' is used currently to identify people whose ongms lie outside the Umted Kingdom, but more speafically, it is used for people of Afncan, Afro-Canbbean or Asian ongm (McNaught 1987) The terms 'migrant', 'immigrant', Ijlacks' or clients from developmg countnes are often used m research papers when refemng to minonty groups In this review, these terms are used to mean the same as ethnic mmonty, the 1 investigating follow-up arrangements made for tenn used here, despite its limitahons, to refer to people or pahents of Afro-Canbbean and Asian ongins on dis- groups whose ongms he outside the United Kmgdom charge from hospital, 2 mveshgatmg how many comply with attendance at FoUow-up arrangements on disdiarge out-patient appointments. It IS difficult to know speaficaUy what Littlewood & Lipsedge (1989) and other researchers mean when they talk Correspondence Mr 11 Crowley 33 Opetishmv Road Abbey Wood, London SEZ OTD, about tlw provision of mental health 'services' to ethnic 1078
Mental health, race and ethntaty
groups m Bntam, but attempts to find research in Bntam that identified follow-up arrangements on discharge from hospital for ethnic groups and compare these with 'wbtes' were fruitless In the United States, a review by Cole & Pilisuk (1976) suggests that blacks and dients from developing countnes were unlikely to be offered the range of services extended to white clients However, the authors' own research found that services such as supportive services, outreach, followup and referrals to other agencies were given as frequently to black clients and clients from developing countnes as to whites In fact, m some cases clients from developing countnes were offered more services However, the researcher points out that these clients are in greater need of such extensions of care, and, overall, may still be receivmg less services, proportionately, than whites In Bntam, there is evidence that in the case of psychotherapy blacks are less likely to be offered it, and more likely to be given powerful phenothiazme drugs and electro-convulsive treatment (Littlewood & Cross 1980) Compliance with appointment-keeping Much research done m the area of compliance with appointment-keeping is not speafic to mental health, but a review by Ley (1988) suggests that non-compliance rates m psychiatry are on a par with other health areas In a review of appomtment-keepmg in medical settings, Sackett & Snow (1979) found that only 40% to 50% of patients comply with appomtments for preventive regimens, and 60% to 70% comply with appointments for curative regimens Haynes et al (1979), using 'showing up' as a definition of compliance m psychiatnc out-patients, found a comphance rate of 60% with appomtments Many studies have looked at the compliance rate of the 'first out-patient' psychiatnc appointment following refen-al (Carpenter et al 1981, Hoemg & Ragg 1965, McGlade et al 1988, Whyte 1975) The non-comphance rate vaned from 15% to 40% Rosenberg & Raynes (1976), as quoted m Carpenter et al (1981), indicated that between 15% and 75% of pahents fail to keep their initial outpahents appomtments m psychiatry Sue (1977) found that approximately half of all ethmc-group cLents failed to retum afrer one session, compared with a 30% failure rate for whites In the area of appointments, the effect of race and ethmaty is undear Deyo & Inui (1980), in a major review of this topic, suggest that when age, education and soao-economK status is accounted for, race is probably unimportant
In a review of studies m the Umted States mvolvmg Community Health Cenh-es O'Sulhvan et al (1989) consistently found the drop-out rates for ethmc mmonhes to have been sigmficantly higher than those for whites In his own study, O'Sullivan et al (1989) found that the rate for blacks was significantly higher than that for whites, while the rate for Asian Amencans was sigmficantly lower However, overall, he found that ethmaty was not a significant factor m the premature termination of treatment appomtments He also found that 'failure to tum up' rates were significantly different from those previously reported, l e between 12% and 22% This differs from the findmgs of Sue (1977) m which all ethnic groups had a failure rate of around 50% Snowden et al (1989) found that race as a predictor of endunng or successful treatment partiapation was not a significant factor Race proved unrelated to the status of clients at termination
DEMOGRAPHIC DATA Studies based on hospital admissions (Carf)enter & Brocfangton 1980, Dean et al 1981, Rwegellera 1977) show an mcreased overall rate of mental illness disorder among West Indians The same study by Carpenter & Brockmgton (1980) showed that Asians have an increased rate of first-time psyduatnc hospital admissions, although they failed to differentiate between those bom m India and Pakistan Dean et al (1981) showed that Pakistams have fewer first-time admissions that the Bntish, while Indians have a higher rate However, since the mentioned studies sampled hospital m-patients only, they are biased in favour of major psychiatnc disorders and may therefore relate more narrowly to those illnesses that require admission rather than to the total psychiatnc morbidity Of West Indian patients admitted to hospitai schizophrenia appears to be the commonest diagnosis (Cochrane 1977,Dean etal 1981) However, Hemsi (1967), as quoted m
London (1986), and Rwegellera (1977) do not agree with these findings Among Asians, schizophrema is also the commonest hospitai diagnosis and occurs with a higher than expected frequency (Cochrane 1977, Dean etal 1981) When two senous mental illnesses, schizophrema and the affective psychoses, are combmed and compared to milder psychological disturbances such as phobias and anxiety, the rate of diagnoses differs between groups For Enghsh men the psychoses are twice as common, for Asians, five to six times as common, while for West Indians they are 16 times as common (Littlewood & Lipsedge 1989) This may mean that for the same sort of problem a
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/ / Crowley amis Simmons diagnosis of psychosis is given more readily to members of some ethmc groups than others Rack (1982a) and Littlewood & Lipsedge e R (1987) First psychiatnc admission rates of hrst and second generation Afro Canbbeans Soaal Psychtatry 22, 139-149 McNaught A (1987) Health Actton and Ethntc Mtnonttes Bedford Square Press, London, p 2 O'SuUivan M J, Peterson P D , Cox G & Kirkeby J (1989) Ethmc populations, community mental health services ten years later Amencan Jourrtal of Communtty Psychology 17(1), 17-30 Patmore C (1987) Cautions about caruiabis Openmtnd 25, February/March, 8-9 Rack P H (1982a) Migration and mental illness, a review of recent research m Bntam Transcultural Psychtatnc Revtew 19,
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