Introduction
Morgan & Hutchinson's call for a prevention strategy is very welcome (Morgan & Hutchinson, Reference Morgan and Hutchinson2009). It would be superb if this could be a rallying call for those interested in the mental health of people of Caribbean and African origin. But in order for this to happen there needs to be a consensus. My aim here is to find areas of agreement on which a consensus could be built.
The first area of agreement would be the basic premise that social forces are important in the genesis of psychosis.
The issue of misdiagnosis may be tricky. This is in part because researchers have aimed to ensure that diagnoses are made in a repeatable way rather than to consider underlying validity of diagnostic rubrics (McKenzie et al. Reference McKenzie, Fearon, Hutchinson, Morgan, McKenzie and Fearon2008). But even here there may be more agreement than disagreement. Leading researchers have indicated that there are fundamental difficulties with our systems of diagnosis and this has led to calls for dimensional, as opposed to categorical, diagnoses – particularly to improve the accuracy and acceptability of diagnosis of psychosis across cultural groups (Dutta et al. Reference Dutta, Greene, Addington, McKenzie, Phillips and Murray2007).
Accuracy is the issue. When a Jamaican psychiatrist was asked to interview and make diagnoses on black patients in a London teaching hospital, there was agreement on what percentage of in-patients suffered from a psychosis but there was a surprisingly low agreement on which patients suffered from which psychosis (Hickling et al. Reference Hickling, McKenzie, Mullen and Murray1999).
From the research evidence it seems clear that there is high rate of psychotic symptoms in groups of African and Caribbean origin. And, given our diagnostic systems, it would not be surprising if there was disagreement about the nature of these symptoms, which category best describes them, and whether a new conceptualization would be useful (McKenzie, Reference McKenzie1999; Dutta et al. Reference Dutta, Greene, Addington, McKenzie, Phillips and Murray2007).
One way forward would be simply to accept that there may be differences in opinion. It may be possible to build a consensus around the assertion that social factors lead to an increased rate of presentation of people of African and Caribbean origin to mental health services and those who come to services have symptoms of mental health problems that require treatment. Prevention strategies often improve more than one problem.
Linking rates of illness and service use
There has been an unfortunate tendency for the increased incidence of psychosis in people of African and Caribbean origin to be presented as a reason for their increased prevalence in hospital settings (Healthcare Commission, 2007). The prevalence of a disorder in the community is a better indication of need. The prevalence, if raised, is not raised sufficiently to account for the numbers of people in hospital beds (Sproston & Nazroo, Reference Sproston and Nazroo2002). But this is a very different discussion to the one concerning incidence.
The incidence issue offers a challenge to mental health services (in the widest sense) to deliver equity. Despite clear differences in incidence no concerted prevention strategy has been developed (McKenzie, Reference McKenzie2007). The problem could be conceived as institutional in nature because mental health services have concentrated on developing treatment services when a preventive public health approach would be a useful adjunct. It may be possible to reach agreement that the response to high incidence rates should be prevention and this should be considered separately from the issue of treatment services.
The reasons for the lack of a public health response
It is difficult not to accept the proposition that we should decrease racism and improve the environment of children, the socio-economic position of African and Caribbean people in the UK, social support, social capital and cohesion. However, it may be more difficult to deliver such an initiative. This strategy may not be attractive to policy makers. It will be expensive, requires buy-in from a number of government department and the results would be seen many years in the future. There is also the question about whether the social factors identified actually increase risk themselves or are risk indicators. If they are risk factors, then reducing them may have an impact on an illness rate, but if they are risk indicators, then their impact is less predictable.
Then there is the fact that some may argue that Delivering Race Equality contains a prevention strategy (Department of Health, 2005) and that prevention is part of the remit of the 500 community development workers that were to be employed in England. This would decrease the attractiveness of a new initiative.
Lastly there is the issue of the general dominance of treatment services which take precedence over prevention and health promotion services.
Because of all these issues, it could be argued that the lack of a concerted public health approach to the issue of high rates of psychosis in people of African and Caribbean origin is not due to conflating the issues of misdiagnosis and service use with incidence rates but rather reflects a more general difficulty in getting adequate mental health promotion and mental illness prevention strategies into social policy.
A way forward
Moving forward with a comprehensive prevention strategy for mental illness in people of African and Caribbean origin could be difficult. The research indicates that a wide-based strategy would be needed moving from childhood onwards. This may seem daunting to policy makers and it may be that a more profitable approach would be, at least initially, to focus on one stage of development – say adolescence –and to target the prevention of the conversion to psychosis.
But before approaching policy makers it would be important to develop a consensus among stakeholders and to have a constituency. Such a consensus needs to focus on agreements rather than discord.
Could we agree that social factors lead people of Caribbean and African people in the Diaspora to be distressed, that this distress is real and that it leads to a need for mental health services? Could we agree that the high rates of problems are a public health emergency? Could we agree the need for a comprehensive and concerted prevention strategy? If so, this may be all the agreement that is required.
If we are to have any chance in convincing policy makers that this is an imperative then we do need to change the tenor of debate. The aim would be to understand and accept other perspectives and use their ideas as leverage to go forward. The challenge to governments will be to agree to develop a prevention strategy but the challenge to professionals is to understand how to convince governments.
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Introduction
Morgan & Hutchinson's call for a prevention strategy is very welcome (Morgan & Hutchinson, Reference Morgan and Hutchinson2009). It would be superb if this could be a rallying call for those interested in the mental health of people of Caribbean and African origin. But in order for this to happen there needs to be a consensus. My aim here is to find areas of agreement on which a consensus could be built.
The first area of agreement would be the basic premise that social forces are important in the genesis of psychosis.
The issue of misdiagnosis may be tricky. This is in part because researchers have aimed to ensure that diagnoses are made in a repeatable way rather than to consider underlying validity of diagnostic rubrics (McKenzie et al. Reference McKenzie, Fearon, Hutchinson, Morgan, McKenzie and Fearon2008). But even here there may be more agreement than disagreement. Leading researchers have indicated that there are fundamental difficulties with our systems of diagnosis and this has led to calls for dimensional, as opposed to categorical, diagnoses – particularly to improve the accuracy and acceptability of diagnosis of psychosis across cultural groups (Dutta et al. Reference Dutta, Greene, Addington, McKenzie, Phillips and Murray2007).
Accuracy is the issue. When a Jamaican psychiatrist was asked to interview and make diagnoses on black patients in a London teaching hospital, there was agreement on what percentage of in-patients suffered from a psychosis but there was a surprisingly low agreement on which patients suffered from which psychosis (Hickling et al. Reference Hickling, McKenzie, Mullen and Murray1999).
From the research evidence it seems clear that there is high rate of psychotic symptoms in groups of African and Caribbean origin. And, given our diagnostic systems, it would not be surprising if there was disagreement about the nature of these symptoms, which category best describes them, and whether a new conceptualization would be useful (McKenzie, Reference McKenzie1999; Dutta et al. Reference Dutta, Greene, Addington, McKenzie, Phillips and Murray2007).
One way forward would be simply to accept that there may be differences in opinion. It may be possible to build a consensus around the assertion that social factors lead to an increased rate of presentation of people of African and Caribbean origin to mental health services and those who come to services have symptoms of mental health problems that require treatment. Prevention strategies often improve more than one problem.
Linking rates of illness and service use
There has been an unfortunate tendency for the increased incidence of psychosis in people of African and Caribbean origin to be presented as a reason for their increased prevalence in hospital settings (Healthcare Commission, 2007). The prevalence of a disorder in the community is a better indication of need. The prevalence, if raised, is not raised sufficiently to account for the numbers of people in hospital beds (Sproston & Nazroo, Reference Sproston and Nazroo2002). But this is a very different discussion to the one concerning incidence.
The incidence issue offers a challenge to mental health services (in the widest sense) to deliver equity. Despite clear differences in incidence no concerted prevention strategy has been developed (McKenzie, Reference McKenzie2007). The problem could be conceived as institutional in nature because mental health services have concentrated on developing treatment services when a preventive public health approach would be a useful adjunct. It may be possible to reach agreement that the response to high incidence rates should be prevention and this should be considered separately from the issue of treatment services.
The reasons for the lack of a public health response
It is difficult not to accept the proposition that we should decrease racism and improve the environment of children, the socio-economic position of African and Caribbean people in the UK, social support, social capital and cohesion. However, it may be more difficult to deliver such an initiative. This strategy may not be attractive to policy makers. It will be expensive, requires buy-in from a number of government department and the results would be seen many years in the future. There is also the question about whether the social factors identified actually increase risk themselves or are risk indicators. If they are risk factors, then reducing them may have an impact on an illness rate, but if they are risk indicators, then their impact is less predictable.
Then there is the fact that some may argue that Delivering Race Equality contains a prevention strategy (Department of Health, 2005) and that prevention is part of the remit of the 500 community development workers that were to be employed in England. This would decrease the attractiveness of a new initiative.
Lastly there is the issue of the general dominance of treatment services which take precedence over prevention and health promotion services.
Because of all these issues, it could be argued that the lack of a concerted public health approach to the issue of high rates of psychosis in people of African and Caribbean origin is not due to conflating the issues of misdiagnosis and service use with incidence rates but rather reflects a more general difficulty in getting adequate mental health promotion and mental illness prevention strategies into social policy.
A way forward
Moving forward with a comprehensive prevention strategy for mental illness in people of African and Caribbean origin could be difficult. The research indicates that a wide-based strategy would be needed moving from childhood onwards. This may seem daunting to policy makers and it may be that a more profitable approach would be, at least initially, to focus on one stage of development – say adolescence –and to target the prevention of the conversion to psychosis.
But before approaching policy makers it would be important to develop a consensus among stakeholders and to have a constituency. Such a consensus needs to focus on agreements rather than discord.
Could we agree that social factors lead people of Caribbean and African people in the Diaspora to be distressed, that this distress is real and that it leads to a need for mental health services? Could we agree that the high rates of problems are a public health emergency? Could we agree the need for a comprehensive and concerted prevention strategy? If so, this may be all the agreement that is required.
If we are to have any chance in convincing policy makers that this is an imperative then we do need to change the tenor of debate. The aim would be to understand and accept other perspectives and use their ideas as leverage to go forward. The challenge to governments will be to agree to develop a prevention strategy but the challenge to professionals is to understand how to convince governments.
Declaration of Interest
None.