Race, Culture and Mental Health
Updated by Inger Hatloy, August 2002
Note: please refer to the appendices at the back of this factsheet for important information on
context and terminology.
About this factsheet: This factsheet is targeted at mental health professionals, journalists and
students. However, it is also our aim to present mental health statistics in a way which makes the
subject accessible to all those who are interested in mental health.
Are there any differences in relation to the numbers of people from Black and minority
ethnic groups who enter the psychiatric system as compared with native born white people?
Ethnic origin has only recently begun to be recorded in official statistics in England and
Wales.[1] However, much existing research shows that certain groups, notably African
Caribbean, African and Irish people, are over-represented in psychiatric hospitals.[2]
[3] A study in south London found that Black populations had a rate of admission to mediumsecure care 7-fold higher than their white counterparts: 28 per 100,000 population as compared to
4 per 100,000 population for white people.[4] Research by Deryck Browne carried out at two
psychiatric hospitals found that black people were over-represented among compulsorily detained
patients compared with their numbers in the local population. Of the 224 patients admitted to one
hospital, 106 (51%) were Black, 16 (8%) Asian and 86 (41%) white. Census data from 1991
showed that 71% of the population of the area studied was white (including the 5.2% who were
Irish), 17.2% Black, and 9.2% Asian. 2.7% classified themselves as ‘other’.[5]
[6] They are more than twice as likely to be hospitalised for mental distress than their native-born
counterparts.[7]
Are some groups more likely to receive a diagnosis than others?
[8] One report states that African Caribbean men have 4.3 times, and women 3.9 times, the rate
for white people for first admission with a diagnosis of schizophrenia. [9] Psychiatrist Suman
Fernando states that young African Caribbean men are up to ten times more likely to be given this
diagnosis than their white counterparts.[10] In one study of over 100 African Caribbean and
African users of mental health services in Britain, it was found that almost half had been given a
diagnosis of schizophrenia.[11][12]
How reliable are the statistics that indicate that Black populations and minority ethnic are
more likely to suffer from a mental disorder than their white counterparts?
Statistics can appear very convincing simply because most people interpret numbers as facts.
However, the story behind the numbers may be more obscure than the figures indicate.
Recent research suggests that although more Black Caribbean people are treated for psychosis,
this may not indicate that they are more likely to have such illness. Rather, it could be that the
way they express their symptoms is interpreted in such a way that they are more likely than others
to be prescribed treatment for these symptoms.[13]
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Further, research indicates that more African Caribbean and other Black people with psychosis
are being admitted to hospital for treatment because of the way they initially got in contact with
the mental health services. Evidence suggests that they are more likely to have been in contact
with the police or other forensic services prior to admission. They are also more likely to have
been referred to treatment by a stranger rather than by a relative or a neighbour. It is important to
note that this happens despite the fact that they are less likely than whites to show evidence of
self-harm and are no more likely to be aggressive to others before admission to a mental health
hospital. [14]
Research also suggests that although there is no evidence indicating that African Caribbean
people are more likely to be aggressive than their white counterparts, staff in mental health
hospitals are more likely to perceive them as potentially dangerous. Evidence also suggests that
psychiatrists are more likely to consider this group as potentially dangerous to others. It is
therefore possible that African Caribbean people are more likely to be diagnosed with psychosis
because of bias among those who treat them.[15] Research in the US shows similar results.
How many people in England are diagnosed with psychosis?
Psychotic illness affects a very small portion of the population, around 1 person in 200 in the
UK.[16] Because of the small numbers it has been difficult to produce statistics that accurately
reflect any differences between ethnic groups. Although the above figures indicate some
differences in the prevalence of psychosis, it is important to note that only the difference between
Black Caribbean women and white women can be considered as statistically significant.[17]
Estimated annual prevalence of psychosis by gender [18]
percentages
Men
Women
Total
White
1.0
0.7
0.8
Irish
1.0
1.0
1.0
Caribbean
1.6
1.7
1.6
Bangladeshi Indian
0.6
0.9
0.6
1.3
0.6
1.1
Pakistani
1.4
1.3
1.3
The above figures are from the Fourth National Survey of Ethnic Minorities (FNS). As expected,
it shows a higher rate of psychotic illness for Black Caribbean people than for white people, with
Black Caribbean people being twice as likely as white people to be diagnosed with psychosis.
However, the difference is much lower than previous studies have indicated. More importantly,
previous studies have indicated that the rate of psychosis is particularly high among Black
Caribbean men. The FNS study suggests that the difference was largely due to higher rates of
psychosis among Black Caribbean women. The study further showed that those from a poorer
background were more likely to suffer from a psychotic illness. This was the case for Black
people as well as for White people. It also emerged that those living in inner cities seemed at
higher risk.[19] These findings support the theory that mental illness is related to living
conditions rather than ethnicity or race.
How many people from different ethnic groups in England are diagnosed with neurosis?
Neurosis is much more common than psychosis. As the table below indicates, there are some
differences between different ethnic groups.
Page 2
Any neurotic disorder in past week for men and women by ethnic group Percentages
White
Irish
Black
Bangladeshi Indian
Pakistani
Caribbean
Any
neurotic
disorder
Men
11.6
18.4
13.8
12.9
12.1
12.6
Women
19.9
18.6
19.8
12.3
23.8
26.0
Total
15.8
18.5
17.3
12.3
18.1
19.6
Depressive
episode
Men
2.4
1.8
2.2
2.1
1.7
2.4
Women
3.3
3.5
2.5
1.6
5.7
6.3
Total
2.9
2.8
2.4
1.9
3.8
4.5
Any
Anxiety
Disorder
Men
3.0
5.9
4.7
3.6
1.4
4.4
Women
3.9
5.4
4.0
1.9
7.3
5.4
Total
3.6
5.6
4.3
2.8
4.4
4.9
Obsessive
Compulsive
Disorder
Men
0.3
0.6
0.6
1.0
0.6
2.1
Women
1.4
1.2
1.2
0.9
1.7
1.4
Total
0.9
1.0
1.0
1.0
1.2
1.7
All Phobias
Men
1.8
1.9
0.9
1.0
0.3
2.5
Women
1.7
2.3
1.9
0.4
1.3
1.7
Total
1.8
2.1
1.5
0.7
0.8
2.1
Panic
Disorder
Men
0.5
2.0
1.8
1.7
1.7
0.6
Women
0.5
1.5
1.0
0.9
3.5
1.8
Total
0.5
1.7
1.3
1.3
2.1
1.2
Generalised
Anxiety
Disorder
Men
1.5
2.9
2.0
0.5
0.2
1.4
Women
1.4
3.0
0.8
0.6
2.0
1.3
Total
1.4
3.0
1.3
0.6
1.2
1.4
Mixed
anxiety
depressive
Page 3
disorder
Men
Women
Total
7.4
13.7
10.9
11.5
11.7
11.6
8.3
14.5
12.0
8.7
9.4
9.0
9.7
14.1
11.9
7.1
17.0
12.3
Source: Weich, S., McManus, S, 2002, Common Mental Disorders, in Sproston, K., Nazroo, J.,
(ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for
Social Research, TSO
Neurotic disorders such as depression and anxiety not considered as serious or disabling for the
individual as psychotic disorders such as schizophrenia or manic depression. However, as the
neurotic disorders are far more common, they affect more people, and have a much greater
impact on the community. It is estimated that they account for one third of days lost from work
due to ill health.[20]
Although the neurotic disorders are more common, around 15 per cent of the population in the
UK may be affected at any time, few studies have attempted to find out how different minority
groups have been affected by these disorders. Most research has focused on the rarer psychotic
disorders.
Depressive episodes
The above table indicates that among men White and Pakistani subjects reported depressive
episodes most often (2.4 per cent). However, it is important to note that as the numbers reported
are small, the differences between the groups cannot be considered statistically significant.
Irish men reported the highest level of neurotic disorders (18.4 percent). However, they reported
fewer depressive episodes (1.8 percent) than men from all other groups, except Indians. [21]
The highest levels of depressive episodes were reported by Pakistani women (6.3 per cent) and
Indian women (5.7 per cent). Both these groups show a much higher rate that their male
counterparts. In other ethnic groups there were no significant gender difference. Bangladeshi
women showed the lowest rate (1.6 per cent).
Anxiety disorders
Irish men reported the highest rate of anxiety (5.9 per cent). In contrast Indian women reported
the highest rate of anxiety (7.3 per cent).
Mixed anxiety depressive disorder
The lowest rate of mixed anxiety depressive disorder among men was found in the White (7.4 per
cent) and Pakistani (7.1 per cent) groups. However, the differences between the men were not
statistically significant.
Pakistani women reported the highest rate (17.0 per cent). Among the women, the Bangladeshi
reported the lowest rate (9.4 per cent) of mixed anxiety depressive disorder. The differences
between women in the other groups were not statistically significant.
Page 4
Are there any differences in the types of treatments offered to people from Black and
minority ethnic groups in comparison with those offered to the native-born white
population?
Black people are more likely to given ‘physical’ treatments (drugs and ECT) than their white
counterparts; this is well documented in the literature. [22] African people are likely to be given
higher doses of medication in comparison to other groups, and stand a greater chance of receiving
this intramuscularly, which can be very painful. [23] Black people are less likely to be offered
counselling, other talking treatments or non-medical interventions than white people and are
rarely offered counselling in a different language.[24] There are no figures available for the
treatments most often given to Asian, South East Asian or Irish people. However, it is known that
white middle-class people have greater access to interventions like talking treatments.[25] [26]
For further information about mental health issues for people from African Caribbean
Community, please refer to Mind’s factsheet: The Mental Health of the African Caribbean
Community in Britain.
This factsheet is also available on the web
What are the mental health issues for Chinese people in Britain?
Chinese people are the third largest visible minority ethnic group in Britain. The Chinese
community does not see the mind, body and soul as distinct from each other when treating mental
health problems. Mental health problems are treated by dealing with other aspects of the body,
which are thought to be out of alignment. There may be a degree of stigma attached to mental
health problems and it is thought that Chinese people may therefore not use mental health
services. The treated prevalence rates for mental distress within the Chinese population of Britain
are less than 50% of the rates for the white population.[27] However, in one study, 93% of
Chinese people interviewed said that they would use services if they knew what was
available.[28]
What are the issues for Vietnamese people in Britain, in relation to mental health?
Most Vietnamese people in Britain arrived in the 1970s and 80s as refugees. There are about
26,000 Vietnamese people living in Britain today – about 80% of these are ethnic Chinese. The
Government used a ‘dispersal policy’ to deal with this group in order to avoid ghettoisation and to
lessen the pressure on local authorities. However, this tended to cause isolation and probably lead
to an increased incidence of mental distress within this group.[29]
For further information about mental health issues of Chinese and South Vietnamese people,
please refer to Mind’s factsheet: The Mental Health of the Chinese and Vietnamese People in
Britain.
This factsheet is also available on the web
What are the issues for South Asian people in relation to mental health?
Asian people from India, Pakistan and Bangladesh make up the largest black groupings in Britain.
Page 5
The findings about mental health problems in South Asian people are not consistent. Some
studies show higher hospital admission rates for this group than those for the British born white
population. However, the balance of evidence from hospital admission rates, GP consultation
rates, and community surveys, suggests that Asian people have rates of psychiatric morbidity
equal to or lower than the white indigenous population.
Interestingly, a national community survey by the policy studies institute found an estimated
prevalence of mental health problems to be much higher among South Asians born in this country
or who had migrated at an early age compared to those who had migrated aged 11 or older.[30] A
leading researcher, James Nazroo, has presented evidence that suggest that these figures might be
misleading. The South Asian interviewers who had helped conduct the study reported they had
great difficulties in translating the term depression. This, in turn, seem to have made it difficult to
accurately measure the level of depression among the South Asian population who were
interviewed in their native language. In other words, the instrument used to measure depression
may not have cross-cultural validity. In primary care, rates of anxiety and depression amongst
Asian attenders are the same or lower than in the general population.[31]
Some local studies show that admission rates in some areas can be higher for Asian people than
for the white population. A study in east London shows an over-representation of Asian women
being referred to psychiatry through GPs and a rising number of Asian men being given a
diagnosis of schizophrenia. [32]
For further information about mental health issues of the South Asian Community, please refer to
Mind’s factsheet: The Mental Health of the South Asian Community in Britain.
This factsheet is also available on the web
Appendix 1
Raised Voices: African Caribbean and African Users’ Views and Experiences of Mental Health
Services in England and Wales
Appendix 2
Note on language and terminology: The language and terminology (including that of psychiatric
diagnosis) used in this factsheet reflects that of the original sources referred to. The use of such
language in this factsheet in no way implies Mind’s unqualified acceptance of it.
Mind uses the term ‘Black’ for people of African, African Caribbean and Asian origin who face
particular pressures as ‘visible’ minorities in a racist society. ‘Minority ethnic people’ refers to
people who may or may not be visibly part of a minority: for instance Irish people. We
acknowledge that no terminology is acceptable to all and that self-definition should be
encouraged and respected.
Note on context: This factsheet explores statistical information relating to the
disproportionately excessive numbers of Black people and Irish people being diagnosed
with mental health problems and entering psychiatric hospitals, both as formal and
informal patients.
Page 6
It is vital that these statistics are applied within the intended context. As Melba Wilson and Joy
Francis point out in Raised Voices (1997, Mind):
There is a growing body of research literature indicating that African and African Caribbean
people are over-represented in psychiatric institutions. They are most likely than any other ethnic
group to have a diagnosis of schizophrenia, are most likely (together with Irish people) to be
detained in psychiatric wards, and most likely to be treated with higher doses of medication
(Suman Fernando, 1995, Good Practices in Mental Health). This appears partly because Black
people experience racism and disadvantage in education, housing, work and other areas of life,
which then impacts on their mental health, and partly because they experience racism and a lack
of understanding of cultural differences when they enter the mental health system itself.
In addition, as Deryck Brown points out in Black People and Sectioning (1997, Little Rock
Publishing):
‘In general, research studies have tended to claim that the Black over-representation as detained
patients in the psychiatric system is attributable to either genetically determined high illness rates,
the reactions of Black people to white racism or some cultural dissonance that exists between
Black patient and white practitioner. However, some writers (Littlewood and Lipsedge, 1982;
Fernando, 1988) have broken outside of this mould, questioning the validity of using current
methods of diagnosis and assessment in a multicultural setting, addressing the need to examine
social models of ‘mental illness’ and examining the role played by racism in the interaction
between the psychiatric system itself and Black people’.
Certain authors have also examined the role of racist ideology in the historical development of
Western psychiatry. Fernando takes account of the differences in background in which current
psychiatric thought has evolved (Western culture) and the cultures of the majority of mankind
(Fernando, 1991); and of the racism that has permeated psychiatry throughout its development,
informing and fashioning its theory and practice. In addition psychiatry in general has often been
accused of serving a social control function to the extent that African Caribbean communities are
perceived as marginal and as a potential threat by the mainstream culture. This may filter through
to psychiatric decision making on the control of those deemed somehow to be deviant.
Note: for more comprehensive background information on context see the introductory chapter of
Deryck Brown, Black People and Sectioning, 1997, Little Rock Publishing, London. Melba
Wilson and Joy Francis, Raised Voices, 1997, Mind Publications.
References
[1] Although ethnicity figures are collected for hospital inpatients and also detention rates under the Mental Health Act,
according to the Department of Health, administrative problems have so far meant that these figures are unreliable.
[2] Wilson, M., Francis J., 1997, Raised Voices, Mind Publications
[3] Smaje, C, 195, Health, ‘Race’ and ethnicity: making sense of the evidence. London: King’s Fund
[4] Guite, H et al., 1996, Diversion from courts and prisons to psychiatric inpatient care in a district. Unpublished
report, Dept. of health and epidemiology, King’s College London
[5] Browne, Deryck, 1997, Black People and Sectioning, Little Rock Publishing, London
Page 7
[6] Braken, P., 1998, Mental Health and Ethnicity: The Irish Dimension, British Journal of Psychiatry, 172, 103-105
[7] Cochrane and Bal, 1989, Mental Hospital Admission Rates for Immigrants to England, Social Psychiatry, 24, 2-11
[8] Dutt, R Ferns, P., 1998, Letting through the light. A training pack on black people and mental health. REU/ DoH
[9] Cochrane, R., Sashideran, S. (undated) Mental Health and Ethnic Minorities: A Review of the Literature and
Implications for Services. Report available from Professor Cochrane, School of Psychology, University of Birmingham
[10] Fernando, S., 1991, Mental Health, Race and Culture, Mind Publications
[11] Wilson, M., Francis, 1997, J. Raised Voices, Mind Publications
[12] Bracken et al., 1998, Mental health and ethnicity: an Irish dimension. British Journal of Psychiatry, 172, pp 103-5
[13] Nazroo, J., King M., 2002, Psychosis – symptoms and estimated rates, in Sproston, K., Nazroo, J., (ed) Ethnic
Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[14] Nazroo, J.Y, 2001, Ethnicity, Class and Health, Policy Studies Institute
[15] Nazroo, J., King M., 2002, Psychosis – symptoms and estimated rates, in Sproston, K., Nazroo, J., (ed) Ethnic
Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[16] Ibid
[17] Nazroo, J.Y, 2001, Ethnicity, Class and Health, Policy Studies Institute
[18] Nazroo, J., King M., 2002, Psychosis – symptoms and estimated rates, in Sproston, K., Nazroo, J., (ed) Ethnic
Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
[22] Smaje, C. Health, 1995, Race and Ethnicity: Making sense of the evidence. London: King’s Fund
[23] Moodley, P., 1993, Setting up services for ethnic minorities, in Bhugra, D and Leff, J (eds.) Principles of social
psychiatry. Oxford: Blackwell 490-501
[24] Willmot, J.,1996, Poor recognition, poorer services for Black women. Openmind, 81, Sept-Oct, 8-9)
[25] Parry,G., Richardson, A., 1996, NHS Psychotherapy Services in England, Doh
[26] Mind, 1993, Mind’s Policy on Black and Minority Ethnic Groups and Mental Health, Mind
[27] Furnham, A. and Li, Y., 1993, The Psychological Adjustment of the Chinese Community in Britain – A Study of
Two Generations, British Journal of Psychiatry, 162, 109-113
[28] Xiang, K., 1993, A Survey Report on the Use of Health Services by the Chinese Community in Oxford City, East
Oxford Health Authority. [29] Christie, Y and Smith, H, et al, 1997, Mental Health and its Impact on Britain’s Black
Communities, Mental Health Review, 2:1, Pavilion Publishing, Brighton
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