Psychiatry in multicultural Britain Dr. Afzal Javed

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Psychiatry in multicultural BritainDr. Afzal
Javed
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Psychiatry in multicultural Britain

• Britain is a multicultural society
• Nearly 6.5 million people in England belong to
  Ethnic minority communities
• About 1 in 8 in Englands population

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Population in England Wales(Commission for
Racial Equality,1999)
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Ethnic population (Commission for Racial
Equality,1999)
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Psychiatry in multicultural Britain

• But disadvantages and discrimination characterise
  their experiences in almost all walk of
  lifeparticularly true in the area of health and
  health care
• Black minority health is part of the wider
  social exclusion agenda. Social determinants such
  as overcrowding, unemployment, financial strains
  / pressures and poor housing make it even
  difficult to lead healthier lives
• Our Healthier Nation, 1998 London, HMSO

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Psychiatry in multicultural Britain

• Ethnic minorities
• Have higher than expected psychiatric morbidity
• Do not use the services to the same extent as
  white population
• Differences in expectations, requirements needs
  
• issues relating to first second generation
  population

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Psychiatry in multicultural Britain

• No specific National strategy or policy
  specifically intended for ethnic communities
• NSF in Mental Health do not adequately address
  the particular needs of black ethnic minority
  populations
• Some recent papers like Inside Outside,
  Sainsbury centre for mental health, Racism
  mental health, Ethnicity an agenda for
  mental health

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Psychiatry in a multi-ethnic society

• Difference also in level of
• Stress distress
• Discrimination
• Experiences of individuals Cultural identity
• Influenced by
• Personality, social support,
• networks etc

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Psychiatry in a multi-ethnic society

• Role of
• Culture
• Racism

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Cross Cultural Psychiatry
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CULTURE

• Culture generally fulfils four main functions
• Culture enable individuals to represent at
  different levels of functioning (Representational
  function)
• Culture develops entities and describes
  functional norms (Constructive functions)
• Cultural norms have an impact on peoples lives
  directing their behaviour (directive functions)
• Culture evokes emotions and set rules for how to
  feel at certain point (Evocative functions)

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Race, Culture Ethnicity
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Culture Mental Health

• Perception
• Presentation
• Help seeking behaviour
• Treatment approaches
• Outcome

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Race, Racism and Mental Illness
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Race, Racism and Mental Illness

• Universality of relationship between life events
  psychiatric morbidity
• Race, Racism Crime
• Discrimination, prejudice and racism cited as
  potential barriers in the adjustment of
  non-indigenous population
• Racial discrimination at individual
  institutional levels
• Racism, general health psychological morbidity

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Race, Racism Crime(Commission for Racial
Equality, 1999)
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Racism, Discrimination and Mental Illness

• Perception of racism discrimination results in
  poor mental than physical health
• Low self esteem leads to higher rates of
  morbidity
• Commission for racial equality, 1993,
• CRD report 5, 1996 NHS Centre for reviews
  disseminations

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Institutional Racism Rejection
Threats /
attacks Prejudice
DiscriminationIndividual
Lack of control over environment
PSYCHOLOGICAL DISTRESS Vulnerability factors
Low self esteem, Hopelessness,
helplessness, worthlessness
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Race, Racism and Mental Illness

• Associations with
• Depression
• Anxiety states
• PTSD
• Psychosis
• Recent life events psychiatric morbidity
• in Psychiatric in multicultural Britain (Ed)
  Bhugra and Cochrane, Gaskell,2001

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Mental illness Ethnic minority groups
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Mental illness Ethnic minority groups

• Differences in
• Epidemiology
• Aetiology Causation
• Manifestations
• Access to care

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Mental illness Ethnic minority groups
Epidemiology
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Psychiatry in multicultural Britain

• Ethnic minorities
• Have higher than expected psychiatric morbidity
• Do not use the services to the same extent as
  white population
• Differences in expectations, requirements, needs
• have poor physical health, social exclusion and
  social adversity
• ( 4th National survey of ethnic minorities, 2001)

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African-Caribbean population

• Higher admission rates
• Diagnosed as schizophrenia
• more often
• Over represented in detained patients
• Receive stronger forms of treatment
• Misdiagnosis ?

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Asian Population

• Higher admission rates than British-born
  population
• Rates of depression and anxiety comparable with
  indigenous population
• Recognition of morbidity difficult due to
  linguistic and / or communication problems
• Suicide attempted suicide rates are high among
  first-generation Asian women

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Suicide attempted suicide Asian Population

• Women born in India south Africa have a 40
  higher suicide rate than women born in England
  Wales
• Young women of South Asian origin are at high
  risk for suicide
• For young Asian people cultural conflict as a
  major precipitating factor
• (Ethnicity Agenda for action 1999 Nat Suicide
  Prevention Strategy, DOH, 2002 National
  Association for black mental health, 2002)

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Mental illness Ethnic minority groups
Aetiology causation
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Causes

• Migration
• Alienation
• Cultural identity
• Racism, prejudice, discrimination
• Culture bound syndromes

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Mental illness Ethnic minority groups
Illness pattern service usage
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Pathways to careDisease refers to
malfunctioning of biological / or psychological
processesIllnessrefers to the psychological
experiences and meanings of perceived disease
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Help seeking behaviour in minority ethnic
groups meanings applied to symptoms,stigma,th
e cultural level,familiarity with the
services,perceived utility of services,perceived
ease of access
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Presenting complaints in Primary care with ICD
Disorders-WHO Study (1995)
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Under detection of Depression(in transcultural
settings )

• Different explanatory models between Patient
  doctor
• Focus on somatic symptoms
• Variation of clinical features across cultures
• Linguistic, cultural and racial barrier between
  doctor pt
• Insufficient probing by the clinician
• Pts familiarity with psychiatric diagnosis
• (Bhugra Mastrogianni, Globalisation mental
  disorders, BJPsych, 2004)

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Somatic idioms of distress

• India, Pakistan ( Bhugra et al 1997, Javed 1996)
• Sinking heart, feeling hot, gas
• Dubai (Sulaiman et al 2001)
• Jesmi metkasser (broken body), Tabana ( I am
  tired), sadri dayeq alayya (my chest feels
  tired)
• UAE (Hamadi et al 1997)
• The heart is poisoning me, As there is hot water
  over my back, soething is blocking my throat
• Chinese ( Parker et al 2001)
• Shenjing shuairuo ( neurasthania)
• Nigeria (Ebigo 1982)
• Heat in the head, biting sensations all over the
  body, Heaviness in head

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Culture Bound Syndromes

• Forms of psychopathology produced by certain
  systems of implicit values, social structures
  obviously shared beliefs indigenous to certain
  areas
• considered them to be atypical variants of
  western psychiatric syndrome
• Culture being pathogenic pathoplastic

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Culture Bound Syndromes

• Dhat syndrome
• Possession syndrome

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Dhat Syndrome

• C/o vague somatic symptoms, visual problems,
  headaches, weakness, lethargy, lack of
  concentration memory
• Guilt of masturbation, excessive sexual
  indulgence, doubts of potency
• Symptoms ascribed to passing of dhat in urine
• Whitish discharge noticed by the patient

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Dhat Syndrome

• Deep seated belief that loss of semen through
  nocturnal emission/masturbation/sexual relations
  is harmful
• Its preservation guarantees health longevity
  (Arthur Koestler 1961)
• Akhtar (1988) refers to religious scriptures
  according to which
• 40 meals produce one drop of blood
• 40 drops of blood produce one drop of marrow
• 40 drops of marrow form one drop of semen

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Culture Bound Syndromes Co-morbidity

• Generalized Anxiety Disorder
• Neurotic depression
• Psychotic depression
• Phobia
• ? Pre-schizophrenic manifestation (in some)

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Possession Syndrome

• Dissociative phenomenon a restricted sense of
  consciousness, verbal motor behaviour governed
  by possessing agent--a God, a devil, ancestors
  spirit
• Culturally sanctioned in many societies induced
  for religious or therapeutic purposes
• However, it is not uncommon to see these
  possession states occurring in popular temples
  where emotional climate of crowd fosters
  dissociative phenomena

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Culture Bound Syndromes

• Role of traditional healers
• Incorporation of native methods of treatment
• Role of family and carrers

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Future Directions
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An American sign. Obviously!

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Services for ethnic minorities

• Conceptual issues
• colour blind-culture blind psychiatry
• to
• colour friendly-culture friendly psychiatry
• Phases of including culture in service
  development
• Recognition of differences
• Treatment variations
• Treatment changes
• Cultural beliefs and values

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Focus for change

• To reduce eliminate ethnic inequalities in
  mental health service experience and outcome
• To develop a mental health workforce delivering
  effective services to a multicultural population
• To enhance or build capacity within the ethnic
  communities for dealing with mental health
  mental ill health
• ( Inside Outside- NIMEH paper)

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Needs assessment Establishing services

• Identification of needs
• (differences between needs, demands wants)
• Assessing the quality of care
• Primary prevention-a path for future
• Involvement of communities
• Separate psychiatric services???

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Separate psychiatric services ??

• FOR
• Institutional racism
• Race Relation Act 2000
• Provision of services by voluntary sector
• Pts satisfaction
• Gaps in service provisions

• AGAINST
• Culture as a problem
• Separate different Us
• Experiences in education, housing
• Difference in actual needs vs perceptions
• Economic

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Psychopharmacology

• Ethnic population may need lower doses
• P-450 iso-enzymes show clear individual
  cross-ethnic variations
• Dietary habits, religious taboos need to be kept
  in mind
• Smoking, alcohol and illicit drug usage
• Complimentary medicine

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Conclusion

• Requirements needs of ethnic populations
  need constant monitoring in terms of
• Assessment
• Identification of specific needs
• Service provisions

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Conclusion

• Socio-cultural aspects - migration, geographic
  location of origin, political-religious-spiritual
  affiliations are important in history taking
• Idiom of distress explanatory model of illness
  (E.M.I.) to be understood
• Traditional healers will continue to play a role
  hence some way has to be found to collaborate
  with them

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THANKS