Crossethnic differences

There are important cross-ethnic and cross-national differences in the permeability of filters along the pathway to care. Recognition of symptoms by mental health professionals is an important factor. Recognition of distress is dependent on the way symptoms are elicited. As a consequence, instruments used in prevalence studies may differ in their sensitivity. For example, in the United Kingdom Office of Population Censuses and Surveys ( OPCS) morbidity survey, which used the Revised Clinical Interview Schedule, black respondents had similar rates of disorder. (31) However, in the United States National Comorbidity Survey, in which the Composite International Diagnostic Interview was used, black respondents were only half as likely to present with any lifetime disorder compared to white people. (32> The recognition by primary care doctors of psychiatric disorder in African-Caribbeans and South Asians in the United Kingdom has been shown to be poor. (33) There are a number of reasons for this including differences between the symptoms expected by doctors and those presented by different groups of patients. (13) In the United Kingdom, women of South Asian origin with depression are less likely to be diagnosed and treated than white British women. South Asian women with depression do, however, visit their general practitioners regularly. Whether they have their depression recognized or not depends not only on whether the general practitioner is able to recognize depression but also on whether the patient tells the general practitioner about her worries. Those who believe that a doctor is the right person to deal with depression were found to be more likely to disclose information and more likely to be diagnosed and treated. (13> South Asian women are less likely than white British women to think that a doctor was the right person to deal with depression. (34> A 1-year follow-up of the sample of the Epidemiologic Catchment Area Program revealed that African-Americans, Hispanics, and other minorities were much less likely to have consulted with a professional in the specialized mental health care sector than white people. The odds of consultation in African-Americans, adjusted for other factors such as sex and diagnosis, was less than one-quarter of that in white people/35 Similarly, African-American children and adolescents may also remain undertreated compared to their white peers, although they may have higher levels of symptomatology/36ยป Differences between American ethnic groups are also apparent in populations with identical insurance coverage. (37) Therefore, these and other American findings3) suggest low permeability of filters on the pathway to mental health care for ethnic minorities and therefore lower levels of service use. Reasons for this may include that African-Americans are less inclined to seek professional help because of increased tolerance to depressive symptoms, but also because of fear of hospital admission. (39> In comparison to all other ethnic groups, African-Americans make more use of emergency rooms for routine psychiatric care.(40)

In spite of the low permeability of the filters on the pathway to care for many ethnic minority groups, there is an important over-representation of African-Caribbeans and African-Americans at the level of hospital-based psychiatric services. Possible mechanisms for this include failure of community services to engage mentally ill African-Caribbean men(41) and bypass of the usual filters by, for example, compulsory admission to hospital with or without police involvement. It has been shown that police involvement and compulsory admission to hospital is strongly associated with the absence of general practitioner involvement and the absence of help-seeking by a friend or relative.(4) Levels of perceived violence and rates of involuntary admission may be due to stereotyped attitudes of the police and mental health professionals or may be in part due to a higher rate of presentation of psychosis that is superimposed on intact premorbid personalities. It has been suggested that reactive forms of psychotic illness in African-Caribbeans are wrongly labelled as schizophrenia. (42) Higher functioning, less withdrawn patients may be perceived as constituting a higher risk by police and mental health professionals. Another factor is that, in spite of low rates of recognition by general practitioners, African-Caribbeans are most likely to be referred on to a specialist, followed by white people and then people from south Asia even when socioeconomic class and diagnosis are taken into account. (33>

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