“To some extent, people who are insane are nonconformists, and society and their family wish they would live what appear to be useful lives.” – Nobel Prize Winner John Nash Who Suffered From Schizophrenia
The median global prevelance of schizophrenia has been estimated at 4.6 per 1000 of the general population. In the UK, a GP with an average list size of just under 2000 patients can expect to care for about eight patients with Schizophrenia, and possibly 12 if their practice is in an urban area. But the incidence rates of Schizophrenia in UK-resident Black-Carribeans have been consistently reported to be a great deal higher. When these findings were first reported many assumed it to be a first generation migrant effect or merely the result of methodological artefacts associated with inconsistencies in the diagnosis of schizophrenia in black carribeans. More recently however it has become clear that incidence rates of schizophrenia is even higher in second generationUK Black-Carribeans.
There was an enormous study conducted by the UK based Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP). It looked to examine the ethnic variations in schizophrenia incidence in the UK. In 2006, it was reported that there is a ninefold increase in the risk of developing schizophrenia in the UK Black-Carribeans when compared to the white British population. To put it into perspective Black Africans had a 5.8 increased likelihood and South Asians had a 1.4 increase. These findings are a big concern to Black-Carribean communities in Britain, to their GPs and to health service management responsible for their wellbeing. So why is Schizophrenia more prevalent in UK based Black Carribean communities?
Genetics seems to be quite a powerful risk factor in the development of schizophrenia.
The lifetime risk increases with genetic relatedness: 2% in third-degree relatives (first cousins); (uncle/aunt) to 6% (half-siblings) in second degree relatives; and 6% (parents) to 9% (siblings) in first degree relatives of suffering individuals. For twins, the risk is highr still: 17% for dizygotic twins and 48% for monozygotic twins.
Since studies have demonstrated a genetic contribution, it would then be that schizophrenia among Black-Carribeans are a feature of the emigrated rather than the native community. And indeed studies have found pretty similar levels of Schizophrenia in both populations. But there is still a huge argument stating that UK-based clinicians can do more to better protect the UK-resident Afro-Carribean community.
Alot of the time with psychiatric diagnoses, the process has a slightly subjective element. This may mean that clinicians may diagnose incorrectly at times. Clinicians are like average people, and can sometime carry limited biases that may impact the diagnosis of schizophrenia in UK based Black-Carribeans. To quantify the possibility of clinical bias, British and Jamaican psychiatrists were compared. The british psychiatrists classified 62% of Afro-Carribean patients as having schizophrenia where as the Jamaican psychiatrists recorded this diagnosis for 55% of these patients. ‘Race thinking’ (resorting to cultural stereotypes), and examples of institutional racism within the mental health service (discriminatory within an organisation) may also result in a degree of clinican bias in everyday practice. Cultural differences may also contribute to diagnostic error. At one extreme, Fernando has argued that existing cross-cultural incidence studies are flawed by the ‘category fallacy’ whereby western definitions of mental illness are applied to non-western cultures. Differences between cultures in the way hallucinations and religious experiences are regarded may have contributed to excess diagnoses in ethnic minority groups, as many non-western cultural beliefs could be considered to overlap with features of schizophrenia. The role that clinician bias plays in diagnoses of Schizophrenia in UK Black-Carribeans is often overlooked, but it is an incredibly important discussion to be had.
TREATMENT AND PATHWAYS TO CARE
Another issue that has to be mentioned is the marked differences between African-Carribean and white British patients with psychosis in terms of their pathways to care. Black Carribeans typically follow adverse pathways during their first and subsequent episodes of psychosis they are more likely to experience compulsory admission, more likely to be referred to psychiatric services through the criminal justice system, less likely to be referred by a GP, and have more protracted untreated symptoms during their first episode of psychosis. This difference in treatment between the two ethnic minority groups is slightly alarming to say the least. Are UK Black-Carribeans receiving the same care that White British people are when their psychotic epsiodes begin?
The association of schizophrenia with unemployment, poverty, and lower social class is well known. Urbanicity itself is associated with the incidence of schizophrenia, even allowing for confounding by known socioeconomic indicators, with growing up in an urban environment increasing the risk of developing schizophrenia later on in life by a factor of around 1.7. Since most Black-Carribeans in the UK live in inner city areas, and growing up in an urban area contributes to the risk of developing schizophrenia, it can be argued that undertermined factors operating in an urban environemnt may account for some of the ethnic variations in incidence. Levels of social and family support may also play a role in the excess incidence of schizophrenia in UK Black-Carribeans. Parental separation and loss before the age of 16 years were found to be strongly associated with the onset of psychosis. UK resident Black-Carribeans living in predominantly white neighbourhoods have been found to have a higher incidence of schizophrenia. This has been termed, the ‘ethnic density effect’, and may be another expression of social isolation. Individuals living in areas where their own ethnicity constitutes a smaller proportion of the local population have been reported to feel excluded from local social networks. It seems that many Schizophrenic episodes may be triggered by feeling of social isolation. Being Black-Carribean in a largely white society with limited community support may be a reason behind the increased incidence of Schizophrenia in these communities.
Psychological factors appear to play a large role in the development of Schizophrenia, adversity in many forms appears to contribute to higher rates of Schizophrenia, but attitudes to adversity are also likely to play a role. Studies show that migrants whose skin colour is substantially darker than that of the native population are most vulnerable to schizophrenia. Racism based on the darkness of skin colour rather than merely on ethnic grouping may account for such findings, and perception of racism have been found to increase according to skin darkness. Larger visible differences between an ethnic group and the host population may enhance an outside status. Again it seems that the darker you are in a predominantly white society means the greater amount of racism you may receive.
The higher level schizophrenia in Black-Carribeans living in the UK probably reflects the interaction of multiples risk factors, many of which cluster in the Black-Carribean community in the UK. Particularly significant factors appear to be the combination of isolation and exclusion, both within society (living in areas of low ethnic density and reduced participation in society) and within the family (family break-up and paternal separation). These factors seem to be more powerful than socioeconomic disadvantage, which is more likely to be a consequence than causal. Racism itself may contribute to social exclusion, further increasing the vulnerability to schizophrenia.