journal of mental health promotion journal of mental ...

PUBLISHED BY Pavilion The Ironworks Cheapside BRIGHTON BN1 4GD Telephone 0044 (0) 1273 623222

journal of mental health promotion VOLUME ONE • ISSUE ONE • APRIL 2002

Fax 0044 (0) 1273 625526 Email [email protected] Website www.pavpub.com

CONTENTS EDITORIAL Lynne Friedli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 GUEST Remembering the Forgotten Standard EDITORIAL Louis Appleby . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 FEATURE Transcultural Mental Health Promotion Kamaldeep Bhui and Katja Rüdell . . . . . . . . . . . . . . . . . . . . . . . .8

EDITOR Lynne Friedli ASSISTANT EDITOR Mary Tidyman mentality 134–138 Borough High Street London SE1 1LB Telephone 020 7716 6777 Email [email protected] ISSN 1462–3730

USER ABWA: A Better Way Ahead PERSPECTIVE Eileen Philip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 REVIEW Mental Health Promotion and the Early Years: The Evidence Base: Risk, Protection and Resilience Mike Titterton, Malcolm Hill and Helen Smart . . . . . . . . . . . . .20 RESEARCH Not all in the Mind: Mental Health Service User Perspectives on Physical Health Lynne Friedli and Claudia Dardis . . . . . . . . . . . . . . . . . . . . . . .36 RESEARCH Research and publications update . . . . . . . . . . . . . . . . . . . . .47 UPDATE

The views and opinions expressed by authors are their own. They do not necessarily reflect the views of their employers, the Journal, the Editorial Board or Pavilion Publishing.

PAVILION EDITOR Liz Mandeville TYPESETTING

Pavilion PRINTED IN Great Britain by Selwood Printing, West Sussex

Copyright for all published material in this journal is held by Pavilion Publishing (Brighton) Limited unless specifically stated otherwise. Authors and illustrators may use their own material elsewhere after publication without permission but Pavilion Publishing asks that this note be included in any such use: ‘First published in Journal of Mental Health Promotion VOLUME 1 ISSUE 1.’ Subscribers may photocopy pages within this journal for their own use without prior permission subject to both of the following conditions: that the page is reproduced in its entirety including the copyright acknowledgements; that the copies are used solely within the organisation that purchased the original journal. Permission is required and a reasonable fee may be charged for commercial use of articles by a third party. Please apply to Pavilion Publishing for permission.

Kamaldeep Bhui

Feature

Senior Lecturer in Social & Epidemiological Psychiatry

and Katja Rüdell PhD Student Department of Psychiatry, Barts & London Medical School

Transcultural Mental Health Promotion ABSTRACT This paper explores the main issues in the promotion of mental well-being among ethnic and culturally distinct groups in the United Kingdom. A specific UK focus is adopted because of the local idiosyncrasies in policies, practices and organisational cultures through which health and social care are delivered. In addition, general issues of assessing, weighing up and responding to distress among cultural minorities are also considered. We define transcultural health promotion in terms of ‘cultures’, within which ethnic and racial categories are constructed. Cultures are ‘systems of shared ideas, systems of concepts and rules and meanings that are expressed in the ways human beings live’ (Keesing, 1981). When discussing research evidence we will use the terms used in the original research papers.

Background Cross-cultural research shows that diverse cultural groups and ethnic minorities have different levels of mental disorder and vary in their requirements for and take-up of mental health care. Research evidence over several decades has shown that black people of African and Caribbean origin are over-represented in more restrictive levels of mental health services, that is as in-patients, either voluntarily or by compulsion under the powers of the Mental Health Act (Bhui, 1997; Bhui & Olajide, 1998; Bhugra & Bahl, 2001). Generally speaking, the small volume of work so far on South Asian groups suggests that they are less likely to use in-patient services, but they do visit their general practitioners often (Gupta, 1991; Balarajan et al, 1989). In addition, deliberate self-harm and suicide rates are higher among South Asian women (Soni Raleigh et al, 1990; Soni Raleigh & Balarajan, 1992). However, there are significant information gaps. Other cultural groups such as the Irish have, historically, been given less consideration, since it is often assumed that they have the same health care needs as the majority white British population (Bracken et al, 1998). Furthermore, there is little information on Chinese or Vietnamese people, refugees and asylum seekers, or other white nonBritish groups. The evidence suggests different pathways to in-patient care for individuals from diverse cultural groups, and differential management by professionals (Bhui & Bhugra, 2002a).

8

Health promotion is problematic here, as campaigns for better mental health promote the values and lifestyles of the majority culture, which, having no relation to the implicit rules of other cultural groups, are not always taken up. For example, in industrialised nations the treatment of mental distress and mental disorder has evolved into an elaborate system of care in the statutory sector. In many parts of the world people do not automatically consider health and social care agencies as appropriate sources of help. In addition, the structure of psychiatric services, which are often large impersonal organisations, lacking in continuity of care, will also lead some people to avoid services or seek help from alternative sources. For example, African Caribbean people are firmly engaged with mental health services that offer little choice over alternative treatment strategies (Goater et al, 1999; Takei et al, 1998; Davies et al, 1996). As a result, they may fear contact with services and avoid them due to the expectations of forcible treatment that is insensitive to the nature of their health problem, their social care needs and their subjective ‘understanding’ of their condition.

Contextualising transcultural mental health promotion Clinicians, managers and policy-makers now recognise that, among the explanations for variations in service use, culturally determined

journal of mental health promotion • VOLUME 1 • ISSUE 1 • APRIL 2002

© Pavilion Publishing (Brighton) Ltd

Transcultural Mental Health Promotion

Feature

health beliefs, culturally determined styles of coping with distress,

they come into contact with mental health services that replicate

expectations of recovery and previous experiences of services are all

the discriminatory attitudes and procedures found in society in

influential. Social exclusion may be reinforced by variations in

general (Trivedi, 2002; Bhui, 2002). Hence, health promotion

knowledge about available health services and economic resources to

must address these issues at a national, local and individual level

travel to and use services. There are also societal issues to do with the

(see Box 1, below).

position and status occupied by socially excluded groups. Black and ethnic minorities largely live in inner city areas with

BOX 1 Transcultural mental health promotion –

disproportionately high levels of exposure to poverty, noise,

general interventions on national, local and

unemployment and fragmented communities. These environmental

individual levels

factors can affect mental health and can lead to poorer health outcomes, including depression, mediated by stress and the

National intervention

physiological responses to it (Bhui, 2001; Ostler et al, 2001).

•

Address and inform the public of the detrimental

Exercise is known to mediate a protective role against common

effects of cultural discrimination, determine how

mental disorders, and is also advocated as an effective intervention to

these discriminatory attitudes are generated and

reduce mental health and cardiovascular problems (Bhui & Fletcher,

maintained in the general population and challenge

2001). Promoting physical activity is therefore important, but the

them

assumption is that all groups have adequate access to leisure facilities,

•

time for leisure and disposable income to devote to leisure.

construct and conceptualise mental ill-health to

Social exclusion is known to be associated with poorer health.

design culturally appropriate material to promote its

Experiences of discrimination and prejudice further diminish self-esteem and confidence, and can add to a sense of

Establish how individuals from ethnic minorities

prevention

•

Determine cultural groups’ knowledge of mental

disempowerment. In the UK, institutionalised discrimination has

health services and preferences for treatment to

been receiving much attention, largely due to the MacPherson

establish and meet the demand for statutory and

Inquiry into allegations of institutionalised racism and

alternative mental health services in the community

discriminatory practices, but also more recently, due to the

•

Review health and social care in terms of access

Human Rights Act and the Race Relations Act (Amendment

procedures and culturally inappropriate practices to

2000). They emphasise both individual and organisational

determine how they may deter the uptake of

culpability for racial or cultural discrimination and particularly

treatment and care, and remove them

emphasise change in the voluntary and statutory sector, including NHS trusts. The health impact of racism, previously sidelined as

Local

a focus in research and policy, has gathered momentum as a

•

Raise awareness of mental health issues in cultural

subject of legitimate study. Studies of black and other ethnic

groups to ensure appropriate promotion, prevention

minorities subjected to racism in society link poorer health

and detection

outcomes directly to racist experiences producing adverse

•

Support individuals with mental illness from cultural

physiological and psychological effects (Klonoff et al, 1999). To

groups and their families to overcome barriers to

make things worse, if victims of discrimination become ‘mentally

seeking help and accessing effective treatments

ill’ as a consequence, they frequently face discrimination when



9


Feature

•

Target specific population groups living locally with

intervene or interfere with their perceived main sources of

particular risks (such as African Caribbean people

distress, which were social issues.

who appear to be at higher risk of schizophrenia and

We found that both groups were troubled by unemployment,

Asian women who are at higher risk of deliberate self-

discrimination, family conflicts and poverty. These are often of

harm and suicide)

greater importance than emotional distress for individuals who face considerable strain during migration and must adjust to inner

Individual

city life predominantly characterised by deprivation. Emotional

•

Intervene with culturally appropriate promotion and

distress in this situation may be considered to be inevitable and

care for individuals from diverse cultural groups with

not amenable to interventions. In addition, it seems that good

mental illness to achieve optimal recovery and

(mental) health is often considered as a prerogative, taken for

prevent relapse

granted until a problem develops. In the absence of early mental health promotion work at a population level, distress and illness

General or specific transcultural mental health promotion

then become established in the context of deeply ingrained

See Box 2, opposite.

behaviours. They are then more difficult to modify.

patterns of work, lifestyle, risk perception and health-related

Health care is not always the first priority for people facing irrespective of cultural group, having a safe place to sleep at night,

Cultural conceptualisation of mental distress

securing a job and regular income, having friendships and social

While people from Western and industrialised countries are generally

contact are more important. If individuals are to struggle to meet

conversant with psychological models of distress, specific cultural

these basic human requirements, it is important for them to be

groups advocate quite different views of what constitutes distress

resilient and avoid mental illness to achieve their goals. To make

(Sulaiman et al, 2001). Cultures that do not hold psychological

health promotion effective for ethnic minorities, careful

models of distress will be less likely to appreciate the role of

consideration is necessary to overcome these obstacles, and to

psychological or psychiatric services in recovery. Alongside the

prioritise health and mental well-being as determinants of well-

necessity to raise awareness and trust is the obligation to ensure that

being. For transcultural mental health promotion, it is even more

the care offered is culturally appropriate, does not violate cultural

imperative to devise appropriate approaches and ways of working.

taboos and does not replicate institutionalised discriminatory

multiple financial and social challenges. Indeed, for all people,

In our ongoing research, Somali people in East and South

practices. Where there is a markedly different cultural understanding

London are reluctant to talk about ‘mental illness’. They equate

of mental distress, including its genesis and resolution, greater levels

this term with severe psychosis and ‘out of control behaviour’

of public awareness of the symptoms of common mental illnesses and

commonly translated as ‘madness’. More distinct and greyer

the range of potential interventions are helpful. This may still not

shades of distress are difficult to communicate, and talking to

promote accessibility to health care if the rationale for the care is not

Somali people in these terms simply perplexed them. Similarly,

communicated, and where communicated is not accepted, and if risk

our work among Punjabi Asians in South London found that

perceptions favour alternative healing traditions.

they were aware of emotional difficulties, but did not consider general practitioners had the necessary expertise or authority to

10




Feature

BOX 2 Specific issues for transcultural mental

•

Determine and consolidate the different role of treatments in mental health and how professionals

health promotion

can aid recovery and functioning General public

•

Provide detailed education about particular

• •

discriminatory attitudes and challenge complacency

•

Raise awareness among professionals of how transcultural mental health issues require greater

•

•

•

Encourage and enable individuals to take care of their physical health

•

Develop opportunities for sports and activities for

Promote physical activity as a way to promote mental

people with mental illness and educate patients and

health and prevent mental illness; identify the

staff about the beneficial effects of diet and healthy

benefits of a healthy diet and lifestyle and the impact

lifestyles

of alcohol and substance intake

•

Inform individuals about their entitlements and legal rights

skill and resources (health, social, legal, criminal justice, housing)

Increase awareness of groups providing culturally relevant advocacy and social and day care

•

towards them

Avoid admissions through the Mental Health Act

Reduce stigma about mental distress and illness in

• •

Encourage social skills and friendships Increase awareness of the impact of using drugs and

certain communities

alcohol and develop culturally sensitive interventions

Determine and target the origins of stress, distress

to target this

and mental illness

• • • •

Increase awareness of common signs and symptoms

Stigma

of mental distress in self and family and friends

A survey of attitudes assessing the success of deinstitutionalisation

Increase awareness of methods to deal with crises

programmes aimed at reintegrating mentally ill individuals found

(self-help and seeking help)

that minority groups had greater reservations about mentally ill

Increase awareness of services, different professionals

people living close to them, and were more fearful that their children

and their roles

or family would come to some harm (Wolff et al, 1996a). This

Increase awareness among individuals from different

highlights the existence of negative stereotypes of the mentally ill

cultural groups of the importance of social

among cultural groups, which may impede the complete recovery

interaction and support

and successful community functioning of people who have had mental illness. It also suggests that there is a higher level of

People with mental illness

• •

Identify sources of help in a crisis and establish easy

stigmatisation of mental illness among some ethnic groups. The need for culturally sensitive and appropriate information

routes to access them

about mental distress, disorders and the range of treatments and

Increase awareness of the signs and symptoms of

interventions, plus campaigns to reduce stigma, is evident. Some

relapse

excellent mental health promotion material was developed by colleagues in North Birmingham (Mental Health Media, 2000). Because film is a popular and effective medium for



11


Feature

communication with South Asian groups, they developed a series

medication without appearing to know what it was for, or what the

of video productions and workbooks on suicide and mental

name of their condition was, even when they were detained in

illness. These raise issues of oppression of women, unequal

hospital (Bhui et al, 2001). Thus, people with diagnosed mental

treatment of male and female children in the household,

illnesses and those in contact with mental health services also need

domestic violence and the daily pressures on men that may be

specific information. The need for such work is especially great where

understood as depression. They show how unemployment,

expectations about recovery differ from the professionals’ views and

financial strain and family conflicts can be managed in a hopeful

even more where the services encountered by recent migrants are

and non-pathological way, while revealing how existing services

different from those found in their home countries.

can play a role in recovery. Drawing on authentic experiences and realities of the lives of South Asian communities can capture

Physical health

their attention while delivering important information. It also

It is known that people with severe and enduring mental illness have

encourages reflection on a range of cultural barriers to better

a higher risk of premature death not only from suicide but also from

mental health, heightening interpersonal communication and

alcohol and substance misuse (Hiroeh et al, 2001). People with severe

showing the possibility of complete recovery from distress.

mental illnesses such as schizophrenia are more likely to smoke

This work can also achieve its goal of a reduction of the

heavily, indicating a high level of addiction to nicotine. They are also

stigmatisation associated with depression and domestic violence.

less likely to be successful at quitting smoking. In addition, even

It is imperative that such materials are unambiguous and do not

though tobacco consumption has been identified as the largest cause

denounce the attitudes and rules that are prevalent in these

of premature death and has been associated with a tremendous

cultures, or pathologise them and ask for their removal.

amount of disability and suffering from smoking-related disease, the

Transcultural mental health promotion should work with people

opportunity to intervene is often neglected in mental health care.

to encourage them to find alternative solutions for mental

Individuals who suffer from mental health problems should not be

distress, possibly promoting the use of traditional and culturally

treated as second-class individuals by health professionals.

appropriate care alongside statutory mental health services. For

During the publication of the revised guidelines for smoking

example, for severe and disabling states of changed function,

cessation in Britain, smoking cessation specialists introduced

medical, social and psychological interventions may shorten

what they flippantly called the ‘Bangladeshi model’ of quitting

social and emotional distress and disabilities.

smoking. They observed that Bangladeshi individuals who claimed to have given up smoking could still be found to have

Mental health promotion is relevant to everyone

the abnormal levels of carbon monoxide only found in smokers.

Preventive public health campaigns are often perceived to be the

system that equated ‘stopping smoking’ with not buying

mainstay of mental health promotion because they reach more people

cigarettes. When cigarettes were passed on from others, which

and produce greater population health benefits than strategies that

appeared to be a common phenomenon in the Bangladeshi

only promote health among those with diagnosed conditions.

community, they regarded it as not affecting their non-smoking

However, health promotion interventions with mentally ill people

status. It is necessary to intervene and change these habits and

should not be neglected. A small exploratory study among Asian men

beliefs in a way that is non-patronising and culturally

in contact with mental health services found that individuals’

appropriate. Furthermore, the detrimental effects of inhaling

assessments were insensitive to their religious views. Men received

cigarette smoke and supportive approaches to quitting all need to

12

After long discussions with their clients, they elicited a belief




Feature

be communicated in an appropriate dialect and a culturally

information yielded may not always be generalisable. Recently,

meaningful package of intervention.

inventories have been developed to ascertain cultural health beliefs

Psychiatric patients taking psychotropic medication are also

and indigenous explanatory models of distress (Bhui & Bhugra,

at risk of weight gain, which is also linked to poorer health. The

2002b). Kleinman (1988) proposed eliciting people’s ‘explanatory

standardised mortality rates for all causes are significantly higher

model’ by exploring with them their understanding of their

among people with schizophrenia than the general population.

problems. Some open-ended questions included: What is the

Specifically, circulatory, endocrine, nervous and respiratory

problem? Is it an illness? What causes it? What can be done about it?

disorders, alongside suicide and smoking-related diseases, are all

What can doctors do? This approach should be used before imposing

higher (Brown & Barraclough, 2000). Among those not

particular solutions on culturally different groups, so that

considered to have a mental illness, it is known that mortality

practitioners can gain a better appreciation of how service users

rates among South Asian groups are especially high for ischaemic

construct their difficulties and whether any health promotion advice

heart disease and diabetes (Balarajan, 1991; Balajaran et al,

is discordant with their beliefs about their problem and its alleviation.

1984), while Bangladeshi and African Caribbean people are at

In some pilot work, we found that Somalis and Punjabi

higher risk of death due to stroke, irrespective of mental health

Asians found it easier to think freely about distress depicted in

problems (Balarajan, 1995). Health promotion efforts should be

vignette material than to talk about their own distress. We were

aimed at these areas irrespective of the presence of mental illness.

able to elicit some culturally unique explanations for distress

To develop effective health promotion strategies for different

alongside more general issues including unemployment, racism,

ethnic groups, language, indigenous understandings and

possession by spirits, relationship problems and financial

sometimes competing views about the origin of disabilities,

hardship. Treatment approaches included seeing doctors and

taboos and appropriate ways of reaching groups all need careful

health professionals, but also culturally-informed and sanctioned

consideration. Where translation is necessary, it should be

approaches such as reciting religious scripts, using holy water and

conducted by bilingual and psychologically informed people who

seeking advice at mosques.

are grounded in the cultures of interest; technically precise

A key problem for practitioners is that models of mental

translations can be virtually unusable as health-promotional

illness and distress tend to be determined by evidence from

materials. The delivery package must be attractive and raise

research and practice that often assumes a degree of universality.

curiosity as well as engage the cultural groups of interest in the

Rarely are the expectations and culturally appropriate rules for

types of health problem being targeted.

treatment determined directly from service users. Service users are able to come up with innovative methods to manage their

Somalis’ and Punjabi Asians’ constructions own distress, even if these methods have not found a place in conventional therapies backed up by clinical trial evidence of mental distress: an example of (Warnes et al, 1998; Bhui et al, 1998). The more recent emphasis indigenous beliefs In order to focus health promotion efforts towards black and ethnic

on quality of life and user-defined outcomes, such as recovery, is

minority groups, there needs to be a developmental stage to explore

welcome, but has not found a place in health promotion

indigenous understandings of health and illness and the world-view

material. These concepts warrant greater research, exploration

of service users. Although there are no generally agreed methods for

and application, as they may be better indicators of improvement

doing this, ethnography and participant observation methods to

in function, irrespective of professionalised measures of symptom

explore cultures are useful. They are, however, time-consuming and

alleviation. Their validity in different cultural groups also needs



13


Feature

exploration (Collinge et al, 2002; Onwumere & Bhui, 2002).

Publishers.

Mental health outcome measures and health promotion tools

Bhui, K., Aubin, A. & Strathdee, G. (1998) Making a reality of usercentred psychiatry services. Psychiatric Bulletin 22 (1) 8-11.

that are developed without attention to the limitations of these across cultural, linguistic and religious boundaries are less likely to have the desired effect. We have outlined the issues in developing a comprehensive approach to transcultural mental health promotion. All efforts should aim to maximise the chances of successful intervention in terms of health outcomes, not only in terms of greater knowledge. The impact of such interventions on the future mental health and well-being of ethnic groups remains to be demonstrated in future work. For more information contact Dr Kamaldeep Bhui on: Tel 02078827842 Email [email protected] Department of Psychiatry, Barts & London Medical School, Institute of Community Health Sciences at Queen Mary University of London, London E1 4NS

References Balarajan, R. (1991) Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. British Medical Journal 302 (6,776) 560-4. Balarajan, R. (1995) Ethnicity and variations in the nation’s health. Health Trends 27 (4) 114-9. Balarajan, R., Bulusu, L., Adelstein, A. M. & Shukla, V. (1984) British Medical Journal Clinical Research Ed. 289 (6,453) 1,185-7. Balarajan, R., Yuen, P. & Soni Raleigh, V. (1989) Ethnic differences in general practitioner consultations. British Medical Journal 299 (6,705) 958-60. Bhugra, D. & Bahl, K. (2001) Ethnicity and Mental Health: An Agenda for Change. London: Gaskell Publishers. Bhui, K. (1997) Service provision for London’s ethnic minorities. In: King’s Fund Institute London’s Mental Health. London. Bhui, K. (2001) Physical activity and stress. In: M. Marmot & S. Stansfeld (Eds) Stress & The Heart. London: BMJ Books. Bhui, K. (2002) Racism & Mental Health. London: Jessica Kingsley

14

Bhui, K. & Bhugra, D. (2002a, in press) Mental illness in Black and Asian ethnic minorities: pathways to care and outcomes. Advances in Psychiatric Treatment (8) 26-33. Bhui, K. & Bhugra, D. (2002b, in press) Explanatory model of distress: clinical and research implications. British Journal of Psychiatry. Bhui, K., Chandran, M. & Sathyamoorthy, G. (2001) Mental Health Assessment & Asian Men. London: Confederation of Indian Organisations (UK). Bhui, K. & Fletcher, A. (2001) Common mental disorders and physical activity: gender differences in the protective. Social Psychiatry & Psychiatric Epidemiology 35 28–35. Bhui, K. & Olajide, D. (1998) Mental Health Service Provision for a Multi-cultural Society. London: Saunders. Bracken, P., Greenslade, L., Griffin, B. & Smyth, M. (1998) Mental health and ethnicity: an Irish dimension. British Journal of Psychiatry 172 103-5. Brown, S. & Baraclough, B. (2000) Causes of excess mortality of schizophrenia. British Journal of Psychiatry 177 212-7. Collinge, A., Rüdell, K. & Bhui, K. (2002) Quality of life and cultural psychiatry. Unpublished manuscript. Department of Psychiatry. Institute of Community Health Sciences. Queen Mary. Davies, S., Thornicroft, G., Leese, M. et al (1996) Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London. British Medical Journal 312 533-7. Goater, N., King, M., Cole, E., Leavey, G., Johnson-Sabine, E., Blizard, R. et al (1991) Ethnicity and outcome of psychosis. British Journal of Psychiatry 175 34–42. Gupta, S. (1991) Psychosis in migrants from the Indian subcontinent and English-born controls. A preliminary study on the use of psychiatric services. British Journal of Psychiatry 159 222-5. Hiroeh, U., Aappleby, L., Mortenson, P. B. & Dunn, G. (2001) Deaths by homicide, suicide, and other unnatural causes in people with mental illness. A population based study. Lancet 358 2,110-12 . Keesing, L. M. (1981) Cultural Anthropolgy: A Contemporary Perspective. New York: Holt Reinhardt & Winston. Kleinman, A. (1988) Re-thinking Psychiatry: From Cultural Category to Personal Experience. New York: The Free Press. Klonoff, E., Landrine, H. & Ullman, I. B. (1999) Racial discrimination and psychiatric symptoms among blacks. Cultural Diversity & Ethnic Minority Psychology 5 (4) 329-39.




Feature

Mental Health Media (2000) Video material and Workbooks (Talking about suicide & Man Ki Baat) 356 Holloway Rd. London N7 6PA. (Tel 0207 700 8171) Onwumere, J. & Bhui, K. (2002) Recovery and schizophrenia. Unpublished manuscript. Department of Psychiatry, Institute of Community Health Sciences, Queen Mary University of London. Ostler, K., Thompson, C., Kinmonth, A. L. K. et al (2001) Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care. British Journal of Psychiatry 178 12-7. Soni Raleigh, V., Bulusu, L. & Balarajan R. (1990) Suicides among immigrants from the Indian subcontinent. British Journal of Psychiatry 156 46-50. Soni Raleigh, V. & Balarajan R. (1992) Suicide and self-burning among Indians and West Indians in England and Wales. British Journal of Psychiatry 161 365-8.

Takei, N., Persaud, R., Woodruff, P., Prockington, I. & Murray, R. M. (1998) First episodes of pyschosis in Afro-Caribbean and white people - an 18-year follow-up population-based study. British Journal of Psychiatry 172 147-53. Trivedi, P. (2002 in press) Racism, social exclusion and mental health – a black user’s perspective. In: K. Bhui (Ed) Racism and Mental Health. London: Jessica Kingsley Publishers. Warnes, A., Strathdee, G. & Bhui, K. (1998) On learning from the patient: hearing voices. Psychiatric Bulletin 20 (8) 490-2. Wolff, G., Pathare, S., Craig, T. & Leff, J. (1996a) Community knowledge of mental illness and reaction to mentally ill people. British Journal of Psychiatry 168 (2) 191-8. Wolff, G., Pathare, S., Craig, T. & Leff, J. (1996b) Community attitudes to mental illness. British Journal of Psychiatry 168 (2) 183-90.

Sulaiman, S. O., Bhugra, D. & DeSilva, P. (2001) Perceptions of depression in a community sample in Dubai. Transcultural Psychiatry 38 (2) 201-18.



15