The search for biological causes has not been fruitful. For instance, an association between biological risk factors and the rates of psychosis in African—Caribbean people has not been demonstrated (Sharpley et al, 2001). A number of social and service-related risk factors have been proffered to explain differences in illness rates, including socio-economic status, the role of psychiatry in social control, the validity of European illness models in ethnic minority groups, and the use of universalist rather than relativist approaches to psychopathology and diagnosis. These have rarely been investigated in depth and may be better studied using qualitative approaches rather than the quantitative epidemiological approaches that are currently relied on. Racism is a form of discrimination that stems from the belief that groups should be treated differently according to phenotypic difference. It is widespread in the UK (Modood et al, 1997). Racism has many forms; direct attack is less common than perceived discrimination in interpersonal communication, or inequity in the receipt of services or justice. It is easier to measure discriminatory acts such as racist attacks, but some believe that everyday minor incidents or slights (micro-aggressions) and the perception that society is discriminatory may have a greater impact on the individual's health (Laveist, 1996). Measurement of perceived racism is complicated by its possible overlap with paranoid ideation and an external locus of control. However, ‘paranoia’ may represent a healthy coping strategy in a discriminatory environment (Sharpley et al, 2001). The impact of discrimination is influenced by individual factors (such as socio-economic status, skin colour, and coping style), context (for example, where the incident happens, the extent of integration within an area, and the history of the minority group) as well as macro-economics, political ideologies and history (King & Williams, 1995). Longitudinally, racism produces and perpetuates socio-economic difference, and so controlling for this in analyses may decrease a valid association. Previous SectionNext Section
LINKS BETWEEN RACISM AND MENTAL ILLNESS
Despite this complexity there have been efforts to investigate possible links between racism and illness. Interpersonal discrimination
Research has mainly conceptualised racism as a stressor. An individual's perception of society as racist and the experience of everyday minor acts of discrimination are thought to constitute a chronic stressor. Individual, more overtly racist acts are considered as life events (acute stressors) that are superimposed on this chronic stress (Bhugra & Cochrane, 2001). In the USA, interpersonal discrimination has been associated with increased rates of hypertension, depression and stress; poorer self-rated health; and more reported days spent unwell in bed (Krieger, 2000). In the UK, both Burke (1984) and Fernando (1984) have documented relationships between depression and life events thought to be due to racism. Burke reported a 1.5-fold increased incidence of depression in a community sample of ‘West Indians’ living in Birmingham compared with Whites. However, this research has been criticised because of poor diagnostic reliability and outmoded analysis (Bhugra & Cochrane, 2001). There are case reports (but no clinical syndrome) describing the development of post-traumatic stress disorder after racist attacks. Gilvarry et al (1999) investigated life events in African and African—Caribbean patients with psychosis; these patients were as likely to suffer life events as Whites but more likely to attribute them to racism (Gilvarry et al, 1999). Recent qualitative work has reported that patients of Caribbean origin with psychosis were more likely to attribute their problems to racism than to their mental illness (Chakraborty et al, 2002). The Fourth National Survey of Ethnic Minorities provided UK evidence of a cross-sectional association...
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