admissions were diagnosed with psychosis, compared to less than half of the whites. In their
earlier article [1987] the authors reported that schizophrenia was the most common diagnosis
amongst African-Caribbeans admitted into prisons.

An argument has been put forward that the high proportion of diagnoses of schizophrenia
amongst African-Caribbeans can be explained by the fact that because intervention comes so later
than whites, they are sufficiently 'far gone' in their mental illness that their access is at the
coercive stage, and the only diagnosis that can be give is schizophrenia (Harrison [1988]).

Misdiagnosis was an unlikely explanation because second-generation Afro-Caribbeans
appeared to be at a greater risk of developing schizophrenia because there is a higher
proportion of people living alone and the greater likelihood of Afro-Caribbeans being
admitted compulsorily due to higher frequency of contact with Police and prison services.

This argument is the 'crisis point' argument, that black people are more likely to delay seeing a
doctor until they are at crisis point, living alone, getting no support, and getting into trouble
with police, then having to be sectioned (Francis [1989], Mind Raised Voices Littlewood and
Lisledge Aliens and Alienists [1997].

Perhaps diagnosis and culture are at loggerheads here. (See Diagram 2.) In a recent survey
conducted by PSI 1998 on mental health users, Roland Littlewood comments

One of the intriguing and most welcome findings of the PSI study is that the alarmingly
high rates of psychosis among people of Caribbean origin in Britain seem much less when
measured in the home by members of the same ethnic group than when they are assessed
by white psychiatrists in the hospital, and this opens up a demand for future study to look
at how institutions like prisons and psychiatric units might enhance the figures of
pathology. Not so reassuring is the previously unknown frequency of depression and
suicidal thoughts among Caribbeans and that they appear to see their family doctors for
these difficulties but do not receive any treatment.

The argument that black people see their doctors too late and therefore develop schizophrenia
appears to undercut the claim that psychiatrists are more likely to misdiagnose schizophrenia
when presented with black patients. I am not going to try to resolve this issue. It seems to me
that both explanations are partially correct. The least one can say is that either the mental health
system fails black people at one point or another. Either way, it fails.

Speaking at a Conference on black mental health in Kirklees Dr Aggrev Burke saw the health
services as involving five levels of care: Family, GPs, social services, voluntary in-patients, or
locked up:

There is a significant over-representation of black people at the 5th level and it is
understandable that most of the concern is at this level. There is a lot of work to be done at
the earlier levels. If the expertise, creativity and perspective of health professionals were
diverted at earlier levels of intervention the results would be much more positive and
benefits a greater number of black people (Ethnic Health Project [1991]).

3. Health of the Nation 1992: What went wrong?

In the Government document Health of the Nation: A Strategy for Health in England [1992] five
main areas for improvement were singled out. Mental health was one. Mental health had a
devastating impact on the lives of all concerned. So the government aimed to improve mental

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