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Summary This chapter looks at some of the experiences of patients of Black (African and African–Caribbean) descent in forensic psychiatric hospitals and the likely effects of some aspects of the new mental health legislation in England and Wales. It describes the difficulties in meeting the objectives set out in the government's Delivering Race Equality programme and makes suggestions on the way forward through a focus on reducing length of stay in institutions, implementing preventive strategies to reduce the number of people who move into tertiary psychiatric services and improving the experience of those in hospital through a cultural consultation intervention.
The experience of Black service users within forensic psychiatric services in the UK has remained largely unchanged over the past decade. It is similar to that of Black patients in secondary mental healthcare services, as summarised in a Department of Health publication Inside Outside (Sashidharan, 2003). This document brought together evidence from clinical and epidemiological research, clinical observations, anecdotal accounts and testimonies of service users and carers. It summarised the problems of mental healthcare as experienced by Black and minority ethnic groups to be:
• the overemphasis on institutional and coercive models of care
• the prioritising of professional and organisation requirements over individual needs and rights
• institutional racism within mental healthcare services.
Despite the conclusion reached by Professor Sashidharan in Inside Outside, the Department of Health disagrees with the existence of institutional racism (also called structural or systemic racism) in mental healthcare services. Retired judge Sir John Blofield, in the independent report following the death of David Bennett in a medium secure unit, reported that institutional racism was present throughout the National Health Service (NHS) and that greater effort was needed to combat it. He noted that until that problem is addressed, people from Black and minority ethnic communities will not be treated fairly. He described the experiences of patients poignantly: ‘the black and minority ethnic community have a very real fear of the Mental Health Service.
This chapter describes the classical subtypes, differential diagnosis, epidemiology and genetics of schizophrenia and related disorders. Relatives are examined for some of the biological abnormalities which are found in their schizophrenic kin. The relatives of patients with schizophrenia have also been reported to be more likely than control subjects to have poor performance on cognitive tests measuring memory functions. The discovery of risk factors acting in early life has been central to the neurodevelopmental hypothesis of schizophrenia. Magnetic resonance imaging (MRI) studies have consistently demonstrated that people with schizophrenia have increased lateral ventricular volume and also show a slight decrease in cortical volume with greater decrements in the hippocampus, amygdala and thalamus. Children destined to develop schizophrenia often have subtle developmental delays and deficits in motor and cognitive function, tend to be solitary and show an excess of social anxiety. The chapter reviews the essential principles of management for psychosis.