Disproportionate numbers of Afro-Caribbeans in Britain are diagnosed as mentally ill. Is the cause racial or environmental? Geoff Watts reports.

The long-standing and deeply troubled relationship between race and mental illness can be boiled down to two questions. Is there a link between ethnicity and the risk of being diagnosed as mentally ill? And, if so, are you really more likely to be mad if you are black?

The latest effort to answer these politically charged questions comes from medical sociologist Rosemarie Mallett. With the backing of the Centre for Caribbean Medicine, she and colleagues at London's Institute of Psychiatry have carried out a small but searching analysis of the social and psychological factors underpinning schizophrenia in British Afro-Caribbeans. Their conclusion: that race does play a part, but not a direct one.

It is several decades since psychiatrists first noticed a disproportionate number of black people with schizophrenia. Cultural misunderstanding of behaviour patterns alien to predominantly white psychiatrists was one reason put forward. Tighter definitions of mental illness have helped scotch that idea, but the disproportionate numbers remain.

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Many psychiatrists have been keen to demonstrate that theirs is a "proper" branch of medicine in which illness can be shown to have a physical cause. This search for biological explanations - partly a reaction against mid-20th century tendency to show how all mental illness is caused by society and partly a response to techniques such as brain scanning - was at its peak in the early 1990s when Mallett joined the Institute of Psychiatry.

Despite her background as a medical sociologist, she has no desire to return to an emphasis on social factors at the expense of biological ones, believing that both play a part; her aim is to define the social influences.

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"Let's say that biological factors are the bullet and social factors are the trigger," she says. "If the bullet sits in the gun and nobody fires it, nobody will get killed."

In an earlier study, she compared the rate of psychiatric illness among London's Afro-Caribbean population with the rates in Trinidad and Barbados. The London rate was higher, suggesting an environmental factor of some kind.

In her latest work, she and her collaborators have examined the circumstances of black, white and Asian patients with schizophrenia and compared them with similar groups of healthy individuals. What emerged was that Afro-Caribbean patients were significantly more likely to be unemployed and to have been separated from one or both parents at an early age.

On looking at her subjects' perception of racial disadvantage and at the number of incidents of racism they had experienced, she found no evidence of a direct link to their illness. Which is not to say that race is irrelevant. Unemployment among young blacks aged 16-25 is three times the national average. In Mallett's group, 80 per cent of patients were unemployed. So the racial element is there - but acting indirectly.

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Experience of early separation from one or both parents was also more common in Afro-Caribbean patients, although social fragmentation is growing across the board. Are these findings a hint of what is to come for the community at large? Mallett thinks they possibly are.

But if social factors do play an important role in mental illness, doctors can do little more than deal with the symptoms, helping people cope with their predicament. Mallett says: "If treatment doesn't include an awareness of the need for a complete package to help these individuals with their lives, it's not going to work."

Mental illness among black people in Britain is just one of the preoccupations of the Centre for Caribbean Medicine, the virtual organisation for which Mallett is research coordinator. The centre, based at King's College London, brings together researchers in South London and at the University of the West Indies. The catchment area of King's, Guy's and St Thomas's hospitals includes many Afro-Caribbeans, so the tie-up is a logical one.

Other work includes cardiovascular disorders and sickle cell disease. Health service and educational questions also figure, says recently appointed director Roger Jones, also professor of general practice. Despite the number of Caribbean people living in South London, there are few Caribbean GPs and medical students.

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He would like to narrow the gap at both levels, but getting funding to bring Caribbean students to the UK is hard, and European accreditation regulations make GP exchanges difficult. He is optimistic, however, that the hurdles can be overcome. If they are, they will help give this virtual centre some solid presence.

The Centre for Caribbean Medicine is at

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