The mental health of the South Asian community in Britain

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Introduction
Historical background
The South Asian experience in Britain
Depression
Older Asian people
Housing
Families
Asian men
Asian women
Language barriers
Employment
Religion and culture
Coping mechanisms
Racial harassment
Mental health of Asian people in Britain
Racism and mental health
Diagnosis and assessment
Treatment and services
Good practice
Useful organisations
Further reading
Other information
References

Introduction

The provision of mental health services to people from South Asian communities has been the subject of growing concern within the Asian communities. Mind, and other agencies, as well as mental health professionals have also realised the need to improve the services that are currently available.[1] Over half of the minority ethnic population in the UK is of South Asian origin.[2] These communities are not homogeneous; in fact, they are characterised by a range of diversities, including religion, language, place of origin and cultural traditions. Although the experience of disadvantage and racism is common to all members of the communities, significant differences also exist in terms of their socio-economic and health status.[3]

Research also shows that Asian mental health service users experience problems, including inappropriate treatment and care and lack of services specifically aimed at Asian people with mental health problems. Asian communities have been vulnerable to poor housing, unemployment or low-paid work, and to racism and abuse. The Bangladeshi community in the London Borough of Tower Hamlets, in particular, is among the most disadvantaged.[4]

In recent years there has been a concerted effort by organisations, such as Mind, to highlight the growing concerns that have arisen within the Black and minority ethnic communities regarding racism within the mental health system. This factsheet is primarily for professionals and students and members of the South Asian communities in Britain. Much of the information will also be useful for mental health service users and carers.

A note on terminology

One controversial aspect of writing about race and mental health issues is the terminology used. It is recognised that the terminology used in this factsheet has its limitations and will not be shared by all. Some terms are more acceptable to individuals than others. The term 'Black' has been avoided because many Asians prefer to be identified by culture or country of origin and do not feel represented by this term. It is recognised, however, that there are members of the Asian community who identify with the wider political usage.[5]

The word 'Asian' is used to refer to people who identify with, or whose countries are in, the Indian subcontinent, i.e. India, Pakistan, Bangladesh or Sri Lanka. It does not include, for example, people of Chinese or Vietnamese origin.[6] (See Mind's Mental health of Chinese and Vietnamese people in Britain factsheet.)

The terminology of psychiatric diagnosis used reflects the language of the sources referred to. The use of such language in no way implies Mind's unqualified acceptance of it.

Historical background [7]

In order to avoid generalisation, it must be noted that this summary does not imply that every Asian person will fit into the patterns of migration prevalent within his/her community. This serves only as a backdrop to understanding the social and historical factors that have influenced Asian communities in Britain.

People of Asian origin migrated to Britain for many reasons and came from a variety of backgrounds. The majority of Asian migrants came to Britain during the acute labour shortage of the late 1950s.[8] The purpose was to fill employment vacancies for jobs that were seen as undesirable to the indigenous population.

• People of Indian origin migrated mainly from two states, Gujarat and Punjab, after the Second World War. Migration reached its peak in the early 1960s. In general the men came to Britain initially and were later joined by their wives. They frequently found employment in the manufacturing industries, for example in textile and wool.
• People of Pakistani origin arrived in Britain in the late 1950s and early 1960s. As with the migrants from India, it was common for the men to come first. They came to work in the textile and engineering industries.
• People of Bangladeshi origin began migrating to Britain during the labour shortages of the late 1950s. Many Bangladeshi men in Britain are still living on their own whilst waiting for their families to join them. They are predominantly employed in the catering industry.
• People of Sri Lankan origin came to Britain in the 1950s and 1960s. It was the civil disturbances in Sri Lanka in the 1970s that led to larger numbers of Sri Lankans migrating to Britain. The early migrants were both doctors and teachers. Intensified conflict in 1983 resulted in greater numbers of working class Tamils escaping the civil disorder and coming to Britain as refugees and asylum seekers.

The 2001 Census indicated that about half of the minority ethnic population in the UK is of South Asian origin.

The South Asian experience in Britain

The South Asian communities are fairly settled in Britain since the 1950s and there is now a third generation of British Asians. The first generation is reaching old age, with the Indian community having the highest percentage of those over 60 years compared to all other minorities.[9]

Many Asian people experienced cultural differences, alienation and racism on their arrival in Britain. However, this sense of loss and feeling of alienation are common experiences shared among all minority groups. As with other minority groups, it is the combination of social and cultural needs that increase the likelihood of mental distress.

The effects of the migration process, resettlement and transition on mental health cannot be underestimated. Immigration laws were introduced in 1962 that patently set out to significantly reduce the flow of Asian migrants. This had the desired effect, and since 1973 it has been virtually impossible for migrants to come to Britain. It is also extremely difficult for relatives of British citizens from the subcontinent to join their families here.

Often Asian people have left the comfort of a close community and wide family networks to live in a 'hostile' neighbourhood, where links between members of their community are tenuous.[10] Studies have revealed the importance of community networks and their effects on mental well being.  Those who were satisfied with the settlement conditions in this country were those people who were able to preserve their culture and had access to a community support network.[11] Stresses from family life and culture are intensified by outside factors; for example, in Asian communities there is high unemployment, poor housing conditions, low incomes, failing businesses, experience of racism and discrimination at work.

The following is an explanation of how some of these factors affect the Asian communities and, in turn, has an impact on their mental health.

Depression

A 1991 report by the Confederation of Indian Organisations indicated that mental health professionals found a high prevalence of depression caused by a wide range of combining factors, when working with Asian people. Additionally, Beliappa revealed that within the Asian community, many of these factors are related to marital and family relationships and socio-economic conditions, such as housing, employment, low economic status and racism.[12] Studies have also shown that over a third of older Asian people receive neither a pension or state benefits because they have not qualified for these.[13]

The 1999 Health Survey for England, commissioned by the Department of Health, was designed to provide information on all aspects of the population's health not available from other sources. The survey indicated that in women, depressive episodes were most common among Indian and Pakistani respondents, and least common in the Bangladeshi group.

By 2002, research showed that the highest levels of depressive episodes were reported by Pakistani women (6.3 per cent) and Indian women (5.7 per cent). Both these groups show a much higher rate than their male counterparts. In other ethnic groups there was no significant gender difference. Bangladeshi women showed the lowest rate (1.6 per cent).[14]

Older Asian people

Most of those who migrated to Great Britain as adults in their twenties and thirties in the 1950s and 1960s are now elderly people who may not have intended to stay. The nature of their immigration then was transitory with an expectation of returning to the country of their birth after saving enough money from their working life in Britain.[15] Research has shown that this group has also suffered from isolation and comparatively poor health.[16] Many Asian elders now find that they are faced with having to accept old age in Britain with the realities of the poverty and racism suffered in the earlier years of immigration. They may have to access services which are different from their lifestyles and which are seen as belonging to a Eurocentric perspective of caring rather than their own.[17]

Housing

Decent housing is an essential factor in helping individuals to make the most of employment opportunities, education and good health. It provides a place where people are able to live out their lives. For many people their home is closely connected with their sense of identity and the way in which they relate to other people.

The traditional stereotype of Asian families is one of a cohesive, extended family, which usually includes the elderly parents of either the father or the mother of the household, and where individual members offer support and respect to each other. It is believed that in this setting they would not need the support of other bodies. The extended family structure does still exist amongst some families (one in 10 households are made up of two or more families compared to one in 100 amongst other communities). Families are often forced to live together for economic reasons rather than as a means of support.

Further research has shown that there is also homelessness amongst these communities.[18] The Bangladeshi community tends to occupy the worst and most overcrowded housing.[19] In the London Borough of Tower Hamlets, Bangladeshi families made up nearly 60 per cent of all homeless families in the borough, but only 10 per cent of all families in the borough.[20]

Families

Nearly three-quarters of South Asians were in a formal marriage, compared with three-fifths of whites and Chinese, but only two-fifths of African Caribbean people.[21] A higher proportion of Asian elders lived with their son or daughter, which means that there are significantly more two-generation households among South Asians than among other ethnic group.[22]

A number of families experience distressing events, which can include experiencing violence or abuse and pressure around marriage and relationships.[23]  Studies show that the individuals who were reporting distress had few outlets in which to express this distress; people did not feel that they could look to their families for support. 

Asian families are more likely to be caring for one or more members with a major health problem.

Asian men

A common myth is that Asian men never need help and support. Practitioners often assumed that they will be cared for by the extended family. However, studies by the Asian Family and Marriage Counselling Service have revealed that discrimination is prevalent in the experiences of many Asian men. If, for example, a man is unemployed, he will have little status in the Asian community as his standing is influenced by his income and employment status. Assumptions that Asian men do not need services have been described as 'dangerous' as they not only imply that they 'will be looked after by the community, but that as male figures they don't necessarily have emotions.'[24]

Asian women

Several studies have shown high levels of unreported psychological distress in Asian communities in general, and in Asian women in particular.[25] [26]The cultural and religious beliefs of Asian women are seldom recognised in the planning and delivery of psychiatric services. Many Asian women are isolated in their homes without any form of support.[27] [28] 

Another report highlighted that the suicide rate among young Asian women was twice the national average. The report found that during 1988 to 1992, 1,979 women of all races aged between 15 and 34 took their own lives. Of these, 85 were Asian (4.3 per cent) which was nearly double their proportion of the population.[29]

In an attempt to explain the high mortality rates of suicide among young women born in South Asian communities, research has explored the reasons given by those who have attempted suicide. Analysis of hospital records of such people has focused on cultural explanations for attempted suicide and particularly on a notion of culture conflict, where the young woman is apparently in disagreement with her parents' or husband's traditional or religious expectations.[30]

The Health Education Authority's Mental health promotion and South Asian people factsheet 1998 stated that there were conflicting values, beliefs and differences in expectations between generations and genders. Conflicting cultural values, traditions and beliefs around divorce, widowhood, marriage outside culture or religion and the preservation of family honour can negatively affect individuals and cause mental health problems. (See the Religion and culture section in this factsheet.)

Language barriers

The fact that English is a second language for many Asian people means that interaction with the relevant authorities can be very difficult, hindering access to mental health services. A survey commissioned by Nuffield Interpreting Project in 1991, on the use of possible interpreters in England and Wales, recognised the need for interpreters, because of the severe disadvantage experienced by non-English speakers in dealings with public services.

Language Line was one of the organisations which participated in the project and they commented that 'non-English speakers are definitely losing out.'

Language is a contributor to incidences of mis-diagnosis, as well as low referral for psychotherapy and counselling. People for whom English is a second language are unable to access certain types of treatments. This is not because they do not believe in such therapy, but because of the difficulty they encounter in making their views or feelings known to mental health professionals schooled in a European ethnocentric tradition, which is often alien and alienating.[31] (See Treatment and services.)   

However, there are ways in which people whose first language is not English can receive appropriate treatment and make their views known. In the past this has usually been through the use of family members as interpreters. However, service providers have recognised that this is often inappropriate, especially if, as is often the case, children are interpreting for parents. Here bilingual health advocacy can play a crucial role. (Mind guide to advocacy is available from Mind Publications.)

Employment

In 1995/6, the unemployment rate for people from minority ethnic groups (18 per cent) was more than double the rate for white people (8 per cent). Unemployment levels were highest for both men and women in the Pakistani and Bangladeshi groups at 27 per cent and 28 per cent respectively. The Bangladeshi community has an exceptionally high unemployment rate.[32] Studies show that while Black Caribbean women had the highest employment rate amongst minority ethnic groups (60 per cent), Bangladeshi and Pakistani women had the lowest – 13 per cent and 17 per cent respectively.[33]

Figures from Social trends 2001 show 73 per cent of people from minority ethnic groups were in employment. The Indian population had the highest employment rate (63 per cent), whilst the employment rate for the Pakistani and Bangladeshi communities were 30 per cent and 20 per cent respectively.[34]

Figures show that for the broad grouping of Asian British women, employment rates are at 45 per cent compared to 57 per cent[35] amongst Black British women. This grouping also disguises larger differences amongst the female Asian community 'for example 20 per cent of Bangladeshi women were in employment compared with around 60 per cent of Indian women'.

However, where there are lower levels of employment amongst Asian women, this is not seen as a being a mark of lower status in the community. In the majority of the communities we here describe as Asian, the role of a female full time carer or mother is seen as being of higher status. In fact across Britain 'three-quarters of women who are economically inactive and looking after the family or home are not looking for a job and do not want one' which includes Asian women.

Religion and culture

A Mental Health Foundation user-led research project exploring the benefits that Muslim men with severe mental health problems find from attending mosque found that there was a positive correlation between better mental health and attending mosque.

Asian cultural traditions and religious beliefs sometimes prohibit certain practices, such as drug taking, conception of children outside marriage and relationships before marriage. This can lead to conflict in families. The situation can sometimes be exacerbated by a lack of communication within a family and also by the lack of available, and appropriate, support from services in the community.

In the Bangladeshi Muslim community, for example, the mosque is central to the community's lives, and people turn to it for informal psychological support, often visiting their religious leaders first. Mental health problems may often go undetected, as Asian people may not see the medical practitioner as the appropriate person to contact. Asian women in particular may be at risk as there is a fear that confidentiality may be breached by their GP.[36]

Whilst feelings of depression and anxiety are often associated with life experiences, more severe health problems are explained in more complex ways.

Treatment can also become more difficult when belief in sorcery becomes an issue. Many people originate from small villages, so this can be common:
'Some people insist they are under a spell and they don't recognise that they are mentally ill' said a mental health worker from Tower Hamlets mental health team.[37]

A 1995 conference, organised by the Muslim Women's Helpline, concluded that culture is the determinant of mental aetiology, and healthcare providers need to be sensitive to spiritual beliefs in others to see positive outcomes to treatment.[38]

Coping mechanisms

Beliappa (1991) highlighted the fact that the lack of awareness of existing local support services meant that many coped with their distress by using internal mechanisms such as praying, crying and hard work. However these methods provided only temporary relief to the distress suffered. Most of those experiencing distress had expressed a desire for more constructive help which they felt could be gained by talking through their problems with individuals who could offer support and confidentiality. For the majority of South Asian people, there is a relatively high level of denial and this can lead to the late recognition of symptoms.

Racial harassment

Disadvantage and poverty among Asian minorities is rooted in a history of racism, which dates back to the immigration policies of the 1950s. Research carried out in 1994-95 revealed that racial abuse and racism have become a common experience for Asians living in the middle-class areas of North London, as well as in the more deprived areas such as the London Borough of Tower Hamlets.[39] Most of the racially motivated incidents that occur appear to be either verbal harassment or damage to property.[40] [41]

The estimated number of racially motivated offences in England and Wales in 1999 was 280,000, substantially below the estimated 390,000 for 1995, but similar to the 291,000 for 1993.[42] In 1999, the annual risk of being victim of a racially motivated offence was 0.3 per cent for white respondents. The risks for minority ethnic groups were considerably higher (an estimated 2.2 per cent for Black groups, 3.6 per cent for Indians and 4.2 per cent for Bangladeshis and Pakistanis.[43]

Mental health of South Asian people in Britain

"There is no doubt that people from minority ethnic groups experience double discrimination when they come into contact with mental health services."
'Race and Culture in Europe' (Openmind 69 Jun/Jul 1994)

Racism and mental health

Mind recognises that mental health problems are caused by many factors; oppression in the form of racism is undoubtedly one. The stressful circumstances of racism lead to isolation and distress and a feeling that there is nowhere to turn. This is exacerbated if people are suffering from a mental health problem and feel they are in a hostile and unsympathetic environment. Cultural differences between patients and doctors, social workers, therapists and other professionals who are trained in a European psychiatric tradition, account in large measure for inappropriate mental health service provision to Black and minority ethnic people. This can have alarming and complicating consequences on a person's mental and physical well being. Asian people who have mental health problems suffer a double disadvantage, as a result. The aim of Standard One of The National Service Framework for Mental Health which recognised “that some black and minority groups are diagnosed as having higher rates of mental disorder than the general population” is to ensure health and social services promote mental health and reduce the discrimination and social exclusion of those with mental health problems.[44]

In a Commission for Racial Equality report on racial attacks and harassment in the Bangladeshi and Pakistani communities, five per cent of the Indian community and eight per cent of the Pakistani and Bangladeshi communities thought that racism was a factor in offences against them. This compares to four per cent of Black people and one per cent of white people.[45]

Diagnosis and assessment

Psychiatrists, the police and Approved Social Workers (ASWs) all have statutory responsibilities under the Mental Health Act 1983 with respect to the recognition of mental health problems. There is concern, particularly in relation to people from Asian backgrounds, that these professionals do not have the necessary awareness of cultural values, norms and general knowledge of ethnic communities, to do this task effectively. There is little knowledge within the Asian community about:

• the roles of the different professionals responsible for mental health
• how they can access the services
• what they can expect from them.

Of the three professions with responsibilities for assessment under the Mental Health Act, only ASWs have a statutory requirement to show an understanding of working in a multi-racial society. ASWs are involved in the assessment of people in a 'mental health emergency'. They receive specific training for the purposes of this assessment and it is their role to decide the best course of action. This could involve a decision to detain an individual in hospital under a section of the Mental Health Act.

Interpreting services are often unavailable, which makes the diagnosis or assessment procedure unreliable and highly stressful. Asian children are sometimes used as interpreters in psychiatric assessments, as are husbands, wives, friends and relatives. In addition to the stress caused to the person being assessed, their family and the interpreter by this situation, such informal interpreters are not trained and are unpaid.[46]

Under-diagnosis of mental health problems is particularly common within South Asian communities. GPs play an important role for people from minority ethnic communities, as they are frequently their first point of contact with the psychiatric system. Although there is little research or information about GPs in relation to Asian patients,[47] studies have shown that in the case of GPs, even where there is a shared culture, there is still a likelihood that psychological distress will be missed. A study in the London Borough of Waltham Forest analysing hospital records cited in the Confederation of Indian Organisation report showed:[48]

• Asians were most frequently admitted by a GP under Section 4 of the Mental Health Act (admission for assessment in cases of emergency).
• Eight per cent of Asian and African Caribbean people admitted under Section 136 (removal by police to a 'place of safety') were found not to be suffering from any mental illness and subsequently discharged.
• Individuals are more likely to be misunderstood and misdiagnosed and more likely to be prescribed drugs and ECT rather than talking treatments such as psychotherapy and counselling.
• A low or delayed take-up of services until the point of crisis, by Asians. Mental distress is also more likely to be detected at a stage when conditions have deteriorated.  

The Confederation of Indian Organisations has commented on the fact that a number of GPs fail to respond to what the patients are saying, or to recognise the emotional affects of a physical condition. GPs also tend not to refer Asian patients to other agencies, such as counselling or psychotherapy services, and, says the Confederation, there is an 'adherence to myths and stereotypes related to gender, culture and race'.[49] As with psychiatrists, the police, ASWs and indeed all health professionals, better training is needed for GPs to increase their awareness of minority ethnic communities and hence provide an improved service.

In 1992, a specialist mental health team for the Borough of Tower Hamlets' 40,000 Bangladeshi people in East London found that, although services were inappropriate and the need for an ethnically sensitive approach to mental health obvious, people were repeatedly misdiagnosed and misunderstood because of cultural ignorance.[50]

“It is easier to talk to someone in your own language who understands your culture. A lot of our clients cannot speak English or cannot express themselves well in a foreign tongue, especially when trying to express emotional feelings.”
The Asian and Chinese Counselling Project, Camden North London

“Cultural sensitivity is crucial for appropriate treatment.”
Tower Hamlets' specialist mental health team for the Bangladeshi community.

“I soon came to realise how one's prejudices and assumptions can diminish a person in need of care and support.”
Karma-Nirvana, Asian Women's health project in Derby.

Stereotypes also influence the diagnosis and treatment which Asian people receive from many mental health service providers. Visions of 'passive Asians' who 'look after their own' do little to aid an understanding of the diverse cultural characteristics, which contribute to multicultural Britain.[51]

Studies have indicated that many clients would welcome the opportunity for talking treatments and have found it more helpful than the physical treatments offered.[52] Often treatment and services for the Asian communities are not relevant to their needs or of a high enough quality: a counselling service, for example, should be appropriate to the culture of its clients in order to be effective.

Reports have also shown that there is a lack of both well-trained specialist interpreters and Asian-speaking mental health professionals, and a dearth of appropriate advocacy schemes.

Good practice

The effectiveness of services provided by Black and minority ethnic service providers, operating with few resources, has been highlighted and documented. They are largely responsible for the innovative service developments, which appropriately meet the mental health needs of Black and minority ethnic communities.[53]

Some organisations that have developed over the last five years have established themselves as models of good practice. Both Karma-Nirvana, which is based in Derby, and the AWAAZ group in Manchester are at the cutting edge of providing new and innovative services which are needs-led and user-led.

Appropriate service development for people from Asian communities, as with other Black and minority ethnic communities, requires their involvement in planning and implementation from the outset, rather than attempting to slot them into services that are not tailored to meet their needs.

“Having an awareness of culture and the needs of people from different cultural backgrounds, for example, would work against a tendency to slot people into cubby-holes for diagnosis; it would mitigate against blanket diagnoses for particular groups, and it would engender working with clients and carers in the planning as well as implementation of appropriate treatment.”
Melba Wilson, Mind Race Advisor, 1998

Mind recognises that Black and minority ethnic groups and organisations can provide valuable input to mainstream statutory agencies regarding diagnosis, assessment and treatments. Where this occurs, the notion of 'mainstream' can appropriately be redefined and good quality services can be established.

End notes

1. Ethnic Minorities in Britain, Commission for Racial Equality (1997)
2. Haskey. J., (1991) Office of Population, Census Surveys
3. Mental Health Promotion and South Asian People Factsheet  (1997) – Health Education Authority 
4. Radia, K. (1996) Ignored, Silenced, Neglected – Housing and mental health care needs of Asian people in the London Boroughs of Brent, Ealing, Harrow and Tower Hamlets
5. Webb-Johnson, A. (1991)  A Cry for Change – An Asian Perspective on Developing Quality Mental Health Care
6. Webb-Johnson, A. (1991)  A Cry for Change – An Asian Perspective on Developing Quality Mental Health Care.
7. Webb-Johnson, A. (1991)  A Cry for Change – An Asian Perspective on Developing Quality Mental Health Care
8.www.britishcouncil.org/languageassistant/ess_uk_multiculturalukcv8.Mental 9. Health Promotion and South Asian People Factsheet 1997, Confederation of Indian Organisations
10. Webb-Johnson, A. (1991)  A Cry for Change – An Asian Perspective on Developing Quality Mental Health Care
11. Billiappa, J (1991) Illness or Distress? Alternative Models of Mental Health, Confederation of Indian Organisations
12. Billiappa, J (1991) Illness or Distress? Alternative Models of Mental Health, Confederation of Indian Organisations 
13. Jadeja, S & Singh, J 'Life in a Cold Climate', Community Care, 22nd April (1993)
14. Nazroo, J., King M., 2002, 'Psychosis – symptoms and estimated rates', in Sproston, K., Nazroo, J., (ed) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric), National Centre for Social Research, TSO
15. They Look After Their Own, Don't They? Inspection of Community Care Services for Black and Ethnic Minority Older People (1998) Social Service Inspectorate
16. Felton, S,  (1987) Ageing Minorities: Black People as they Grow Old in Britain, Commission for Racial Equality, London
17. They Look After Their Own, Don't They?Inspection of Community Care Services for Black and Ethnic Minority Older People (1998) Social Service Inspectorate
18. Mental Health Promotion and South Asian People Factsheet 1997, Confederation of Indian Organisations
19. Radia, K. (1996) Ignored, Silenced, Neglected – Housing and mental health care needs of Asian people in the London Boroughs of Brent, Ealing, Harrow and Tower Hamlets
20. Housing and Homelessness, Commission for Racial Equality, 1997
21. Madood, T. et al.  (1998)  The Fourth National Survey of Ethnic Minorities - Ethnic Minorities in Britain – Diversity and Disadvantage.  Policy Studies Institute
22. Madood, T. et al.  (1998)  The Fourth National Survey of Ethnic Minorities - Ethnic Minorities in Britain – Diversity and Disadvantage.  Policy Studies Institute.
23. Mental Health Promotion and South Asian People Factsheet 1997, Confederation of Indian Organisations
24. 'Extended Care Circle', Community Care 21-27 September 1996
25. Billiappa, J (1991) Illness or Distress? Alternative Models of Mental Health, Confederation of Indian Organisations 
26. Fenton, S and Sadiq, A. (1993)  The Sorrow in my Heart – sixteen Asian women speak about depression, CRE
27. 'A Community at risk: Isolation and Asian women, living with racism', S. Flockhart, Inside Out (GAMH) 1986 Issue 13 pp. 4-5
28. 'Female, Asian and Isolated', M Jervis, OpenMind, April/May 1986 pp.10-12
29. 'Asian Wives 'being driven to suicide'' The Daily Telegraph, 22 April, 1996
30. Handy et.al.  'Ethnic differences in adolescent self-poisoning: a comparison of Asian and Caucasian groups'. Journal of Adolescence, vol.14 pp. 157-162
31. Wilson, M. (1993) Mental health and Britain's Black Communities, King's Fund
32. Employment and Unemployment, (1997) Commission for Racial Equality
33. Ethnic Minority Women, (1997) Commission for Racial Equality
34. Social Trends 2001. Office for National Statistics.
35. Young Asian Women and Self-Harm, (1998)  Newham Innercity Multifund and Newham Asian Women's Project
36. Unearthing Hidden Illness, Community Care 27 February, 1992
37. Mental Health and the Muslim Woman: Proceedings of conference held on 23rd  January 1995, transcript, ed. Riffat Yusuf, Muslim Women's Helpline
38. Radia, K. (1996) Ignored, Silenced, Neglected – Housing and mental health care needs of Asian people in the London Boroughs of Brent, Ealing, Harrow and Tower Hamlets.
39. Racial Attacks and Harassment (1999) Commission for Racial Equality.
40. Maynard, W. & Read,  T.  (1997)  Policing Racial Motivated  Incidents, Home Office Police Research Group, Crime Detection and Prevention Series, Paper 84.
41. Crime, Policing and Justice: the Experience of Ethnic Minorities:  Findings from the 2000 British Crime Survey (2001) Home Office Research, Development and Statistics Directorate
42. Crime, Policing and Justice: the Experience of Ethnic Minorities: Findings from the 2000 British Crime Survey (2001) Home Office Research, Development and Statistics Directorate
43. National Service Framework for Mental Health, Modern Standards and Service Models (1999). Department of Health
44. Racial Attacks and Harassment (1999) Commission for Racial Equality.
45. Female, Asian and isolated, M Jervis, OpenMind, April/May 1986 pp.10-12
46. Fernando, S. (1989) Black People and the Psychiatric System
47. Wilson, M. (1993) Mental health and Britain's Black Communities, King's Fund
48. Wilson, M. (1993) Mental health and Britain's Black Communities, King's Fund
49. Unearthing Hidden Illness, Community Care, 27 February 1992
50. Wilson, M. (1993) Mental health and Britain's Black Communities, King's Fund p 15
51. Nursing Times,  March 4, Vol. 88, No. 10, 1992
52. Black Mental Health – A dialogue for change, NHS Executive Mental Health Task Force
53. Black Mental Health – A Dialogue for Change, NHS Executive Mental Health Taskforce

Useful organisations

Individuals need information and support to feel confident to access and use services. There are some specific services, which offer help, information, support and counselling services to Asian people. 

Asian Health and Social Care Association
The Nursery, Easton Community Centre, Kilburn Street, Easton, Bristol BS5 6AW
tel. 0117 954 0178
Day services for elderly Asian people or those with physical or mental health problems.

Asian Resource Centre
110-114 Hamstead Road, Handsworth, Birmingham B19 2QS
tel. 0121 551 4518 
email: asian.resource@btclick.com
Advice and information; specialist advice for older Asian people and Asian women. Leaflets in Asian languages.

'AWAAZ' 
Ethno – Sensitive Mental Health Project
464 Cheetham Hill Road, Cheetham Hill, Manchester M8 9JW
tel. 0161 740 3273
Advice, information on treatments and alternative therapies, individual support and advocacy.

Black Mental Health Resource Centre
Bushbury House, 4 Laurel Mount, St. Mary's Road, Leeds LS7 3JX
tel. 0113 237 4229
Advice, information, counselling and support for people from the Caribbean, Asian and African Communities.

Black Orchid
First Floor, 189c Newfoundland Road, Bristol BS2 9NY
tel. 0117 907 9982
email: black@orchid189c.fsnet.co.uk
Support, advice and advocacy for black and Asian mental health service users, with a holistic approach to mental health issues.

Confederation of Indian Organisations (UK)
5 Westminster Bridge Road, London SE1 7XW
tel. 020 7928 9889 
email: cioheadoffice@aol.com
Umbrella body which aims to represent the needs of the South Asian community in the UK. Vishwas Project (in Southwark and Lambeth) aims to ensure that Asian women with mental health problems have access to appropriate information and support services.

Diverse Minds
Mind's Black and Minority Ethnic Unit
15-19 Broadway, Stratford, London E15 4BQ
tel. 0208 215 2218
web: www.diverseminds.org.uk
Working to ensure that mental health services are responsive to the needs of people from Black and minority ethnic communities.

Karma-Nirvana – Asian Women's Health Project
Unit 39, Rosehill Business Centre, Normanton Road, Derby DE23 6RH
tel. 01332 604098/299166
email: kirma.nirvana@btinternet.com
Range of services promoting the health and well being of South Asian women. Befriending, advocacy and friendship groups.

Mental Health Shop
40 Chandos Street, Leicester, LE2 1BL
tel. 01162 471 525 
email: bmhgrc.mhs@care4free.net
Advice, information, advocacy and support for people with mental health problems and their carers. Also offers a service to in-patients in psychiatric hospitals and units outside Leicester.

Nai Zindagi Project
Stonebridge Centre, Cardiff Street, Carlton Road, Nottingham NG3 2FH
tel. 0115 941 4255
Counselling, advice and information for Asian women with mental health difficulties. Carers' group for Asian women carers. All services available in Asian languages.

Qualb Centre
17 Forest Drive West, Leytonstone, London E11 1JZ
tel. 020 8558 6241 
email: theqalbcentre@hotmail.com
Counselling and complementary therapies for Asian people with emotional problems or difficulties with domestic violence. Support group for women.

Rethink Severe Mental Ilness
(formerly National Schizophrenia Fellowship)
28 Castle Street, Kingston upon Thames, Surrey, KT1 1SS
tel. 020 8974 6814 
email: advice@nsf.org.uk 
web: www.rethink.org
Advice service providing information on mental illness issues. Central office for a network of over 300 projects in the UK.

Rethink Severe Mental Illness – Sahayak Asian Befriending Project
4-5 High Street, Gravesend DA11 0BQ
tel. 01474 364 837
Befriending service for Asian people aged 16 and over with mental health problems or who are experiencing emotional distress. Assistance with accessing mental health services. Promotion of mental health awareness within the Asian communities.

Sahara – Asian Women's Group
Youth Workshop, Stanley Street South, Bolton
tel. 01204 337 550 
email: andy@band.org.uk
web: www.band.org.uk
Social, recreational and educational activities for Asian women with mental health problems.

Sathi – Asian Men's Group
Socialist Club, Wood Street, Bolton BL6 6BN
tel. 01204 337 030  
email: andy@band.org.uk
web: www.band.org.uk
Social, recreational and educational activities for Asian men with mental health problems.

Tulip Mental Health Group
Unit 3, System House, Deanery Road, Stratford, London E15 4LT
tel. 020 8519 1194
Range of support services and recreational activities for people with mental health problems including Asian women's and men's groups.

Further reading

Articles

'Approaches to cultural awareness', 26 September 1990, Nursing Times vol. 86, no. 39.

'Asian women refugees', April 1991, Sitra Bulletin, Issue 27.

'Bringing about change for the Asian community', Aug/Sept 1994, Openmind 70.

'Bridging the language gap', M. Turner, October 1994, Voluntary Voice.

'Clinical management of patients across cultures', D. Bhugra & K. Bhui, 1997, Advances in Psychiatric Assessment, vol.3, pp. 233-239.

'Cross-cultural psychiatric assessment', D. Bhugra & K. Bhui, 1997, Advances in Psychiatric Treatment (1997), vol.3, pp. 103-110.

'Ethnic and cultural factors in psychopharmacology', D. Bhugra & K. Bhui, 1999, Advances in Psychiatric Treatment, vol. 5, pp.89-95.

'Extended care circle', 21-27 September 1993, Community Care.

'Incidence of psychotic illness in London: comparison of ethnic groups', Michael King, Eleanor Coker, Gerard Leavey, Amanda Hoare, Eric Johnson-Sabine, 1994, British Medical Journal, 309, 1115-1119.

'Recognising limitations in mental health diagnosis and care for members of the South Asian community', Tanzeem Ahmed, 1993.

'Unearthing hidden illness', 27 February 1992, Community Care

Books

A shattered world: the mental health needs of refugees and newly arrived communities. CVS Consultants and Migrant and Refugee Communities Forum, CVS, 2000

Aliens and Alienists, Roland Littlewood and Maurice Lipsedge, Routledge, 1997

Between two cultures: Effective counselling for Asian people with addictive problems, Zaibby Shaikh & John Reading, 1999

Black people and the psychiatric system, S. Fernando, 1989

Black British, White British, D. Hiro, 1971

Creating solutions: developing alternatives in black mental health, Sharon Jennings, Kings Fund, 1996

Counselling services for Asian people: a directory, Department of Health, 2002

Directory of mental health services for the Asian community, Sarah Greenwood, Confederation of Indian Organisations, 1994

Ethnic minorities in Britain – diversity and disadvantage, T. Modood and R. Berthoud, Policy Studies Institute, 1997

Ethnicity, class and health, James Nazroo, Policy Studies Institute, 2001

Forensic psychiatry, race and culture, Suman Fernando, David Ndegwa and Melba Wilson, Routledge, 1998

Getting the evidence: guidelines for ethical mental health research involving issues of 'race' ethnicity and culture, Mind, in association with TCPS, 2000

Health-related resources for Black and minority ethnic groups (a directory of manuals and guides, videos, audio-cassettes, booklets and training packs), Health Education Authority, 1994

Illness or distress? Alternative models of mental health, Jayanthi Beliappa, Confederation of Indian Organisations, 1991

Intercultural therapy, J. Kareem and R. Littlewood, Blackwell Scientific Publications, April 1992

Is race on your agenda? Improving mental health services for people from Black and minority groups, Yvonne Christie and Roger Blunden, King's Fund Centre, February 1991

London Ethnic Elders Service Directory, Help the Aged, 1999

Mental health in a multi-ethnic society, Ed. Suman Fernando, 1995

Mental health, race and culture, Suman Fernando, Macmillan/Mind, 1991

Race and health, an information sources guide, Frances Presley and Anne Shaw, King's Fund, 1994

Race, culture and mental disorder, Philip Rack, Tavistock, 1982

Racism and mental health: prejudice and suffering, Ed. K. Bhui, Jessica Kingsley Publishing, 2002

'Racism and transcultural psychiatry', Kobena Mercer, in: The power of psychiatry, Peter Miller and Nikolas Rose (eds.), Polity Press, 1986

Resistance to multiculturalism: issues and interventions, Jeffrey Scott Mio and Gene I. Awakuni, Brunner/Mazel, 2000

Safe haven: residential mental health services for people from Black and minority ethnic communities, Ujima Housing Association, CVS, 2000

The butterfly and the serpent: essays in psychiatry, race and religion, Roland Littlewood, Fab, 1998

Reports

Ageing minorities: Black people as they grow old in Britain, Commission for Racial Equality, 1987

A cry for change – An Asian perspective on Developing Quality Mental Health Care, Amanda Webb-Johnson, Confederation of Indian Organisations, 1991

Age and race: double discrimination. Life in Britain Today for Ethnic Minority Elders, Commission for Racial Equality/Age Concern, March 1995

Awaaz – Progress report, 1997

Black and minority ethnic groups in England, Kai Rudat, MORI Health Research Unit, Health Education Authority, 1994

Black mental health – A dialogue for change, NHS Executive, Mental Health TaskForce, DoH, 1994

Concepts of  mental health in the Asian community – Seminar report, The Confederation of Indian Organisations, 1992

Ethnic differences in the context and experience of psychiatric Illness: A qualitative study. National Centre for Social Research, 2002

Ethnic minorities and the criminal justice system – Research Study 20,  M. Fitzgerald, The Royal Commission on Criminal Justice, 1993

Ethnic minority women factsheet, Commission for Racial Equality, 1997

Ethnic minority psychiatric illness rates in the community (empiric) 2002, National Centre for Social Research.

Ethnic minorities in Britain, Commission for Racial Equality, 1997

Health and race: a starting point for managers on improving services for Black populations, Yasim Gunaratnam, King's Fund, 1993

Ignored, silenced, neglected – housing and mental health care needs of Asian people in the London Borough of Brent, Ealing, Harrow and Tower Hamlets, K. Radia, 1996

Mental health promotion and South Asian people Factsheet, Health Education Authority, 1997

Mental health and the Muslim women: proceedings of conference held on 23rd January 1995, transcript, ed. Riffat Yusuf, Muslim Women's Helpline

Not just Black and White – an Information pack about mental health services for people from Black communities, complied by Caroline Harding, Good  Practices in Mental Health Publications, 1995

Race relations – code of practice for the elimination of racial discrimination and the promotion of equal opportunity in the provision of mental health services, The Commission for Racial Equality, 1992

Raised voices – African-Caribbean and African users' views and experiences of mental health services in England and Wales, Melba Wilson and Joy Francis, 1997, Mind

Response to violence: a framework for fair treatment, in psychiatric patient violence – risk and response, Gerald Duckworth & Co. Ltd

Responding to diversity: a study of commissioning issues and good practice in purchasing minority ethnic health, Office for Public Management & Department of Health, 1996

Safe haven: residential mental health services for people from Black and minority ethnic communities, CVS, 2000

Services for people from Black and ethnic minority groups – Issues of race and culture: A discussion paper, 1992. Department of Health

Social trends. No. 3, Office for National Statistics, 2001

They look after they own – don't they? Inspection of Community Care Services for Black and Ethnic Minority People, 1998

Yellow card for reporting drug side effects, a report of user's experiences, Mind, 2001

Other information

Cultural identity and racism video directory, a comprehensive list of videos for sale or for hire in the UK, Mental Health Media Council, 1993

Creative thoughts for troubled minds, Video, MBAS, 2000 (tel. 020 7561 9847)

Different cultures, different needs, Video, NHS Executive, 1994

Executive summary of the yellow card scheme for reporting drug side effects in 10 languages – copies available from Diverse Minds (see address above)

Home Office research studies  www.homeoffice.gov.uk/rds/horspubs1.html

HORS 223 – Crime, policing and justice: the experience of ethnic minorities, findings from the 2000 British Crime Survey

Research Findings 39 – Ethnic minorities, victimisation and racial harassment

Research Findings 146 – Ethnic minorities' experience of crime and policing: findings from the 2000 British Crime Survey.

Mind's policy on Black and minority ethnic people and mental health, Mind, 1993 (available from Mind Information Unit).

Useful publications available from Mind

Mind has produced a range of leaflets, factsheets and brief guides addressing different mental health problems. To order any of these, call Mind Publications on 020 8221 9666 or email publications@mind.org.uk

The mental health of the African Caribbean community in Britain

The mental health of Irish-born people in Britain

The mental health of the Chinese and Vietnamese communities in Britain

Suicide

Race, culture and mental health

The financial aspects of mental distress

Treatments and services for people with mental health problems

The criminal justice system

The social context of mental distress

Public attitudes to mental distress

Resource list of mental health literature in translation

Carole Reid-Galloway
Mind Information Unit
March 2003