Culture and ethnicity have an important influence on the clinical presentation of psychiatric distress, more so than that of other medical problems. However, ethnocultural and racial perceptions could color the assessment and management of psychological problems (1, 2). This issue is particularly relevant in multiethnic, multicultural societies like the United Kingdom, where psychiatrists and their patients often come from different cultural and ethnic backgrounds. The U.K. Department of Health highlights the importance of “cultural competence” in overcoming potential barriers in these situations (3).

In the United States, the APA Committee of Black Psychiatrists proposed a curriculum for training psychiatric residents specifically for the care of minority ethnic groups (4). Cultural competence has also been recognized as a core requirement in psychiatric training by the Royal College of Psychiatrists in the United Kingdom (5).

Given that culture can influence clinical presentation and that ethnocultural perception could itself affect clinical assessment and management, we felt it was important to explore these perceptions and belief systems among senior psychiatry trainees (specialist registrars) in the United Kingdom. The present report was intended as a baseline survey to plan an effective training program to develop cultural competence among these trainees. As an exploratory survey, this study did not set out to test any a priori hypothesis; rather, it aimed to explore some widely prevalent ethnocultural belief systems among senior psychiatry trainees in the northwest of England.

Study Setting and Sample

The survey was conducted at “specialist registrar” training days held in Manchester in 2005 and 2006. The events were attended by senior psychiatry trainees under the North Western Deanery of the northwest region of England (equivalent to senior residents in the United States). The northwest region has a total population of 6.7 million, according to the 2001 U.K. census, and in certain parts of this region the ethnic minority population constitutes more than 10% of all residents. The trainees completed at least 36 months of basic training in psychiatry and had passed the membership exams of the Royal College of Psychiatrists (MRCPsych) or an equivalent thereof. The study investigators (AS, NH) explained the study rationale to all the trainees who attended the training days, and consenting trainees were invited to complete the study questionnaires.

Sixty trainees (out of 85 potential) completed the study questionnaires and constituted the study sample (response rate of 70%). These included participants from different ethnic and cultural backgrounds, but these (and other) background variables were not specifically recorded at the time of data collection. Further, this completely anonymous survey was planned only as a baseline training-need assessment, and surveys of such nature in the United Kingdom do not require formal ethical committee approval.

Questionnaire

The study questionnaire consisted of the Personal Values Questionnaire, which was extracted from a U.K. Department of Health publication (6). The Questionnaire is composed of 15 statements relating to ethnic and culturally based personal beliefs, values, and perceptions, which are rated on a 5-point Likert scale (1=strongly disagree, 5=strongly agree).

All study participants (N=60) completed the Personal Values Questionnaire. A subsample of 20 trainees also completed a brief, three-item questionnaire to explore the existence and perceived need for cultural competence training in the region. Data were collected anonymously, and trainees provided verbal consent to the study investigator who collected data on the training day.

Analysis

The 15 statements of the Personal Values Questionnaire were categorized into three main themes: ethnic stereotypes, ethnocultural service issues, and perceptions of racism. Responses were aggregated into “agree,” “neutral,” and “disagree” categories. The data were analyzed descriptively using frequencies and percentages.

The results are presented in Table 1. A large proportion of trainees did not agree with some commonly held ethnic stereotypes. The trainees also had contrasting views on the need for culture-specific services. Another important finding was that the majority of trainees perceived institutional racism in mental health services. A subsample of 16 of the 20 trainees who were approached with the brief questionnaire of cultural competence training needs expressed interest in such training and reported that their current training scheme did not adequately meet the cultural competence training need.

Ethnic Stereotypes

This survey explores some widely prevalent societal stereotypes toward minority ethnic subjects in contact with mental health services, which could potentially influence clinical practice. Nearly three quarters of the trainees disagreed with prevalent stereotypes relating to the low frequency of depression in African-Caribbean people, although studies have shown it to be widely prevalent among older black Caribbean people (7). On one hand, this could suggest an increased sensitivity of trainees to the occurrence of depression in this population. On the other hand, most trainees attributed high rates of police-related problems in this population to single parents and lack of discipline. This could potentially increase the risk of overlooking underlying mental health problems.

Three-quarters of trainees disagreed with the belief that support from extended families obviates the need for psychiatric help among Asian communities. In fact, they considered the underrepresentation of Asian people in the psychiatric system as an unmet need. This is in contrast with the finding that a majority (60%) agreed that Asian women have a higher rate of suicide due to their culture, despite the absence of any strong evidence to support this. The clinical implications of these perceptions are difficult to interpret, because, on one hand, trainees may be more sensitive to undetected mental health problems in Asian families but, on the other hand, may tend to attribute suicidal gestures in women to situational/cultural factors, thus missing underlying psychiatric problems.

Ethnocultural Service Issues

Evidence suggests that black patients have a higher risk of being misdiagnosed with schizophrenia than white patients (1, 8). About half of the respondents agreed that this was due to lack of cultural sensitivity among psychiatrists. The group was divided in its view on developing culture-specific services. This is in keeping with the longstanding debate around the need for ethno-specific services (9, 10).

Most trainees (78%) were positive about involving black service users in planning and delivery of services; it would certainly help address some of the cultural barriers in this area.

Perceptions of Racism

Nearly half of the respondents believed that institutional racism affects every mental health service in the United Kingdom and that racist stereotypes influence the perception of “dangerousness” in black patients, with a resultant increase in compulsory admissions under the Mental Health Act (a legal framework in England and Wales for the assessment, treatment, and detention of people with a mental disorder against their wishes). In fact, a recent systematic review on compulsory admissions found that black and minority ethnic patients were 3.34 times more likely to be detained, but concluded that most explanations suggested are unsupported by evidence (11). However, increasing the number of people from black and minority ethnic backgrounds in services was not necessarily seen as a solution by respondents. Perhaps formalized training on cultural issues in mental health may have a role in “optimizing” cultural sensitivity; a “cultural consultation model” of psychiatric services may be the way forward (10).

Our survey is limited by the relatively small sample size, which was drawn from a single region of the United Kingdom. It would have been interesting to look at the respondents’ ethnic and demographic details and their relationship with ethnic perceptions. We believe this to be an important limitation of our study. The absence of background data makes it difficult to ascertain whether responders were systematically different from those who did not participate in the survey. However, the study sample constituted a majority of the trainees in the region, and findings could reasonably be applicable for this region in the United Kingdom. Limitations notwithstanding, our findings highlight the importance of ethnic perceptions in shaping cultural sensitivity and their potential clinical implications. Our findings also suggest a need for incorporating training into cultural awareness, sensitivity, and competence in psychiatric practice within the North West of the United Kingdom.

The northwest of England is home to over 50 different linguistic and cultural groups. Personal beliefs, perceptions, and values are likely to influence psychiatric assessments and care in such multicultural settings. This study explores some widely prevalent ethnocultural beliefs among senior psychiatry trainees and their potential effects on mental health care—both at an individual and service level. A training program on cultural aspects of mental health could help improve awareness and sensitivity of these issues and could have downstream effects on improving mental health care for all ethnocultural communities.

Dr. Chaudhry is a member of the Speakers’ Bureau of Eli Lilly, Janssen Pharmaceutical, AstraZeneca, and Bristol-Myers Squibb. Dr. Husain has served as an advisor for AstraZeneca and he has received support for educational activities from Eli Lilly, Sanofi-Aventis, Wyeth, AstraZeneca, Janssen, Bristol-Myers Squibb, Lundbeck, and Shire. At the time of submission, Drs. Neelam and Antonysamy declared no competing interests.