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      Understanding the excess psychosis risk in ethnic minorities: the impact of structure and identity


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          Psychotic disorders, which are associated with substantially increased morbidity and mortality, are up to five times more common in some ethnic minority groups compared with the white majority in Western countries. This long-standing and well-replicated public mental health disparity has hitherto largely eluded adequate explanation. We argue that this might have arisen in part due to the lack of attention given to theoretical work characterising the complex and multidimensional social nature of ethnicity by those epidemiological investigations that have dominated the literature.


          To bridge this gap, we draw on theoretical and empirical literature from across the social sciences considering the ontological significance of ethnicity (as biology, migration, racialised structures and identity) and its relationships with psychotic disorders to illuminate probable drivers of excess psychosis risk.


          The largest gains in our theoretical understanding of excess psychosis risk among ethnic minority groups are to be made by considering ethnicity in relation to disempowerment resulting from structural and identity-based exclusion. The former is readily studied through the social gradient in health: socioeconomic disadvantage clusters in some ethnic minorities and increases the risk of poor health outcomes, including psychosis. Furthermore, limitations on identity acquisition and expression imposed by the ethnic majority can further contribute to alienate ethnic minorities and increase psychosocial disempowerment (a lack of control over one’s life).


          We theorise that structural and identity-based exclusion act as the primary drivers shaping variation in rates of psychotic disorder by ethnic minority status.

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          Most cited references73

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          The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action.
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            Stereotype threat and the intellectual test performance of African Americans.

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              Health inequalities among British civil servants: the Whitehall II study

              The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10,314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.

                Author and article information

                Soc Psychiatry Psychiatr Epidemiol
                Soc Psychiatry Psychiatr Epidemiol
                Social Psychiatry and Psychiatric Epidemiology
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                24 August 2021
                24 August 2021
                : 56
                : 11
                : 1913-1921
                [1 ]GRID grid.83440.3b, ISNI 0000000121901201, PsyLife Group, Division of Psychiatry, , UCL, ; 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7DN UK
                [2 ]GRID grid.5335.0, ISNI 0000000121885934, Department of Psychiatry, , University of Cambridge, ; Herchel Smith Building, Forvie Site, Robinson Way, Cambridge, CB2 0SZ UK
                [3 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, School of Sociology, Politics and International Studies, , University of Bristol, ; 11 Priory Road, Bristol, BS8 1TU UK
                [4 ]GRID grid.450563.1, ISNI 0000 0004 0412 9303, CAMEO, Cambridgeshire and Peterborough NHS Foundation Trust, ; Elizabeth House, Fulbourn Hospital, Cambridge, CB21 5EF UK
                [5 ]Present Address: Centre for Transcultural Psychiatry ‘Veldzicht’, Ommerweg 67, 7707 AT Balkbrug, The Netherlands
                Author information
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                : 4 March 2020
                : 29 January 2021
                Funded by: FundRef http://dx.doi.org/10.13039/501100000269, Economic and Social Research Council;
                Award ID: ES/S011714/1
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;
                Award ID: 101272/Z/13/Z
                Award Recipient :
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                © Springer-Verlag GmbH Germany, part of Springer Nature 2021

                Clinical Psychology & Psychiatry
                psychotic disorders,ethnicity,social gradient,identity,psychosocial disempowerment


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