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BMJ. Oct 9, 1999; 319(7215): 1007.
PMCID: PMC1116771

Rates of anxiety and depression in African-Caribbeans may not reflect reality

Kwame McKenzie, clinical lecturer

Editor—Shaw et al add welcome breadth to the literature concerning psychiatric disorders in African-Caribbeans.1 However, there are methodological problems which make interpretation of the results difficult.

Contrary to BMJ guidelines, there is no rationale for the choice of ethnic variables used.2 Hypotheses for why depression in the inner city should be expected to be related to Office for National Statistics’ definitions of ethnicity may have led to the measurement of possible explanations or confounders such as financial worry, religion, housing, racism, and ecological variables such as community cohesion.

The use of a white European comparison group is problematic because of high rates of mental disorder in subgroups such as the Irish and refugees.3 Were white minority groups more likely to be cases?

It is unclear how representative the African-Caribbean population is. Compared with other studies the proportion of Caribbean born African-Caribbeans is high. The mean age of the white and African-Caribbean groups were the same; however, other studies had to standardise rates for age because of the relatively low mean age of the African-Caribbean population.4 Half of those eligible took part in the study. The need for registration with a general practitioner may have led to fewer young African-Caribbeans being sampled. This could have led to errors in calculations of rates of depression.

The screening instruments that Shaw et al used have never been validated in an African-Caribbean population. Standardised instruments may underdiagnose depression in minority groups. Using a white European psychiatrist for subsequent interviews would not correct this error.4

The percentage of an ethnic minority group in an area affects the rate of mental illness.5 Hence rates gained from areas with a high concentration of people of Caribbean origin may not be generalisable. People of Caribbean origin were better educated than whites but were as likely to be unemployed and had similar incomes. Thwarted aspirations have been linked to higher rates of mental disorder. However, that better educated African-Caribbeans live in poor inner city areas shows that wider social forces are at work and underlines the need for a larger and more diverse sample to explain the findings. The questions that need to be answered are what would be the predicted prevalence of common mental disorders taking into account all known risk factors and what is the difference between this and that found for African-Caribbeans and whites? The answers could lead to the investigation of the extent to which culture, psychological, or social variables account for such differences.

Supplementary Material


1. Shaw CM, Creed F, Tomenson B, Riste L, Cruikshank JK. Prevalence of anxiety and depressive illness and help seeking behaviour in African Caribbean and white Europeans: two phase general population survey. BMJ. 1999;318:302–306. . (30 January.) [PMC free article] [PubMed]
2. McKenzie K, Crowcroft NS. Describing race. ethnicity and culture in medical science. BMJ. 1996;312:1054. [PMC free article] [PubMed]
3. Littlewood R, Lipsedge M. Aliens and alienists. London: Routledge; 1997.
4. Nazroo J. Ethnicity and mental health. London: Policy Studies Institute; 1997.
5. Halpern D. Minorities and mental health. Soc Sci Med. 1993;36:597–607. [PubMed]

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