Cochrane Interview

Raymond Cochrane, a Professor of Psychology at the University of Birmingham, UK, is also Director of a Mental Health Trust in that city. The Health Trust covers a part of Birmingham where a substantial number of people of Caribbean origin live. A year ago he met Dr. Frederick Hickling, a Jamaican psychiatrist who was visiting Britain as a consultant on mental health services for black people. When the two compared notes, they realized there are stark differences in treatment results for black patients in Britain when compared to Jamaica. Dr. Cochrane is now here on a two month visit to study those difference. Panmedia Features interviewed him about the findings of his research.

Panmedia : What is the most significant feature of your findings?

Cochrane : That most patients with serious mental illnesses in Britain go to a mental hospital, whereas in Jamaica they often choose other options. Many more people here are managed in their own home or community than happens in Britain. Our study follows people from the time they first come to the attention of the mental health services, whether they are admitted to a hospital or not. We follow them for the first three years of their illness using standard procedures both in Jamaica and in Britain. Dr Hickling firmly believes there really is a better cause and outcome of diseases such as schizophrenia in Jamaica. But we need hard data to prove it, and that's what I'm doing on this visit.

PM : Is there evidence that among minority groups in Britain Jamaicans have more mental health problems?

C : In Britain there is, and serious problems at that. My own research done over the last 20 years looking at ethnic minorities in Britain has shown that, generally, Asian minorities, usually large groups of people from India and Pakistan, tend to have fewer mental health problems, and they recover in a more benign fashion than the white indigenous population. Black people from the Caribbean on the other hand, have more illnesses and their recovery is even less certain than the white population. So it's not just the fact of being a minority, because the Asian minorities don't show the same pattern as the Caribbean minorities do in Britain. There's also some interaction between minority status, the culture and the whole society.

PM : Were there differences in the support from families among the three groups: Asians, Blacks and Whites?

C : Yes. That is a major difference in a study I did recently with two colleagues in Birmingham. We found that most Asian people treated in a hospital would be discharged back to a family, whereas only a minority of Caribbean patients were, and white patients were somewhere in the middle. Caribbean patients not necessarily those born in the Caribbean, as quite a number of them are second generation, born in England were much less likely to be discharged to a standard family unit; they were more likely to be living in hostels or on their own. And all the evidence from around the world shows that people going back to a family do better than those who don't. So that's a big difference.

PM : And did you find it less likely for people with solid family support to end up in a mental hospital, compared to those who don't have such support?

C : In general we did. Often, in the early stages of a serious illness, there is considerable stress on the family, perhaps even before the illness has come to the attention of doctors. It can disrupt the family and lead to break-up, and the person often moves out of the home because he can't stand what he considers family pressures. And such persons often seek low quality accommodation in inner city areas because it's cheap and readily available. But despite this drift away from family, if you can send the person back, it's the best form of therapy he can have on the road to recovery.

PM : Do your patients tend to be of any particular age group?

C : The most serious mental illness is schizophrenia, and that tends to affect younger people, starting in their late teens and early twenties. You may get it in older people, but mainly, especially for men, it's between 20 and 25. Often they're just starting out on a career and this serious illness disrupts their career pattern. Even when they recover from the illness, it's difficult for them to re-establish themselves in the pattern that they may have followed. It's a serious illness with quite devastating consequences and even when people recover from it, it may have a profound effect on the way they live.

PM : Are you studying this question in other Caribbean members of the black community?

C : In Britain there are people from all the Islands in the black population, but the vast majority are Jamaican, they outnumber the others probably ten to one. So we tend to regard the issues as Jamaican, rather than Caribbean. There really aren't enough people from the smaller Islands to study them separately, because mental illness is still a relatively rare occurrence, and you'd have to wait a long time to get a group of people from, let's say, Trinidad, coming to a mental hospital; maybe only one a year or one every two years. From Jamaica there'd be twenty or thirty. So the people from the smaller Islands tend to get ignored a bit.

PM : Are these West Indian people, or Jamaicans, coming to you from upper or lower socio-economic backgrounds?

C : Schizophrenia, in whatever ethnic group, tends to affect people from lower social status groups much more than people from middle class backgrounds. There are two theories about that. The first is that the stresses and strains of poverty, poor housing and overcrowding etc. cause schizophrenia or increase the vulnerability of people to the condition. The other hypothesis and there's much more evidence for this one is that the illness itself causes people to lose jobs, to tumble down the social hierarchy and end up at the bottom of the heap. That's much more likely to happen because, as I've said, it's such a debilitating illness. In addition, it happens at a critical time in a person's life cycle, before he gets a chance to really establish himself. So it tends to consign one to a lifetime of, possibly, no work at all, or to very low level jobs. In somebody who was well established, in his forties and fifties, it wouldn't cause such social decline because such a person, being well established, would have reserves. But it does cause serious long term economic consequences in younger people.

PM : So what have you found out here?

C : What I've been doing is looking at the way in which the same types of illnesses are treated in Jamaica, compared to the way they are managed in Britain. I've visited Bellevue Hospital here in Kingston, and seen mental patients in other hospitals cared for in general medical wards which, incidentally, we don't do in Britain and we visited the Cornwall Regional Hospital, which has a psychiatric unit within it. I've also, with Dr. Hickling, visited some patients who are being treated at home. This afternoon I'm going to visit an out-patients clinic. So I think I've seen all aspects of the way mental illnesses are treated here. The big difference is the use of general medical beds in ordinary wards for even quite severely mentally ill patients and this does avoid stigmatizing them.

It puts them into a "normal" hospital environment, and although I've only seen a little of that, it does seem to work. The hospital I visited, Falmouth Hospital, isn't a very modern hospital at all, and yet it seemed to work very well. It was a very crowded, busy hospital, but patients seemed to be managed there quite successfully in the general medical wards. The nurses didn't have any particular expertise for the job but they managed the patients along with all the others with general medical problems. It seems to me that's an excellent model and it works here. Whether it would be acceptable to patients and to doctors and nurses in Britain, I don't know.

PM : There's some kind of negative image then?

C : Yes, that's just it. If you put people into a place that everyone knows is a mental hospital, it has a stigma attached to it, as I understand Bellevue has. I've met some mental health officers who are senior nurses, trained in the management of mental health people at home, and they seem to have a very good relationship with the community they serve. Everyone there seems to know, trust, and respect them and this helps them do their job. M

PM : But, the problem is further complicated in Britain?

C : Yes, the problem in Britain, unfortunately, is that many black people regard the mental health system as another form of racist repression, so they try to avoid contact with it, if they can. Now clearly, here, where the nurses and doctors and all the workers are also black, there's no problem. In Britain, at least in some areas, there is considerable reluctance on the part of the black population, to come into hospitals or to be in any way engaged with the mental health system, which is not trusted or respected by many of these people it is trying to serve.

PM : What do you think accounts for this difference?

C : Well, I think it comes out of a long history of difficult relationships, where the only form of provision was in hospitals run by white people and black people were afraid or reluctant to go there. Even though we've moved to a much more community based system, there's still this residual anxiety about what happens to you if you get into the clutches of the mental health system. That seems to be totally absent here. There seems to be a much greater willingness on the part of families and neighbours to cooperate with the services, locate people when they need help and make sure they take their medicine. It's accepted as part of the community's responsibility. That's my impression so far, it isn't a systematic study yet.

PM : Is there any connection between drug abuse and schizophrenia?

C : Yes, there is. Often a history of drug abuse occurs in people who develop schizophrenia. The question is: does it cause schizophrenia, or is it a symptom of a pre-clinical, developing mental illness? I think it seems to be the latter, that very heavy drug abuse can trigger an episode of schizophrenia, but it's not likely to cause it in someone who wasn't already predisposed that way. I've noticed, looking at the records I've seen here, that it's much more common to identify drug abuse in the antecedents of schizophrenia than happens in Birmingham or anywhere in Britain, I think. A significant proportion of the patients here seem to have a history of chronic use, either of ganja or cocaine, prior to their coming to the attention of the medical health system. In Britain that seems to be much less common. I'm sure cannabis use is widespread in young communities black and white in Britain; but not to the same extent as here. The level of usage seems higher here, and perhaps more people use ganja at very high dosages here, because it's more easily available, I guess. In Birmingham, it tends to be recreational use, occasionally, at weekends or at parties, rather than on a daily basis, as I've observed first hand here. So it does seem to be much more intimately involved with the development of mental illness. It may not necessarily cause it; I'm sure there are ten times as many people who use ganja regularly and don't become mentally ill, as who do. But it is noticeable, just from looking at patients' records, that drug induced psychosis is commonly referred to.

PM : And then the use of ganja may take them into the market for harder drugs?

C : Yes, that is always a risk as well. Again there's been a lot of research done on whether this is progression from softer drugs to the harder narcotic kind. The evidence isn't clear, but they are both illegal, the two are linked together, and the same people tend to supply both drugs, so I suppose there is a link, a stepping stone, towards the use of harder drugs.

PM : Have you studied this kind of thing in other countries?

C : Yes. As I've done a lot of research in Britain with people from India and Pakistan, I've visited India and Pakistan and looked at mental hospital services there. We're trying to do a cross-sectional study again of Indian and Pakistani people because, as I told you earlier, Asian people in Britain have a relatively low rate of mental illness and they have relatively good chances of recovery. It still doesn't seem to be as good as it is in India or Pakistan, but it's very difficult to tell there because the services are so underdeveloped there, compared to Britain or Jamaica. There are very very few mental hospitals available, and most people who develop mental illness never come into contact with psychiatric services at all, especially in rural areas. So determining what's going on in rural districts of India and Pakistan where there are millions and millions of people living, is very difficult indeed. It's much easier in a country like Jamaica, partly because it's small, but also because there is a well developed mental health system here, and most people who become ill do come to the attention of the authorities. Now, that's generally not the case in India, where there are six or seven hundred million people, most of them in fairly remote areas. So gauging the extent of mental illness and the cause and outcome is almost impossible.

PM : Are there other aspects of your life that you think you may be indulging in Jamaica, any other things that interest you apart from your professional life?

C : Well, I'm a very keen photographer, and I've brought my photographic equipment with me. I've been seizing every opportunity to take some pictures, which I hope will turn out to be as spectacular as they look when you see them in the flesh, so to speak.

PM : What are you interested in, people or landscapes?

C : Mainly landscapes, but people too. I've visited some very beautiful mountainous areas and in Montego Bay over the weekend, I took a lot of pictures as well. So that's my main recreation, and Jamaica's an ideal place for it. The colours are so bright, and the air is so clear, that should make very good photography.