ol'.III')H JUUKNAL Ut" t'')TLHIAI KT (1991),171,101-105

Table I Age-standardised mental hospital admission rates for all diagnoses by selected nativity groups in

England and Wales (1971) and England (1981). Rates per 100000 population (data from Cochrane & Bal. 1989)

Mental health and ethnicity: an Irish dimension

PATRICK J. BRACKEN. LIAM GREENSLADE. BARNEY GRIFFIN andMARCELINO SMYTH

Evidence that the Irish are grossly over-represented as users of psychiatric serviceshas been available for a number of years. Inboth the 1971 and 1981 Mental HealthEnquiries (see Table 1; Cochrane, 1977;Cochrane & Bal, 1989) Irish people inBritain had the highest rates of mentalhospitalisation and were more than twiceas likely as the native-born to be hospital-ised for some forms of psychological distress

1981

(see Table 2). Irish people were over-represented in most diagnostic categoriesbut the figures for depression and alcohol-related disorders were particularly striking.Men and women born in the Republic ofIreland had rates of admission for depres-sion approximately two and a half timesthose of their native-born counterparts. Foralcohol-related disorders, men born in theRepublic of Ireland suffered approximatelynine times, and women seven times, the rateof English-born people. The figures forpeople born in Northern Ireland weresomewhat less than those of the Republic,but are considerably higher than Englishrates (Cochrane & Bal, 1989). Irish rates ofschizophrenia were second only to those ofthe African-Caribbean population. How-ever, the overall hospitalisation rate forIrish people was far higher than for theAfrican-Caribbean group, relatively a moreresearched population in the field of eth-nicity and mental health.

The Irish-born population in Britain isan ageing one, with over 26% of its

1971

MENTAL HEALTH OF IRISHPEOPLE IN BRITAIN

Country of birth

The importance of issues such as ethnicity,culture and racism in relation to mentalhealth is now well established and generallyaccepted in psychiatry. However, the de-bate around these issues in Britain has beenlimited by an almost exclusive identifica-tion of ethnicity with skin colour. In mostresearch ethnic minority groups are com-pared, by and large, with a 'White' groupwhich is assumed to be homogeneous,particularly with regard to issues of cultureand the experience of social disadvantageand racism. There is now considerableevidence that of all the ethnic minoritiesin Britain, the Irish have the poorest recordof both physical and mental health(Cochrane & Ba11989; Pearson et ai, 1991;Greenslade, 1994). In spite of this, littleresearch has been focused on the healthneeds of this community.

Males Females Males Females

Table 2 Rates of mental hospital admissions for selected nativity groups in England (1981) per 100000population by gender and diagnosis (data from Cochrane & Bal, 1989)

I. Schizophrenia and paranoia.2. Affective psychoses and depressive disorders.3. Includes neurotic depression.4. Alcohol psychosis and alcohol dependence and non-dependent use of alcohol.

Schizophrenia' 158 174Other psychoses 36 50Depression2 197 410Neuroses) 62 IIIPersonality disorder 62 80Alcohol misuse" 332 133Drug misuse 13 8

IRISH PEOPLE IN BRITAIN

This lack of research interest is particularlyanomalous given the size of the Irishcommunity in Britain. Irish-born peoplemake up approximately 1.50/0 of Britain'spopulation, and when people of Irishparentage are included, the size of thecommunity rises to 2.5 million, that is,4.60/0 of the population (Hickman &Walter, 1997), making Irish people InBritain the largest migrant minority inWestern Europe.

The mortality rates of Irish-born peopleexceed those of all residents of England andWales by approximately 300/0 for men and200/0 for women (Haskey, 1996). Irish menare the only migrant group whose lifeexpectancy worsens on emigration toEngland (Pearson et ai, 1991). In a recentstudy (Harding & Balarajan, 1996) it wasshown that these excessive mortality ratespersist into the British-born children ofIrish migrants, a finding which is veryunusual in migrant mortality research(Haskey, 1996).

Irish Republic

Northern Ireland

England

Diagnosis

10651391434

Irish Republic

Male

1153102551

Female

10~

793418

Country of birth

England

Male

6116792830385

1102880583

Female

5827

1665635183

103

.RACKEN ET AL

members above pensionable age (Green-slade, 1993). In view of the fact that up to15% of elderly people suffer depressiveillness, it is likely that the over-represent-ation of Irish people in mental hospitalswill continue for the foreseeable future.

Admission rates for various diagnosticcategories are influenced by a number offactors and cannot be taken to reflectdirectly the level of psychiatric morbidityin any particular population. A number oftheories have been offered to explain thelow rates of admission for Asian people inBritain. For example, it has been suggestedthat Asian general practitioners may thinkit inappropriate to refer people with psy-chiatric symptoms to hospital (lneichen,1990). In relation to the observed higherrates of hospitalisation of African-Carib-bean people with a diagnosis of schizo-phrenia, a number of problematic issueshave been identified. Most important ofthese are numerator problems of casedefinition and case identification. How-ever, issues of diagnostic accuracy do notarise when admission figures alone arebeing examined. It would be difficult toexplain the marked difference between theIrish admission rates and those of thenative-born simply on the basis of numer-ator inaccuracy. Likewise, it is widelyaccepted that census data relating to Irishpeople in England and Wales are unre-liable. It is likely that the census figures forthe size of the Irish population represent anunder-estimation (Hickman & Walter,1997). However, the true size of the Irishpopulation would have to be double thecensus figure if this denominator questionwere to account for the excess of Irishadmissions.

Some commentators have pointed tothe fact that high mental hospital admissionrates have also been recorded in parts ofIreland itself and in Irish immigrants toNorth America. This has been used toexplain the excess of Irish people admittedin Britain, particularly with a diagnosis ofschizophrenia, the assumption being thatall excess admission rates reflect an actualincreased prevalence of schizophrenia inIrish people (Cochrane & Bal, 1987).However, in a World Health Organizationstudy in which identical case-finding anddiagnostic techniques were used in 12centres worldwide it was found that theincidence of schizophrenia in Dublin,Ireland, was in the mid-range of all thecountries studied (Sartorius et ai, 1986) andin a recent study in the west of Ireland the

104

lifetime prevalence rate for schizophreniawas not in excess of rates found elsewhere(Kendler et ai, 1993).

In a series of reports, published in the1980s, the Irish Health Research Board haspresented strong evidence for a socialexplanation for high admission and re-admission rates in Ireland. A number offactors have been identified as important:

Ma relatively large provision ofpsychiatric hospitalbeds. few outpatient services (especially in ruralareas). rural poverty, unemployment, isolationand a large percentage of elderly men andwomen" (Cabot. 1990).

If these features of Irish society areimportant in promoting high hospitalisa-tion rates, one could reasonably expect tofind lower rates after emigration to a moreaffluent country. This does not appear tohappen in Britain. It appears that which-ever way one examines the data pertainingto mental illness and Irish people inEngland and Wales, one has to concludethat there is a real problem and that thereare real issues to be faced. This is unlike thesituation in North America where there hasbeen conflicting evidence regarding theincidence and prevalence of mental illnessamong Irish people.

This excess of hospital admissions ofIrish people in Britain has its materialcorrelate in suicide, parasuicide and self-harm. For the period 1979-1983 excessmortality for suicide was 26 and 300/0 forIrish-born men and women, respectively(Raleigh & Balarajan, 1992). Amongyounger age groups in the same period theexcess was even greater. For Irish-bornwomen aged 20-29 the excess was 167%and for men 740/0. Other studies haveshown that Irish-born people are over-represented in admission figures for at-tempted suicide and self-poisoning.

For the period 1988-1992 Irish peoplein Britain had an age-standardised mortal-ity rate for suicide of 17.4 per 100000. Thiswas 53% in excess of the native-born rate(11.4 per 100000). Among second-gener-ation Irish people, who are excluded fromthe mental hospital admission data, theexcess due to suicide was 250/0 (Harding &Balarajan, 1996).

SOCIAL SITUATION OF IRISHPEOPLE IN BRITAIN

Like Asian and African-Caribbean immi-grants to Britain, Irish people have come asmigrant workers. Because of this, manyexperiences have been shared by these

groups. For example, they have tended tosettle in the major cities where they havetraditionally found employment. In addi-tion, Irish people share in the socialdisadvantages experienced by African-Caribbean and Asian immigrants. Irishpeople are twice as likely to be unemployedas native-born people (16.7% comparedwith 8.60/0 for heads of household) andmore likely to be involved in manual,unskilled and personal service employment(44.50/0 compared with 28.20/0 Britishpeople; Greenslade et ai, 1991). Many Irishmen who migrated to Britain have beenemployed as unskilled workers. Many seekwork in the building industry where em-ployment is often erratic and conditionsunhealthy. Such men often lead a nomadicexistence, following work from one site toanother, moving from one city to another,never putting down roots and graduallylosing contact with families and commu-nities back in Ireland. Poor housing andhomelessness are problems particularlyassociated with Irish people in Britain. AsO'Meachair (1988) has commented:

"In London, one-in-three occupants of hostelsfor the homeless in Inner London are Irish; one-in-four in Outer London are Irish. In 1985,38% ofcasual users of DHSS resettlement units wereIrish and two out of every seven people whosleep rough in central London are Irish."

The fact that Irish people were specifi-cally excluded from the tightening-up pro-cess in the series of Nationality andImmigration Acts since the Second WorldWar is often taken as evidence that there isnow more tolerance and acceptance of theIrish compared with other immigrantgroups. However, the study by Harding &Balarajan (1996) indicates that high mor-tality rates continue in the second gener-ation. Harding & Balarajan (1996) arguethat there is a need to explore cultural aswell as socio-economic issues in relation tothe health of the Irish in England andWales. In particular they note that theconflict in Northern Ireland has made itvery difficult for Irish people living inEngland and Wales to promote a "positiveIrish identity".

In a recent report, prepared' for theCommission on Racial Equality, consider-able evidence was presented of strong anti-Irish discrimination in many parts of Britishsociety (Hickman & Walter, 1997). Thereis also evidence that with regard to theexperience of racism there is much incommon between the Irish communityand the African-Caribbean and Asian

communities. Within living memory, manyimmigrants to English cities were facedwith signs such as UNo Blacks or Irish" inthe windows of rented accommodation.The tabloid press in Britain can sometimesbe overtly racist in its reporting of the Irishcommunity and Irish affairs.

USE OF ETHNICITYCATEGORIES IN RESEARCH

MENTAL HEALTH AND ETHNICITY: AN IRISH DIMENSION

PATRICK J. BRACKEN. MD. Department of Social and Economic Studies, University of Bradford: L1AMGREENSLADE, Liverpool Irish Centre. Mount Pleasant. Liverpool: BARNEY GRIFFIN, BPhil. Birmingham Irish

Mental Health Forum, Ladywood. Birmingham; MARCELINO SMYTH. MRCPsych. Northern BirminghamMental Health Trust. Birmingham

Correspondence: Patrick J. Bracken, Consultant Psychiatrist ISenior Research Fellow. Department ofSocial and Economic Studies. University of Bradford, Richmond Building. Bradford BD7 lOP

(First received II March 1997. final revision II September 1997. accepted II September 1997)

In recent years a number of prominentacademics have begun to question the easyuse of the categories White, Asian andAfrican-Caribbean in health and socialresearch. These categories, which carry astrong racial connotation, are simply in-adequate to address the complex ethnicreality of modern Britain. In spite of this, allethnic categorisations are, in the end,strategic devices, and it can be argued thatthe use of relatively crude categorisationscan be helpful as a first step in demonstrat-ing differential social and health experi-ences. However, once it becomes clear thatsuch categorisations are in fact working toconceal such differential experiences, thereis surely a compelling argument in favourof using more thoughtful approaches. Ourargument is that the category 'White'requires substantial re-examination, bothin terms of its usefulness in empiricalresearch and also as a conceptual tool. Itnow behoves researchers working in differ-ent areas, including the field of mentalhealth, to explain more clearly why they areusing particular ethnic categories.

In the British mental health and eth-nicity debate there has been a great deal ofinterest in two particular trends: the appar-ent higher rates of schizophrenia amongboth first- and second-generation African-Caribbean people and the lower rates ofutilisation of psychiatric services by Asians.The neglect of an Irish dimension in thisdebate and the almost exclusive concernwith these two trends is associated with awider academic neglect of the Irish com-munity in Britain.

The dominant paradigm for under-standing ethnicity within the British dis-

courses of transculturalism, race-relationsand anti-racism has been in terms of aBlack-White dichotomy. To a large extentthese discourses have been developed asantitheses to earlier colonial frameworkswhich involved notions of racial superi-ority. The Irish, a native population whichhappened to be White, were always diffi-cult to place within such frameworks. Theyconstituted, by their existence as a colo-nised people, an affront to the very idea ofthe 'White man's burden', and thus chal-lenged many of the fundamental assump-tions of colonial discourse. As contempor-ary debates around ethnicity and racismtend to mirror these colonial debates,perhaps it is not surprising that post-colonial transculturalism has found theIrish problematic, and thus easier to ignore.Given the evidence presented here, thecontinued neglect of this community inBritain is now untenable. In particular,there is an urgent need for both quantitativeand qualitative research relating to themental health needs of Irish immigrants.

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