REPRESENTACIÓN PROPORCIONAL Y COALICIONES EN A RGENTINA

Research on the aetilogy of schizophrenia in Africans and Afncan-Caribbeans in Britain has provided rigorous findings that genetic, biological and migration factors cannot explain the inflated rates of this illness in this population. These studies clearly show that rates of schizophrenia in second and third generations of Black people in Britain are higher than in first generation immigrants from the Caribbean, and in Black people who have not emigrated from the Caribbean. Therefore socio-economic factors in Britain have been highlighted to explain these rates. However, these findings are confounded by the fact that the ‘jury is still out’ on the issue of misdiagnosis of schizophrenia. One study has shown that a British psychiatrist more frequently diagnosed Black patients with schizophrenia than a Jamaican psychiatrist, but the literature has not demonstrated the

prevalence of such disagreements. Research also demonstrates the overuse of a diagnosis of ‘cannabis induced psychosis’ to explain the presentation of psychotic symptoms in Black patients. However, this research is vignette based, and it is difficult to conclude that diagnosis of a hypothetical case directly reflects clinical practice. Until these methodological weaknesses are addressed, researchers cannot safely conclude that rates are genuinely higher in this population. If misdiagnosis is greater than first thought, this further validates Black people’s view of psychiatric practice as flawed, and indicates that more research needs to be directed to investigating the ‘social distance’ between Black patients and psychiatrists, and its impact on the diagnostic process. If, however, misdiagnosis is less frequent than has been suggested. Black patients’ experience of psychiatric care continues to demand attention, with perhaps socio-cultural influences on illness beliefs in this population requiring additional attention. There are clearly over­ lapping influences on the rates of schizophrenia that are difficult to separate and control for. It is important for studies to highlight these difficulties when drawing conclusions from its findings. Finally, the diagnosis of schizophrenia also has an influence on assumptions about insight, as the research has shown that insight is poorer in people with schizophrenia than other psychotic disorders.

A broad view of the methodological weaknesses in insight research is highlighted here, which addresses many aspects of the research done in this area so far: The meaning of insight in mental illness, and more specifically schizophrenia, have been debated in the literature for over thirty years. However, the more rigorous investigations, guided by academic models and operationalised, structured measures, are a much more recent

contribution, and have shown that insight is a more complicated construct than the earlier literature suggested. Not only has it been demonstrated that insight has at least three different aetiologies - neuropsychological, psychological and symptomatic, which can overlap in non-linear ways, it has at least three dimensions - recognition that one has a mental illness, complying with treatment, and the ability to re-label unusual mental events as symptoms of psychosis, which can also overlap in non-linear ways. The authors have acknowledged the complicated nature of investigating insight, and are often tom between taking a broad perspective, thereby underestimating the complex details, or carrying out a precise examination of only a small part of the concept, thereby missing the many influences on insight (Strauss, 1998). Added to this, insight itself varies according to the cultural context, situation, psychological method at which it is assessed (e.g., overt self- report, observed behaviour), psychological level at which it is assessed (e.g., neuropsychological, psychological), stage of illness, and the definition of insight espoused - of which there is no general agreement (Strauss, 1998). As insight has been viewed as a key factor in mental illness, it cannot be concluded that insight is so complex that it cannot be researched, and thus continues demands further investigation that is both necessary and unavoidable. However, in any attempt to further advance the understanding of insight, researchers need to remain aware that the findings are limited by these complexities.

The research on institutional and factors in the psychiatric care of Black patients in Britain can be criticised on more basic methodological grounds. The studies reviewed generate important themes for further exploration. However, on their own, they are

essentially clinical audits of service providers’ and service-users’ views, with individual examples of malpractice and bad experiences taken as evidence of the norm. More scientifically rigorous studies are required to quantify and expand upon the results outlined so far. For example, studies need to highlight and control for other factors that might contribute to service providers’ and Black service-users’ views, with comparison to other cohorts or a control group.

A further neglected area in the above research of personal accounts of psychiatric care is factors affecting the measurement of autobiographical memories. For example, it is well known that depression affects the validity of, or biases, recall for past events. In studies based on Brown & Harris’s (1978) investigation into life events and depression in women, it was found that subjects diagnosed with major depression reported an elevated rate of emotion-related, negative memories in daily incidents, and Smith (1997) found a substantially elevated rate of emotional memories of the more distant past. Williams & Scott (1988) also found that depressed people have difficulties in being specific in autobiographical memory, reporting generic memories with omissions. These findings suggest that if patients interviewed about their experience of their first psychiatric admission are depressed at the time of the interview, their accounts might be biased. For this reason, patients’ level of depression at the time of interview requires measurement. As depression is likely to bias both Black and White patients’ accounts, so that as long as one group is not more depressed than the other, findings related to first admission experiences should be less vulnerable to this bias.

It is also known that persecutory delusions affect the validity of autobiographical memories. For example, Kaney et al (1997; 1999) found that people with persecutory

delusions recalled significantly more general memories and fewer specific memories than normal control subjects. This suggests that if patients interviewed about their experience of their first psychiatric admission have persecutory delusions at the time of the interview, their accounts might be biased. For this reason, patients’ severity of psychosis at the time of interview requires measurement. As psychosis is likely to bias both Black and White patients’ accounts, so that as long as one group is not more psychotic than the other, findings related to first admission experiences should also be less vulnerable to this bias.