Racial stereotyping: survey of psychiatrists in the United Kingdom

Ten years ago, psychiatrists rated black male patients as potentially more violent than white patients.¹ We aimed to establish whether such racial stereotyping still occurs.

Participants, methods, and results

We sent a postal questionnaire concerning the first presentation of a young man at casualty—which included a photograph, brief history, and findings on the patient's mental state—to a random sample (generated by SPSS statistical software) of 1000 British psychiatrists obtained from the Royal College of Psychiatrists' database. The sample was randomised so that half received a picture of a black man and half received a picture of a white man. (Photographs were of one of four healthy volunteers, whom we had not seen previously; they were matched for age and occupation, and photographed under identical conditions.) To exclude the possibility that results stemmed from differences between individual photographs, such as facial expression and mode of dress, we photographed two men from each race; one was a footballer and the other an academic (the photographs can be seen on BMJ 's website). We used recommended terminology for ethnicity.² Respondents were asked to rank five questions, in order of importance, to supplement the assessment. χ² tests compared “black” with “white” questionnaires after questions were grouped into “important” (ranking 1-2) and “less important” (ranking 3-5). Respondents rated questions on management issues by putting a cross on a 10 cm continuous line. For each question, mean scores for “black” and “white” questionnaires were compared using the Mann-Whitney U test (table).

Of the 823 psychiatrists who could be contacted (18% had changed address or retired), 59% (n=485)—equivalent to 10% of British psychiatrists—returned completed questionnaires. Forty eight per cent (232) had received a “black” questionnaire. Fourteen respondents, who had all received a questionnaire with a photograph of a black man, guessed the hypothesis; six completed the questionnaire and were included in the analyses. Five others returned questionnaires uncompleted. Prior power calculations, based on expected mean (SD) risks of violence of 2.41 (1.76) v 2.87 (1.53),¹ gave the study 85% power at the 5% level.

Psychiatrists indicated that they were more likely to ask black patients whether they had a social worker or had received learning support at school, whereas they were more likely to ask white patients about problem drinking. They were equally likely to ask a black patient or a white patient if they had a criminal record or had recently used illegal drugs. Psychiatrists thought it would be more difficult to build a rapport with white patients, that white patients would be more of a management problem, and that they were more likely to pose a risk of violence to others. There were no significant differences regarding risk to self, the need for inpatient care, or the need for a locked ward. Psychiatrists were more likely to rate schizophrenia and personality disorder as appropriate diagnoses for white patients, but there were no differences for bipolar illness or brief reactive psychosis (table). There were no significant differences in any of the above variables between patients of the same race.

Comment

Participating psychiatrists did not rate black patients as more likely to be violent than white; this is different from a decade ago.¹ Did psychiatrists guess the hypothesis and overcompensate? Only 1% suggested that they had overcompensated (none with a “white” questionnaire); in addition, ranking of supplementary questions in which psychiatrists with “black” photographs were more likely to ask about social work or learning support suggested that racial stereotyping was occurring. Differences in management strategies were small and may not be clinically important. Racism is evident in the psychiatric system: involuntary admissions of young black men are more common than those of young white men,³,⁴ and schizophrenia is more commonly diagnosed in young black men⁴ even though the prevalence in the community is no different for black and white men.⁵ Our results suggest that the racial stereotyping that occurs at first interview is not sufficient to account for the inequalities seen in secondary care. Urgent exploration is required to find out where these inequalities arise.

Table.

Differences between “black” and “white” questionnaires completed by British psychiatrists in ranking of questions on a 10 cm continuous line. Values are means (SD) unless otherwise stated  

Item on questionnaire	Black (n=232)	White (n=253)	Test statistic (95% CI)*	P value
Question likely to be asked of subject (%)†:
Had a social worker	n=72/231 (31)	n=47/227 (21)	χ2=6.52 (0.02 to 0.18)	0.01
Had learning support	n=24/231 (10)	n=13/227 (6)	χ2=3.35 (−0.003 to 0.10)	0.06
Had a drinking problem	n=106/231 (46)	n=140/227 (62)	χ2=11.47 (−0.25 to −0.07)	0.001
Had a criminal record	n=38/231 (16)	n=35/227 (15)	χ2=0.09 (−0.06 to 0.08)	0.80
Had recently used illegal drugs	n=224/232 (96)	n=219/227 (96)	χ2=0.002 (−0.03 to 0.03)	0.90
Rapport difficult to establish	62.4 (18.3)	68.4 (16.2)	23577.5 (−9.00 to −2.80)	0.01
Management problem	61.7 (16.1)	66.9 (16.6)	22139.0 (−8.10 to −2.20)	0.001
Risk of violence to others	52.6 (20.4)	57.8 (19.9)	63.5 (−8.80 to −1.55)	0.005
Likely diagnosis:
Schizophrenia	77.8 (17.3)	83.0 (13.5)	3500.5 (−8.00 to −2.40)	<0.0001
Personality disorder	29.0 (18.3)	36.6 (21.0)	1408.5 (−11.20 to −4.00)	<0.0001
Bipolar illness	50.7 (21.4)	48.6 (22.0)	26037.0 (−1.84 to 6.00)	0.29
Brief reactive psychosis	65.9 (20.8)	62.8 (23.1)	6308.5 (−0.90 to 7.00)	0.13
Neuroleptic drug indicated	86.7 (12.2)	89.9 (11.24)	3575.0 (−5.30 to −1.10)	0.003

^*Mann-Whitney U unless otherwise stated. ^†Not all questions were ranked by all psychiatrists.