Being a member of Leicestershire Partnership NHS Trust is about being part of a community. It is about helping people who use mental health and learning disability services to lead the lives they want to lead.

A group of our members recently met up with members from other mental health and learning disability NHS Trusts at a special workshop in London called “Communities of Influence’, Members were encouraged to talk about their membership role and how they could use that role to influence the NHS to provide the kind of services wanted and needed by local communities.

Membership Manager, Samantha Quinn said; “The members who attended are keen that they and others use the opportunity to become a ‘community of influence’ so that local NHS mental health and learning disability services continue to develop and progress in the way that local people want them to.”

It was a very productive day which helped members to find out how Trusts are connecting with their staff, the public, and importantly the people who use services and their carers.

Prisoners and mental health

Number of prisoners with mental health problems

According to the ONS (the Office of National Statistics), a large proportion of prisoners in England and Wales have a mental health problem. [1]

In one survey they found that in the week before the interview, 39 per cent of sentenced males and 75 per cent of female remand prisoners had significant neurotic problems, such as anxiety, depression and phobias. Rates for all groups were much higher than the 12 per cent of men and 18 per cent of women found to have significant levels of neurotic symptoms in a similar household survey [2] carried out by the ONS.

Differences between remand prisoners and sentenced prisoners

Remand prisoners (prisoners awaiting trial) have higher rates of neurotic disorder than sentenced prisoners and women have higher rates than men. ONS suggest that 58 per cent of men and 75 per cent of women remand prisoners experience significant neurotic symptoms [3]. The figures are lower for sentenced prisoners, with 39 per cent of men and 62 per cent of women showing some form of neurotic disorder. [4]

Another survey found that 45 per cent of suicides in prisons were by people held on remand and who were still waiting to go to trial. [5]

Self-harm among prisoners

ONS has found that self-harm during the current prison term, without the intention of suicide, is just under 10 per cent for female prisoners and just under 6 per cent for males. [6] The rates reported by remand and sentenced prisoners were similar; however, two thirds of remand prisoners had been in prison for less than three months compared with only about a quarter of the sentenced prisoners.

Women represent more than 50 per cent of all self-harm cases in prison. [7] This is worrying as women represent only 5 per cent of the prison population. [8] The rate of self-harm is particularly high among women under 21. At two women’s prisons they have reported around 10 cases of self-harm per day.

Between 2004 and 2008, incidents of self-harm in prisons increased by 25 per cent. [9] In female prisons the increase was 42 per cent in the same period. The total number of self-harm cases in 2008 was 10,466 for men and 12,560 for women – a total of 23,026.

Attempted suicide among prisoners

ONS has found that a high number of prisoners have tried to take their own lives, particularly women and remand prisoners. Just under one in four men and nearly two in five women reported a suicide attempt at some time in their life. In one survey, over a quarter of female remand prisoners reported attempting suicide in the year before the interview. [10]

Suicide among prisoners

 The suicide rate among prisoners went down from 92 in 2007 to 61 in 2008. [11] However, it is important to note that this followed a sharp increase in the numbers from 67 in 2006 to 92 in 2007. Although the numbers are going down, the suicide rate for prisoners is still alarmingly high with 91 suicides per 100,000 in the prison population compared with 8.5 per 100,000 in the general population.[[12] This means that the risk of suicide is more than 10 times higher for a prisoner than for the general population.

Psychosis among prisoners

In an ONS survey, a random sample of one in five prisoners interviewed previously were selected for an additional interview by a clinician to assess personality disorder and functional psychoses, such as schizophrenia and manic depression (but not organic psychoses such as dementia). In this follow-up interview, 14 per cent of all the women, 10 per cent of the men on remand and 7 per cent of the sentenced men were assessed as having a functional psychosis, in the year prior to interview. These rates for psychosis are much higher than for the general population, where the figure is only 0.4 per cent. [13]

Mental health in-reach teams (MHIRT) confirms high rates of psychosis among prisoners. A survey of clinical records of prisoners treated by the MHIRTs showed that 18 per cent had a diagnosis of schizophrenia and another 18 per cent had a diagnosis of psychosis. [14]  

Personality disorders among prisoners

ONS suggests that over three quarters of the men on remand, nearly two thirds of the males sentenced, and half of the women sentenced fitted a diagnosis of personality disorder. [15] Another survey shows that, among prisoners treated by MHIRT, around 17 per cent have a diagnosis of personality disorder, usually in combination with another diagnosis. [16]

Antisocial personality disorder (ASPD)
The most common type of personality disorder seen in prisons, according to the ONS, is antisocial. [17] This has been found in 63 per cent of males on remand, 49 per cent of males sentenced and 31 per cent of all female prisoners. This would be expected, since the category of ASPD requires the presence of antisocial behaviour before the age of 15 years and persisting into adulthood. Criminal behaviour is often seen as antisocial, so many prisoners are therefore likely to be diagnosed with this disorder. The figures are broadly in line with the results of studies carried out within the United States prison system.

Paranoid and borderline personality disorders
Paranoid and borderline personality disorders are the next most common types of disorder seen in prison, according to ONS. [18] A total of 29 per cent of male remand, 20 per cent of male sentenced and 16 per cent of female prisoners were assessed as having paranoid personality disorder. The equivalent figures for borderline personality disorder were 23 per cent, 14 per cent and 20 per cent respectively.

According to the ONS, paranoid personality disorder is often combined with ASPD in criminal populations and is characterised by pervasive mistrust and suspiciousness. People with borderline personality disorder are considered to be highly impulsive, experience brief mood swings, have a poor sense of self-image and have difficulty in sustaining close relationships. They are the group most often seen by psychiatric services in prisons.

Another survey also found that prisoners in England and Wales have very high rates of mental illness, substance misuse and personality disorder. [19]

Prevalence of personality disorder  [20]

	Male	Male	Female
	Remand	Sentenced	All
	Per cent
Type of personality disorder
Antisocial	63	49	31
Paranoid	29	20	16
Borderline	23	14	20
Avoidant	14	7	11
Obsessive-compulsive	7	10	10
Narcissistic	8	7	6
Schizoid	8	6	4
Dependent	4	1	5
Schizotypal	2	2	4
Histrionic	1	2	1
Any personality disorder	78	64	50
Base (sample size)	181	210	105

Hazardous alcohol use by prisoners

ONS says that the prevalence of hazardous drinking, in the year prior to coming to prison, is higher in men than in women. [21] This applied to over half the men they interviewed regarding this: 58 per cent on remand and 63 per cent sentenced. This compared to 36 per cent of female remand prisoners and 39 per cent of female sentenced prisoners.

Prisoners who have problems with alcohol are often also addicted to drugs. Over 25 per cent of male prisoners and around 20 per cent of female prisoners who are hazardous drinkers are also dependent on one or more illegal drugs. [22]

In 2002/03 around 6,400 prisoners took part in alcohol detoxification programmes. [23] Another 7,000 prisoners joined detoxification programmes for combined alcohol and drug addiction. [24]

The Prison Service published an alcohol strategy for prisoners in 2004. Key aims of the strategy are to balance treatment and support with measures that can reduce supply. [25] Although, it is clear that alcohol misuse is a big problem for prisoners, the government has not been able to provide treatment for those who want it. One report on arrestees showed that of the 27 per cent who wanted treatment, only 9 per cent had been offered treatment. [26]

Drug dependence among prisoners

ONS suggests that drug dependence (as shown by the use of a drug every day for two weeks or more and, for cannabis, some other sign of dependence), in the year before coming to prison, is very common. [27] Drug dependence was reported by 51 per cent of male remand, 43 per cent of male sentenced, 54 per cent of female remand and 41 per cent of female sentenced prisoners.

According to the ONS, the rates of all types of mental disorder – especially drug and alcohol dependency – are higher for prisoners than for the general population. [28]

Remand prisoners are more likely than sentenced prisoners to report dependence on opiates (heroin or non-prescribed methadone) alone or in combination with other drugs, in the year before coming to prison. Opiate dependence has been reported by 41 per cent of females on remand and 26 per cent of males on remand, but only 23 per cent of females sentenced and 18 per cent of males sentenced. [29]

Offenders who are sent to residential drug treatment centres are 45 per cent less likely to commit crimes after release compared to offenders who are sent to prison. [30] Many offenders who are sent to prisons and who want treatment are not offered this. The greatest gap is for those addicted to crack (cocaine). One survey showed that 67 per cent of arrestees had wanted treatment for crack addiction, but only 9 per cent had been offered treatment. The survey also showed that 60 per cent of arrestees who took heroin five or more days a week had not been offered treatment in the past 12 months. HM Chief Inspector of Prisons has said that they get 60 per cent less funding than they had hoped for new integrated drug treatments. [31]

The Home Office suggests that for every £1 spent on drug treatment saves society £9.50. [32]

Prisoners and the Mental Health Act

People sent to hospital (rather than prison) under Part III of the Mental Health Act

During 2007/08, the courts in England sent a total of 1,400 people to hospital for treatment under the Mental Health Act (Part III). [33] Some were sent by the courts at the time of sentencing, while others were transferred from prison to hospital. During 2007/08 the courts in Wales sent 103 people to hospital.  [34]

People detained in high security hospitals under Part III of the Mental Health Act

In England, a total of 7,500 people were sent to secure hospitals (Place of Safety Orders) during 2007/08 – most of these were to an NHS hospital. That means the figures have trebled since 1997/98 when the number of Place of Safety Orders was 2,483. [35]  In Wales, a total of 367 people were put on Place of Safety detention in 2007/08. [36] The figures have increased since 2003/04 when 262 people in Wales were sent to secure hospitals.

Crime and risk in the community

Risk of being killed by someone with a mental heath problem

The public perception is that community care policy has failed and that there are now more people with mental health problems on the streets. Many believe that this means an increased risk of being harmed by somebody diagnosed with a mental health problem. A report by the Audit Commission [37] points out that most people with schizophrenia live relatively normal lives in the community and the risk to the public has actually decreased since the community care reforms. The report cites evidence that the number of homicides by people with mental health problems has not increased, while the number committed by others has more than doubled.

In January 1999, psychiatrists carried out a study [38] based on Home Office Figures. The study shows that the majority of homicides are not linked to care in the community. Contrary to popular belief, the number of homicide convictions of people considered to be mentally disordered has fallen to half that reached in 1979 – before the rush to close old asylums. Compared with all killings, the number committed by people with mental health problems has fallen even faster. The proportion has dropped from almost half in the 1960s, to little more than one in ten today. Although homicide convictions have multiplied fivefold since the late 1950s to more than 500 annually, the number involving a mentally disordered offender has fallen to around 60.

According to the psychiatrists who carried out the study, the likelihood of someone being killed by somebody with a mental disorder is probably less than that of winning the National Lottery outright. Even then, victims are likely to be someone known to the killer, rather than a stranger. Although people today are at slightly increased risk of being killed by a stranger, according to the psychiatrists, that person is highly unlikely to have a mental disorder. [39]

There were 699 homicides in 1995. In 423 cases, the victim was known to the suspect; in 169 the suspect was a stranger; in 88 cases no suspect was identified. In only 32 cases (4.6 per cent) was the suspect ‘mentally disturbed’. [40]

The Confidential Enquiry into Homicides and Suicides by Mentally Ill People [41]  shows that serious mental disorders are rare, and affect only four out of every 1,000 adults. Serious violence is even more rare – there are between 600 and 700 homicides each year, but few of them are carried out by people with mental health problems. The enquiry, which took place over a period of 33 months, identified only 39 homicides in England by people in contact with specialist mental health services in the previous year (between five and six per cent of all homicides).

In 2004, The British Medical Journal published a study which concluded: ‘Stranger homicides have increased in the recent years, but the increase is not the result of homicides by mentally ill people and therefore the “care in the community” policy. Stranger homicides are more likely to be related to alcohol or drug misuse by young men.’ [42]

People with mental health problems are, in fact, at far greater risk of harming themselves than other people and are at increased risk of suicide.

(See Mind’s factsheet Mental Health Statistics 2: Suicide.)

References

---

[1] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[2] Meltzer, H et al. 1995, OPCS Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity among adults living in private households, HMSO.
[3] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[4] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[5] Prison Reform Trust, 2008, The Cruellest Wait
[6] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[7] HM Chief Inspector of Prisons for England and Wales, 2009, Annual report 2007-08
[8] HM Chief Inspector of Prisons for England and Wales, 2009, Annual report 2007-08
[9] The Howard League for Penal Reform, 2009, downloaded from www.howardleague.org , June 2009
[10] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[11] Ministry of Justice, 2009, Deaths in prison custody 2008
[12] Royal College of Psychiatrists, 2009, Multi-agency working needed to tackle ‘worryingly high’ prison deaths
[13] Meltzer, H et al. 1995, OPCS Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity among adults living in private households, HMSO.
[14] HM Inspectorate of prisons, 2007, The mental health of prisoners, A thematic review of the care and support of prisoners with mental health needs
[15] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[16] HM Inspectorate of prisons, 2007, The mental health of prisoners, A thematic review of the care and support of prisoners with mental health needs
[17] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[18] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[19] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London.
[20] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[21] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[22] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[23] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[24] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[25] HM Prison Service, 2004, Addressing Alcohol Misuse: A Prison Service Alcohol Strategy for Prisoners
[26] Home Office, 2006, Home Office Statistical Bulletin, The Arrestee Survey Annual Report: Oct 2003-Sept 2004
[27] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[28] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[29] Singleton, N., Meltzer, H. and Gatward, R. 1998, Psychiatric morbidity among prisoners in England and Wales , The Stationery Office, London
[30] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[31] Prison Reform Trust, 2008, Bromley Briefings, Prison Factfile
[32] NHS Evidence, National Library for Public Health, 2009, 2009 Annual Update – Drugs – Drugs misuse treatment in Offender population
[33] Health and Social Care Information Centre, 2008, In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England 1997-98 to 2007-08
[34] Statistical Directorate, 2008, Admission of patients to mental health facilities in Wales, 2007/08 (including patients detained under the Mental Health Act 1983) National Assembly for Wales, SDR 167/2008. Available from http://new.wales.gov.uk/statsdocs/health/sdr167-2008.pdf
[35] Health and Social Care Information Centre, 2008, In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England 1997-98 to 2007-08
[36] Statistical Directorate, 2008, Admission of patients to mental health facilities in Wales, 2007/08 (including patients detained under the Mental Health Act 1983) National Assembly for Wales, SDR 167/2008. Available from http://new.wales.gov.uk/statsdocs/health/sdr167-2008.pdf
[37] Reed, J. 1997, ‘Risk Assessment and Clinical Risk Management: The Lessons from Recent Enquiries’, British Journal of Psychiatry, 170, supplement 32, pages 4-7.
[38] Taylor, P. and Gunn, J., Institute of Psyhiatry Research, quoted in The Guardian, Wednesday January 6 1999.
[39] Taylor, P. and Gunn, J. 1999.
[40] Parliamentary Written Answers, 14 October 1996.
[41] Royal College of Psychiatrists, 1996, Confidential Enquiry into Homicides and Suicides by Mentally Ill People, London.
[42] BMJ 2004;328:734-737 (27 March), doi:10.1136/bmj.328.7442.734, available at: http://bmj.bmjjournals.com/cgi/content/full/328/7442/734

This factsheet was updated by Inger Hatloy, Information Officer, Mind, July 2009.

Suicide

Note on interpreting suicide rates                                                            

Figures for suicide rates are not usually based solely on those officially classified as having died by suicide. This is because an official verdict of suicide has to show beyond reasonable doubt that suicide was intended – reflecting the fact that, until 1968, suicide was a criminal offence. An alternative verdict of probable suicide or ‘undetermined death’ is given where conclusive evidence is not available. Usually these two figures are combined to give a suicide rate. [1] This applies to the data given in this factsheet.

It is also worth noting that population differences need to be taken into account when comparing figures shown by age or gender. For example, a high rate for young people may be less significant if there are far more young people than other age groups in the population. For this reason, data are given per 100,000 of that population group. For example, in 2005, 74 men and 41 women over 85 years of age died by suicide. So just under twice as many men as women killed themselves. However, because there are far more women than men in this age group, the rates give a different picture. For men aged 85 years and over, as many as 23.3 per 100,000 died by suicide, compared with 5.5 per 100,000 for women. In other words, men of this age group are four times more likely than their female counterparts to end their lives by suicide.

Note on terminology

The language and terminology of psychiatric diagnosis used in this document refers to the original sources used. The use of such language does not imply Mind’s unqualified acceptance of it. The original language has been retained for the sake of accuracy.

How many suicides and attempted suicides are there each year?

Although the overall rate of death by suicide is falling, more than 4,300 people still die by suicide in England and Wales each year. [2] Many more suicide attempts are made. At least one person in every 100 who ends up in hospital after a suicide attempt will succeed within a year, and up to 5 per cent do so over the following decade. [3] A study looking at figures for attempted suicides from several European countries, including the UK, suggests that the figures might be higher – possibly as many as 2 per cent of people who have attempted suicide will kill themselves within a year of the previous attempt. [4] The study also found that about 7 per cent of people in the study died by suicide within the next decade. A British study found that women who have a history of deliberate self-harm (including overdose) are 15 times more likely to die by suicide compared with other women. The risk is particularly high during the 6 months following deliberate self-harm. [5]

Which sex is most at risk of suicide?

Suicide rates are higher for men than women of all age groups, and currently men are almost three times more likely than women to die by suicide. This gender gap has widened considerably over the past few decades: in 1979 the female-to-male ratio for suicides was 2:3, but by 2005 it was about 1:3.

Suicide rates for both men and women have varied over the last 30 years, however. Between 1975 and 1990, the rate increased for men but decreased for women whereas between 1990 and 1997 rates decreased for both men and women. [6] Between 1997 and 1999, there were some increases in overall numbers of suicides, and since 2000 the numbers have gone down for men but have remained fairly stable for women. [7]

The gender difference in the suicide rate is particularly striking for young people. Between the ages of 20 and 24 years, men are more than four times more likely than women to kill themselves. [8]

Amongst 15-19-year-olds girls are more likely to attempt suicide, but boys are much more likely to die as a result of a suicide attempt. [9]

Which age groups are most at risk of suicide?

The group at highest risk of suicide has changed over the years. It used to be men over 65 years of age: 24 per 100,000 population in 1979. [10] In the past decade, the group at highest risk has been men aged 25-34 years. However, in 2002, the risk of suicide in this age group was the same as in men aged 35-44 years: 22 per 100,000 population. During the late 1980s and 1990s, suicide was the most common cause of death for men aged 15-44 years. [11] The suicide rate has gone down since then, however, and suicide is now the second most common cause of death in this age group, behind accidental death. [12] 

In men aged 15-24 years the suicide rate rose from 9 per 100,000 population in 1979 to 13 per 100,000 in 1999; a rise of almost 50 per cent. Since 1999, the figures have shown a downward trend. [13] Among men, the highest rate of suicide since 1997 has been in those aged 15-44 years.

The pattern is different for women. Among women, the highest suicide rate in 2005 was for those aged 45-74 years. [14]

Which group has the lowest risk of suicide?

Young women in the 15-24 year age group are at the lowest risk. The suicide rate in this group has remained fairly constant since 1979, and is now fewer than 3 per 100,000 population. [15]

Suicide mortality

Mortality from suicide in England and Wales, by gender

	Men		Women		Total
Year	Actual number	Rate per 100,000	Actual number	Rate per 100,000	Actual number	Rate per 100,000
1996	3654	14.6	1239	4.7	4893	9.5
1997	3722	14.8	1259	4.8	4981	9.7
1998	3929	15.6	1225	4.6	5154	10
1999	3904	15.4	1284	4.8	5188	10
2000	3659	14.3	1262	4.7	4921	9.4
2001	3531	13.8	1163	4.3	4694	9.0
2002	3468	13.5	1194	4.4	4662	8.9
2003	3455	13.4	1197	4.4	4652	8.8
2004	3388	13.0	1205	4.5	4593	8.7
2005	3223	12.3	1113	4.1	4336	8.1

Source: ONS, 2007, Mortality statistics, Series DH2 no. 32

Source: ONS, 2007, Mortality statistics, Series DH2 no. 32

Factors that increase the risk of suicide

The likelihood of a person dying by suicide depends on several factors: [16]

• mental and physical illness
• social problems: particularly family stress, separation, divorce, social isolation, death of a loved one and unemployment
• ease of access to the means of suicide.

According to a World Health Organization working group, there is ample evidence that social conditions that are liable to change (such as the constant risk of losing one’s job) are among the determinants of suicide.

Marital status affects a person’s risk of suicide. In the early 1970s and late 1980s, suicides among men under 45 years of age were linked to remaining single or becoming divorced. [17] More recent research suggests that divorce is still a risk factor for suicide, particularly for men. [18]

Alcohol and drug misuse can also influence suicide risk. [19] Rates of drug and alcohol consumption are higher among men than women, and are particularly high among younger people. [20]

For many people, a combination of factors is more likely to increase their risk of suicide rather than one single cause. [21]

Suicide and mental health

A number of studies show that as many as 90 per cent of people who die by suicide had one or more psychiatric disorders at the time of death, and that each diagnosed mental illness was associated with an increased suicide risk. In one research study, 36 of 44 disorders considered were associated with significantly higher standardised mortality rates for suicide, leading the authors to conclude that virtually all mental disorders increase the risk of suicide except, possibly, dementia and agoraphobia. [22]  Functional mental disorders such as schizophrenia and depression are associated with the highest risk overall; substance misuse and organic disorders are associated with a lesser degree of risk. The links between mental health and suicide are discussed in more detail in Mind’s Suicide rates, risks and prevention strategies factsheet.

Safer Services reported that one in four people who took their own lives – about 1,000 people each year – were subsequently found to have been in contact with specialist mental health services in the year before death. [23] Of these, 16 per cent were inpatients at the time of their death, and 24 per cent had been discharged from hospital within the previous three months. Many were not fully compliant with treatment when discharged, and in most cases staff perceived the immediate risk of suicide to be low. Safer Services also recorded that about half of the suicides were by people with a history of self-harm and either substance misuse or previous admission to hospital. [24]

Depression

In the case of depression, studies have shown that, on average, the risk of suicide is about 15 times higher than the average for the general population. [25] However, this is likely to be an underestimate, as many who die by suicide may have been experiencing undiagnosed depressive illness.

The Mental Health Foundation estimates that 70 per cent of recorded suicides are by people experiencing depression, [26] often undiagnosed.

Schizophrenia
People with a diagnosis of schizophrenia are at an increased risk of suicide, particularly when they are young. The onset of schizophrenia tends to be between 17 and 25 years of age, at a time when many are struggling to establish an adult identity and relationships. The arrival of distressing symptoms at this time, along with the stigma attached to the diagnosis, increases the risk of suicide. [27] A lifetime risk of up to 10 per cent has been suggested, but even this may be an underestimate, and there is growing concern that suicide risk is increasing. [28] 

Suicide and unemployment

Links between unemployment and suicide have been clearly demonstrated in several studies. [29] In an international study of male suicides in 22 countries between 1974 and 1988, unemployment was found to be a leading factor. [30] Further studies in the UK confirm the links between unemployment, suicide and attempted suicide. [31] The link between suicide and unemployment appears to be particularly strong for young men. [32]

Suicide and employment

Men in unskilled occupations are four times more likely to die by suicide than are those in professional work. [33] However, certain occupational groups such as doctors, nurses, pharmacists, vets and farmers are at higher risk of suicide. This is thought to be partly because of ease of access to the means of suicide. [34]

Suicide and ethnicity

Patterns of suicide and attempted suicide among young black and Asian people in Britain do not reflect those in the wider community. The suicide rate amongst young Asian women is twice the national average. Wives who cannot have children or produce only daughters seem to be at greatest risk. Venna Soni, an epidemiologist and a leading expert on Asian suicides, reported that 1,979 women of all races between the ages of 15 and 34 years killed themselves between 1988 and 1992 in England and Wales, 85 of whom were Asian. This is nearly double their proportion of the population. [35]

One study shows that the suicide rate in young Asian women in the UK is three times higher than amongst their white counterparts. [36] However, this situation is reversed for young Asian men, who seem to be at less risk than young white men of British origin. [37]Recording of ethnicity in government statistics on health and other areas has recently been introduced in the UK and currently few official statistics are available. A Birmingham study found that young African-Caribbean women were at increased risk of attempted suicide, and reported rapid increases in the number of black people who died by suicide during the late 1970s. [38]

More recent studies, including the National Confidentiality Inquiry into Suicide and Homicide by people with Mental Illness, suggest that patterns of self-harm and suicide continue to be different for white people and people from minority ethnic groups. [39] Studies suggest higher rates of suicide among women than men in people of Chinese origin, which is in line with reports of suicide in China. Suicide by burning is unusual in England and Wales, but fairly common in South Asian women. [40]

People from ethnic minority groups who die by suicide are more likely to have been unemployed than their white counterparts. [41] They are also more likely to have been diagnosed with schizophrenia. They are less likely to have self-harmed in the past or to have a history of alcohol misuse than the white population. [42] 

References

[1] Hill, K. 1995, The long sleep – young people and suicide, Virago.
[2] ONS, 2007, Mortality Statistics for England and Wales 2005, Series DH2, no. 32.
[3] Hawton, K., Fagg, J. 1998, Suicide, and other causes of death, following attempted suicide, British Journal of Psychiatry, vol. 152, 359-366.
[4] Owns, D., Horrocks, J., House, A., 2002, Fatal and non-fatal repetition of self-harm, Systematic review, British Journal of Psychiatry, vol. 181, 193-199.
[5] Cooper, J., Kapur, N., Webb, R. et al. 2005, Suicide after deliberate self-harm: A 4-year cohort study, American Journal of Psychiatry, vol. 162, 297-303, published in Evidence-Based Mental Health, 2005, vol. 8, 97.
[6] ONS, 2006, Health Statistics Quarterly 32, winter 2006.
[7] ONS, 2007, Mortality Statistics, DH2, 1996-2005.
[8] NIMHE, 2007, National Suicide Prevention Strategy for England, Annual report on progress 2006.
[9] Hawton, K, (2000), Sex and suicide: Gender differences in suicidal behaviour, The British Journal of Psychiatry, 177: 484-485
[10] ONS, 1998, Social trends vol. 28.
[11] Brook, A., Griffiths, C. 2003, Trends in the mortality of young adults in England and Wales, 1961 to 2001, Health Statistics Quarterly, vol. 19.
[12] ONS, 2007, Mortality Statistics, Series DH2 nos. 30 and 32.
[13] Samaritans, 2004, Information resource pack.
[14] ONS, 2006, Annual Update: Mortality statistics 2004: injury and poisoning, Health Statistics Quarterly vol. 31.
[15] ONS, 2007, Mortality Statistics, Series DH2 nos. 30 and 32.
[16] NIMHE, 2007, National Suicide Prevention Strategy for England, Annual report on progress, 2006.
[17] Charlton, J. et al. 1992, Trends in suicide deaths in England and Wales. Population Trends No. 69. ONS.
[18] NIMHE, 2007, National Suicide Prevention Strategy for England, Annual report on progress, 2006.
[19] Appleby, L., 1999, Safer Services: national confidential inquiry into suicide and homicide by people with mental illness, Department of Health, London.
[20] ONS, 2008, General Household Survey, Smoking and Drinking Among Adults 2006, Crown copyright
[21] NIMHE, 2007, National Suicide Prevention Strategy for England, Annual report on progress, 2006
[22] Harris, E.C., Barraclough, B., 1997, Suicide as an outcome for mental disorders, British Journal of Psychiatry, 170, 205-228.
[23] Appleby, L. 1999, Safer Services: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Department of Health, London.
[24] Appleby, L. 1999, Safer Services: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Department of Health, London.
[25] Cipriani, A., Barbui, C., Geddes, J. R., 2005, Suicide, depression and antidepressants, BMJ 2005, vol. 330, 373-4
[26] Mental Health Foundation 1997, Briefing No. 1 – Suicide and Deliberate Self-Harm.
[27] Hill, K. 1992, The long sleep – young people and suicide, Virago.
[28] Department of Health, 1999, NHS National Service Frameworks for Mental Health – Modern standards and service models.
[29] Department of Health, 2002, National Suicide Prevention Strategy for England.
[30] McDonald, V. 1992, ‘Suicides in young men on the increase’, Sunday Telegraph, 12 January
[31] Department of Health, 2002, National Suicide Prevention Strategy for England.
[32] Department of Health, 2002, National Suicide Prevention Strategy for England.
[33] Department of Health, 1999, National Service Frameworks – modern standards and service models – mental health.
[34] Department of Health, 1999, National Service Frameworks – modern standards and service models – mental health.
[35] Roy, A., 1996, ‘Asian Wives driven to suicide’, The Daily Telegraph, 22 April 1996.
[36] Raleigh, V. S, Balarajan, R. 1992, Suicide and self-burning among Indians and West Indians in England and Wales. British Journal of Psychiatry, vol. 129, 365-368.
[37] Raleigh, V.S., Balarajan, R. 1992, Suicide and self-burning among Indians and West Indians in England and Wales. British Journal of Psychiatry, vol. 129, 365-368.
[38] Burke, A. W., 1992, Sociocultural determinants of attempted suicide among West Indians in England and Wales, British Journal of Psychiatry, vol. 129, 261-266.
[39] Hunt, I., Robinson, J., Bickley, H., et al. 2003, Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey. British Journal of Psychiatry, vol. 183, 155-160.
[40] Hunt, I., Robinson, J., Bickley, H., et al. 2003, Suicides in ethnic minorities within 12 months of contact with mental health services. National clinical survey. British Journal of Psychiatry, vol. 183, 155-160.
[41] University of Manchester, 2006, Five year report of the national confidentiality inquiry into suicide and homicide by people with mental illness, Avoidable deaths.
[42] University of Manchester, 2006, Five year report of the national confidentiality inquiry into suicide and homicide by people with mental illness, Avoidable deaths.

This factsheet was written by Inger Hatloy in 2004, and updated by the author in January 2008.

Introduction

Many of the problems faced by South Asian people who use mental health services are similar to those faced by other minority ethnic communities, though there are differences in access to care and treatment and in the ways people are treated within services and within their own communities. There are also significant similarities and differences in socio-economic and health status.

The provision of mental health services to people of South Asian origin and their experiences of using mental health services have been the subject of research for many decades. Although the need for culturally sensitive care is acknowledged within policy and service provision, the services currently available are far from adequate. This factsheet explores some of these issues and highlights areas of concern.

A note on terminology

In this factsheet the term ‘South Asian’ refers to people born in India, Pakistan, Bangladesh and Sri Lanka and their descendants, but excludes those born (or descended from those born) in Nepal, Bhutan, the Maldives, Tibet, Afghanistan or the Islamic Republic of Iran.

The terminology of psychiatric diagnosis used reflects the language of the sources referred to. The use of such language in no way implies Mind’s unqualified acceptance of it.

Researching ‘South Asian’

There are vast national, regional, cultural, religious, linguistic and political differences between the communities that are often studied under the term ‘South Asian’. The term has often been criticised as misleading because it assumes homogeneity, and renders some smaller communities invisible. For example, very little is known about the mental health needs and experiences of Sri Lankan people. Thus, caution needs to be exercised when assumptions are made.

Historical background

The history and patterns of migration, and the experiences of settling and living in Britain, vary vastly among the communities that constitute the South Asian population of Britain. The following history is an overview of these experiences and trajectories.

There has been a South Asian presence in Britain since the 1600s. Large-scale migration from South Asia began after World War II and continued through the economic boom and labour shortage in the 1950s and 1960s. Some of the immigrants were professionally qualified, but the majority were literate but unskilled labourers from rural areas who found work in manufacturing, engineering and catering industries. The majority of migrants were from Gujarat and Punjab in India, Mirpur in Pakistan and Silhet in Bangladesh. [1] People from Sri Lanka were also part of the migration in the 1950s and 1960s, but a larger number of people migrated to Britain following the civil disturbances in the 1970s. More recently, since the 1980s, working class Tamil people from Sri Lanka have come to Britain as refugees and asylum seekers. [2]

The colonial administration transported South Asians to work as indentured labourers on plantations, roads and railways in other parts of the British Empire, including the West Indies, Mauritius, Guyana, South East Asia and East African countries. This formed the migration route for a large number of people. [3]

Following the ‘Africanisation’ policies in Kenya, Uganda and Tanzania, East African Asians began arriving in Britain in the 1960s and 1970s. In 1972, Idi Amin expelled about 80,000 Asians from Uganda, a large number of whom settled in Britain as refugees, amidst great controversy and opposition. [4]

The British South Asian population today

The 2001 census showed that over half of the minority ethnic population in the UK is of South Asian origin. [5] Indians were the largest minority group, forming 22.7 per cent of the total minority ethnic population; 16.1 per cent were Pakistanis and 6.1 per cent were Bangladeshis. [6] In the 2001 census, Sri Lankans were included in the ‘Asian (Other)’ category, but this is being revised for the next census.

Socio-economic context

At least three generations of South Asians now live in Britain. The vast generational, national and cultural differences in the way South Asians experience life in Britain, their sense of identity and belonging, and socio-cultural aspects of British life are reflected in their socio-economic status. Socio-economic status, along with levels of cultural and institutional exclusion/participation, has been linked to vulnerability to mental health problems. [7], [8]

Education

Children of Pakistani origin were the biggest Asian group in primary schools in the 2001 census, whereas children of Indian origin outnumber Pakistani children in secondary schools. [9]

Employment

The 2001 census showed that rates of unemployment were higher among all South Asian groups than the white population. Indians tended to do better than Pakistanis and Bangladeshis. Unemployment rates were particularly high among the Bangladeshi community, 20 per cent of men and 24 per cent of women being unemployed. [10]

According to 2004 data from the Office of National Statistics (ONS), Bangladeshis and Pakistanis were more likely to be unqualified than white British people. [11]

Housing

According to the 2002 statistics from the ONS, South Asian families tended to be larger than those from other minority ethnic groups, and often had three generations living in one household. [12] The extended family structure was traditionally seen as intrinsic to South Asian communities, giving rise to the stereotype that ‘they look after their own’. The cultural practice of living in extended families was transplanted to Britain when people migrated from South Asian countries. However, often families were forced to live together for economic reasons and not necessarily as a means of support.

Poverty

A review of literature published by the Joseph Rowntree Foundation found that poverty rates were high in all South Asian communities. The risk of poverty was highest for Pakistani and Bangladeshi communities, while Indians face above-average poverty compared with white populations. Over half of Pakistani children and almost 70 per cent of Bangladeshi children were growing up in poverty. [13] Poverty rates were also higher for pensioners from these communities.

Socio-cultural background to the mental health of South Asian people in Britain

As with all immigrant communities, South Asian communities had to face cultural differences, prejudice, racism and alienation in Britain. The communities have evolved and adapted over the course of generations and this is reflected in what we understand as the ‘culture’ of these communities. These experiences have a significant role in the mental health of these people, though this is not often acknowledged in service provision.

Racism

The link between the experience of racism and mental distress is well established. Studies have shown that the ways in which people experience racism as interpersonal violence, institutional racism or socio-economic disadvantage have independent detrimental effects on health. [14], [15] Studies in the last few decades have shown that the social experience of racism is a causative factor in mental health problems, while racism within mental health services results in inappropriate and inadequate service provision.

The complex interaction of racism and mental health and its effect on South Asian communities is further influenced by changing social perceptions of these communities. Recent evidence shows increased animosity towards Muslim groups, and emerging evidence shows that this has an effect on how people from these communities who are also mental health service users are viewed by society. For example, a recent survey of attitudes conducted by Rethink (see ‘Useful organisations’) found that 29 per cent of the people surveyed would not be happy to live next door to a person with mental health problems, but this went up to 47 per cent when asked about living next door to a Muslim person with mental health problems. [16]

According to a research report based on statistics from the British Crime Survey in 2000, South Asian communities were at the greatest risk of being a victim of racially motivated crime – an estimated risk of 3.6 per cent for Indians and 4.2 per cent for Pakistanis and Bangladeshis, compared with 0.3 per cent for white groups and 2.2 per cent for black groups. [17] Subsequent reports in the media, particularly with the increased focus on terrorism, have pointed to an increase in the number of racist incidents targeting people from South Asian communities.

Culture

As suggested earlier, there is a wholly inappropriate tendency within services and in society to see all South Asians as a homogenous group with shared cultural beliefs and practices. Vast differences in national and regional origins, religious beliefs, racial and ethnic subdivisions, language, migratory patterns, experiences of colonialism and extent of Britishness in their identity all influence the wide range of cultural beliefs and practices within the communities.

Culture plays an important part in how communities understand mental health. Evidence shows that many South Asian people understand mental health problems outside of the medical model, and prefer terms such as ‘depression’ and ‘behavioural problems’ to mental illness. [18] It is common to locate the causes of mental health problems in a social context or other external factors (for example, a belief in kismet or fate). In many cultures there is a stigma attached to being mentally ill, and mental health problems are not discussed or disclosed within the community. Several studies involving men and women from South Asian communities have reported on the ideas of family honour (izzat) and personal shame (sharam) as reasons for the stigma and denial of mental health problems that exist within these communities. [19], [20]

While service users and carers have stressed the importance of cultural sensitivity in the provision of mental health services (see ‘Experiences of mental health services’) it is important to remember that a focus on cultural definitions can easily slip into stereotyping of South Asian people and their experiences of mental health.

Language

The issue of language in the context of mental health services involves two important factors: the spoken and written language used to communicate, and the language of mental health itself. Evidence shows that the interactions between South Asian communities and mental health services have been affected by both.

South Asian people in Britain speak a wide range of languages. There is no reliable data on the number of people who speak a specific language. A review in 2003 by The Central Office of Information included Bengali, Punjabi, Gujarati, Urdu and Tamil among the top ten languages that it recommended for translating information made available by the Department of Work and Pensions. [21]

Language has been identified as a barrier for service use and appropriate service delivery. [22], [23] Service users and carers interviewed about their experience of services pointed out the need for translators and interpreters, and emphasised the need for people trained in clinical interviewing who can translate the language of psychiatry in a way that people can understand and relate to.

Questions have been raised about the applicability of certain assessment tools to people from minority ethnic backgrounds, particularly when there is little understanding of their cultures and how they interpret life. [24] Difficulties in interpreting and understanding psychiatric terms and a person’s emotions can lead to misdiagnosis and therefore inappropriate treatment. In this sense, the language barrier goes beyond that of the specific language, and points to a difference between eurocentric psychiatric models of mental ill-health and culturally specific understandings of experiences and emotions.

Religion

The largest faith groups of South Asian people in Britain are Pakistani Muslims, Indian Hindus, Indian Sikhs and Bangladeshi Muslims. [25] Religion, faith and spirituality play important roles in the way people understand and interpret their mental and emotional lives. There are both commonalities and differences in religious practices between the various religious traditions and cultural variations. A person who has a strong religious identity may understand mental health issues in a different way to someone with a eurocentric medical understanding. This can become an issue when people come into contact with mental health services, as their needs may not be matched by the services available.

For many people, faith and spirituality play important parts in healing and recovery. In a recent study of the Pakistani community’s views of mental health services in Birmingham, 59 per cent of participants said that religious worship played an important part in the way they coped with mental health problems. [26] Prayer and religion were also found to be a main coping strategy for Asian women who were interviewed in a small-scale study of people experiencing depression. [27] The need to take people’s religious and spiritual needs into consideration when planning treatment and care is now more widely acknowledged – the Royal College of Psychiatrists has a special interest group in spirituality and mental health.

Mental health needs of South Asian people

Several studies in the last few decades have explored the prevalence of mental health problems in South Asian communities, the majority of which have focused on South Asian women; fewer studies have explored issues experienced by South Asian men. The findings of these studies have often been contradictory and inconclusive, [28], [29] and several factors have been identified as reasons for a disparity. Some (for example, studies on depression among Asian women) tended to study South Asian communities as one homogenous group, but found different results when subgroups are studied separately. Some used research and assessment tools that did not capture cultural diversity in the understanding and meaning of mental distress, while others did not allow for generational or cultural differences between groups.

Women

Traditionally, depression, suicide and self-harm are seen as significant problems for South Asian women, particularly young women. [30] Several factors affect the mental health of these women. A study by the Newham Asian Women’s Project of girls and young women between 11 and 25 years of age from all backgrounds found that most of the factors affecting their emotional health were similar, regardless of class or ethnic background. However, young women from South Asian backgrounds faced a number of barriers to accessing support. These included the male privilege existing in some communities and families, the difficulty that some associated with being part of a tight-knit community, and the idea of family honour (izzat). [31]

Studies exploring the experiences of women diagnosed with depression and other mental health problems highlight similar issues. The need to conform to social and cultural values, experience of violence and abuse, and social isolation are key factors affecting their mental health. However, assumptions about ‘South Asian cultures’ and stereotypes about women from these cultures have meant that service provision does not address these issues. [32], [33] Social isolation, language problems and the anticipation of racism and cultural exclusion also affect women’s access to mental health care.

Men

South Asian men have not been the focus of many studies. A common myth is that they do not need any mental health services and will be looked after by their families. One study suggested that there could be many reasons why South Asian men’s health is studied less than that of women. These reasons include stigma, an unwillingness to participate in such studies, influenced by ideas about men’s roles, and the expectation that Asian men perceive coping with distress as part of their expected response to adversity. [34]

The above-mentioned study, conducted in London, found problems in the way assessments were made and diagnoses explained. A lack of adequate attention to religious and cultural needs was also highlighted, along with choice of key workers and the extent of involvement of family members. The study also highlighted the need for cultural competency training that includes differing expectations of help and health beliefs.

Recent research has addressed the issues of alcohol consumption and drug use among Asian men. A study of ethnic differences in alcoholic cirrhosis in West Birmingham found that Asian men were over-represented compared with other ethnic groups. Almost all of these men were from non-Muslim backgrounds and younger than the patients from white backgrounds. [35] While the reasons for increased alcohol consumption among South Asian men are not clear, it has been seen as a means of self-medication that allows them to maintain their cultural gender roles, and also a result of socio-economic deprivation. [36]

A recent study that retrospectively reviewed case notes and (Mental Health Act) sections papers over one year in a psychiatric unit found that, compared with Caucasians, Asian people were significantly over-represented as inpatients and were more likely to be detained both at admission and under longer term powers. [37] There is also emerging evidence that the recent media attention and focus on Muslims in Britain has had adverse effects on the mental health of South Asian men. [38] The reflection of this in service provision has yet to be studied.

Older people

South Asian populations, like other minority ethnic groups, have a younger age structure than the white population in Britain, though the number of older people is predicted to rise in forthcoming years. [39] There is also evidence that the impact of aging in terms of health and social care needs is felt at a comparatively younger age in many minority ethnic communities. [40] Among South Asian communities, those of Indian origin have the highest number of older people. A substantial number of older people are those who migrated in the 1950s and 60s, and may have come with short-term plans but with the intention of returning to their country of birth. Racism, social isolation and exclusion, along with poverty, have been realities for many of them. [41]

A recent finding showed an alarming increase in the number of suicides among older Asian women compared with white women, [42] linked to long-term illness and bereavement. Older people are also likely to have less information about the type of services available, and hence less access to services, because of language barriers and social isolation. The common assumption that older people in South Asian communities are looked after by their families and communities has been challenged in recent research. A study of 105 carers from Punjabi Sikh, Gujarati Hindu and Bangladeshi and Pakistani Muslim communities found that carers had limited support within nuclear and extended families. The study also showed that fear of stigma and a sense of obligation prevented the carers from accessing help from wider networks – findings that have clear implications for policy makers and service providers. [43]

Experiences of mental health services: key concerns

User-led research that explores the experiences of service users and carers from South Asian communities is scarce, but some record of what these experiences have been comes from other research studies. The following key concerns have been raised by service users and carers.

• Information about, and access to, services that are appropriate for these communities’ needs is inadequate. Reasons for this include stereotypes about South Asian communities (including the assumption that ‘they look after their own’), language barriers and social isolation.
• Once in contact with services, the service user’s experience of assessment and treatment is often negative. Reasons for this include a lack of understanding of their culture, racism, gaps in the availability of appropriate services, lack of support in understanding psychiatric diagnoses, and inadequate support for carers.
• There is often no place for religious and cultural beliefs in assessment and care planning. Mental health professionals disregarded these needs more often than not.
• Service users and carers argue for more culturally sensitive services and feel that mental health professionals should be trained in the provision of services that meet the needs of those accessing them. However, some service users feel that a focus on cultural appropriateness sometimes means that specific issues around the oppression of more vulnerable groups in communities goes unnoticed. For example, the oppression of South Asian women is often overlooked or excused on the grounds that the culture allows men to have the upper hand.
• Stereotypes of South Asian cultures and men and women results in assumptions about their mental health, which are reflected in care delivery.
• There is a need for appropriately trained interpreters and translators to help professionals and service users communicate more effectively and reduce the chances of misdiagnosis and inappropriate treatment.

Improving service delivery: what can be done?

Several organisations are working to improve the mental health of South Asian people (see ‘Useful organisations’). Improvements in service provision should be negotiated in consultation with such organisations. Service users and carers should be at the centre of service improvement and innovation. There is also a need to explore mental health needs within specific communities.

The Delivering Race Equality [44] programme, set up in 2005, aims to tackle mental health inequalities faced by people from black and minority ethnic communities, and to create a situation where people from these communities feel more able to access services and have greater confidence in them. A variety of community engagement projects are working towards these goals. [45] Evidence from these projects should provide the basis for improvement of local services, with the involvement of communities, service users and carers. There is now a significant focus on user involvement in mental health services, but the experiences of service users from minority ethnic backgrounds participating in these initiatives has not always been positive. [46], [47] Service users can play a significant part in commissioning services that are appropriate for them, but for this to become a meaningful reality major shifts in the way organisations and services operate are required. [48]

Useful organisations

Age Concern BME Elders Forum
National Development and Policy Officer (BME Elders)
Age Concern England
tel: 020 8765 7718
web: www.ageconcern.org.uk/AgeConcern/bme_forum.asp 
An initiative of Age Concern England, the forum aims to represent the interests of a wide range of black and minority ethnic elders and organisations working with them, to influence policy, to exchange good practice and support each other. Also publishes a newsletter.

Asian Family Counselling Service
Suite 51, Windmill Place, 2-4 Windmill Lane, Southall UB2 4NL
tel: 020 8571 3933 or 020 8813 9714
email: info@asianfamilycounselling.org.uk 
web: www.asianfamilycounselling.org.uk 
Offers counselling services for individuals, couples and families from South Asian communities, in English, Urdu, Punjabi, Hindi and Gujarati. Runs a range of groups around post-natal depression, self-harm, abuse, relationships (all sexual orientations).

Asian Resource Centre
110 Hamstead Road, Handsworth, Birmingham B20 2QS
tel: 0121 523 0580
email: barc@asianresource.org.uk 
web: www.asianresource.org.uk 
Provides a range of services, including advice, legal aid, home visits and elders project. Languages used include Punjabi, Hindi, Urdu, Bengali, Sylheti, Gujarati and Mirpuri.

Catch-a-Fiya Network
27-29 Vauxhall Grove, Vauxhall, London SW8 1SY
tel: 020 7582 0812/0512
email: info@catchafiya.org 
web: www.catchafiya.org 
A project of the Afiya Trust, Catch-a-Fiya is a national network for service users and carers from black and minority ethnic communities. The forum is service user led and aims to support service users to build their capacity, share learning, and influence policy and service delivery. Catch-a-Fiya helps service users to set up regional user forums.

Confederation of Indian Organisations (CIO)
5 Westminster Bridge Rd, London SE1 7XW
tel: 020 7928 9889
email: headoffice@cio.org.uk 
web: www.cio.org.uk 
CIO is a UK-wide umbrella organisation working with South Asian organisations. CIO aims to provide and develop high-quality services that strengthen these organisations and be a strong voice on policy issues that affect the South Asian community. CIO also provides culturally appropriate counselling services around a range of issues, including cultural isolation, domestic violence, sexuality, marriage, depression etc. Has offices in London, Leicester and Manchester.

Joseph Rowntree Foundation
Head Office, The Homestead, 40 Water End, York YO30 6WP
tel: 01904 629 241
email: info@jrf.org.uk
web: www.jrf.org.uk
The Joseph Rowntree Foundation aims to examine the roots of poverty and disadvantage, and to identify solutions, to find ways to empower communities to have control of their own lives, and to contribute to the building and development of strong cohesive and sustainable communities.

Mothertongue
PO Box 2409, Reading RG1 1ZQ
tel: 0118 957 6393
email: info@mothertongue.org.uk
web: www.mothertongue.org.uk 
Mothertongue is a multi-ethnic, culturally sensitive, professional counselling and listening service where people are heard with respect in their chosen language. The charity offers holistic support to people and professional development to staff and volunteers from black and minority ethnic communities.

Muslim Youth Helpline
2nd Floor, 18 Rosemont Road, London NW3 6NE
tel: 0870 774 3518; helpline: 0808 808 2008
email: info@myh.org.uk 
web: www.myh.org.uk and www.muslimyouth.net 
Offers faith and culturally sensitive services to young Muslim people. Counselling services are available nationally via telephone, email and internet, and face to face in the Greater London area. Also runs www.muslimyouth.net, a peer support site run by young people from a diverse range of Muslim backgrounds.

Nafsiyat Intercultural Therapy Centre
262 Holloway Road, London N7 6NE
tel: 020 7686 8666
email: admin@nafsiyat.org.uk 
web: www.nafsiyat.org.uk 
Provides intercultural psychodynamic psychotherapy to people from a wide range of cultural backgrounds. Intercultural therapy takes into consideration the internal realities of culture (beliefs, values, religion and language) and external realities (poverty, refugee status, racism, sexism etc.) of a person. Access is through written referrals and appointment.

Newham Asian Women’s Project
661 Barking Road, Plaistow, London E13 9EX
tel: 020 8472 0528
email: info@nawp.org 
web: www.nawp.org
Provides services specifically aimed at women and children from South Asian backgrounds. Includes safe and emergency housing, counselling and support around self-harm and experiences of violence and abuse, training to increase confidence and chances of employment, and rights-based advice services. The Zindagi project is aimed at young Asian women from East London who are vulnerable to self-harm and suicide.

Pakistani Resource Centre
1 Great Marlbrough Street, Manchester M1 5NJ
tel: 0161 237 1125
email: info@pakistani-resource.org.uk
web: www.pakistani-resource.org.uk 
The Pakistani Resource Centre aims to empower the South Asian Communities within Greater Manchester. It offers counselling and emotional and practical support to individuals experiencing mental ill health, and their carers and family. It also runs the Trafford Mental Health Service, which offers culturally appropriate mental healthcare to people from the region. Services are offered in a range of languages, including Urdu, Punjabi and Mirpuri.

Refugee Council
Head Office, 240-250 Ferndale Road, Brixton, London SW9 8BB
tel: 020 7346 6700; London advice line 020 7346 6777
website: www.refugeecouncil.org.uk 
Gives help and support to asylum seekers and refugees and works to ensure that their needs and concerns are addressed.

Rethink
89 Albert Embankment, London SE1 7TP
tel: 0845 456 0455 (information); advice line 020 7840 3188
email: info@rethink.org or advice@rethink.org
website: www.rethink.org 
Rethink is a charity working with people affected by severe mental illness, providing services, support and information.

Sainsbury Centre for Mental Health
134-138 Borough High Street, London SE1 1LB
tel: 020 7827 8300
email: contact@scmh.org.uk
website: www.scmh.org.uk 
The Sainsbury Centre for Mental Health aims to improve the quality of life for people with mental health problems by influencing policy and practice in mental health and related services, focusing on criminal justice and employment and supporting work on broader mental health and public policy.

Sharing Voices Bradford
99 Maninghams Lane, Bradford BD1 3BN
tel: 01274 7311 66
email: info@sharingvoices.org.uk
web: www.sharingvoices.org.uk 
A mental health community development organisation working primarily in the inner-city areas of Bradford. Service delivery focuses around self-help and mutual support, and includes groups around creative expressions, music, fitness, mutual interest and befriending. There is also a faith-based community self-help group for South Asian women and for Muslim men of all nationalities.

References

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[12] www.statistics.gov.uk/cci/nugget.asp?id=270 [Accessed October 2008]
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[14] Karlsen, S., Nazroo J.Y. 2002, ‘Relation between racial discrimination, social class and health among ethnic minority groups’. American Journal of Public Health, vol. 92, no. 4, pp. 624-631.
[15] Karlsen, S. 2007, Ethnic Inequalities in Health: The Impact of Racism. Race Equality Foundation, London.
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[18] Greenwood, N., et al. 2000. Asian in-patient and carer views of mental health care. Journal of Mental Health Care, vol. 9, no. 4, pp. 397-408.
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[20] Saeed, S.B., et al. 2006, Report of the Community-led Research Project Focusing on Self Defined Mental Health Needs of the Muslim Community. Bradford: Sharing Voices.
[21] The National Centre for Languages. www.cilt.org.uk/faqs/langspoken.htm [Accessed October 2008]
[22] Bowl, R. 2007, ‘The need for changes in UK mental health services: South Asian service users’ views’. Ethnicity and Health, vol. 12, no. 1, pp. 1-19.
[23] Greenwood, N., et al. 2000, ‘Asian in-patient and carer views of mental health care’. Journal of Mental Health Care, vol. 9, no. 4, pp. 397-408.
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