Declaration of interest None. African–Caribbeans with psychosis in the UK are reported to be at lower risk of suicide and attempted suicide than British Whites (McKenzie et al, 1995). Low rates are also reported for the general population, but rates in young African– Caribbeans may be rising (Soni-Raleigh, 1996; Bhugra et al, 1999). The National Confidential Inquiry (Department of Health, 2001) reported that African–Caribbean service users who committed suicide tended to be younger and suicides often were considered to be preventable. Although previous suicide attempts are the most important risk factor for suicide, such behaviour in African–Caribbean service users has rarely been investigated specifically. Contemporary data are required to inform evidencebased strategies for suicide reduction. We present a secondary data analysis from a large multi-centre case management trial. We investigated whether suicidal behaviour was still less likely in African–Caribbeans with psychosis compared with British Whites and whether any changes in relative rates were due to an effect across the population or just in the young.

Background: People with schizophrenia are more violent than the general population, but this increased risk is attributable to the actions of a small subgroup. Identifying those at risk has become an essential part of clinical practice. Aims: To estimate the risk factors for assault in patients with schizophrenia. Methods: Two hundred seventy-one patients with schizophrenia were interviewed using an extensive battery of instruments. Assault was measured from multiple data sources over the next 2 years and criminal records were obtained. Multiple sociodemographic and clinical variables measured at baseline were examined as possible predictors of assault during follow-up. Results: Sixty-nine (25%) patients committed assault during the 2-year follow-up. The model that best predicted assault included a history of recent assault (OR 2.33, 95% CI 1.17–4.61), a previous violent conviction (OR 2.02, 95% CI 1.04–3.87), having received special education (OR 2.76, 95% CI 1.22–6.26) and alcohol abuse (OR 3.55, 95% CI 1.24–10.2). Conclusions: Previously established risk factors including a history of violence and alcohol abuse are replicated in this study. Although low premorbid IQ did not predict violence, a need for special education did.

Background A report from a 1980s cohort claimed that suicidal behaviour was four times less common in UK-resident people of Caribbean origin with psychosis than in British Whites. Since then, evidence has accumulated that the rate of suicide and suicidal ideation has been increasing. Aims To compare rates of suicidal behaviour in people of Caribbean and British White origin in a large multi-centre sample of patients with psychosis. Method A secondary analysis of 708 patients with psychosis followed up for 2 years. Outcome measures of reported suicide and attempted suicide were adjusted for socio-economic and clinical differences between groups at baseline. Results People of Caribbean origin had a lower risk of suicidal behaviour than British Whites (odds ratio adjusted for age and gender 0.49, 95% C1 0.26–0.92). There was a strong negative interaction between ethnic group and age: suicidal acts were four times less likely in people of Caribbean origin aged over 35 years compared with British Whites, but there was no large or significant difference in those under 35. Conclusions The previously reported lower relative risk of suicidal behaviour in people of Caribbean origin with psychosis is restricted to those over 35 years, suggesting that the protective effect of Caribbean origin is disappearing in younger generations.

OBJECTIVE: The authors examined patients' perceptions of their case management care and the factors that influenced those perceptions. METHODS: A nine-item patients' perceptions questionnaire was administered to 225 patients with severe psychosis who were enrolled in a randomized controlled trial evaluating the efficacy of intensive versus standard case management. RESULTS: Factor analysis of the responses to the perceptions questionnaire revealed two principal components: quality of care received (including relationship and contact with the case manager) and overall perception of case management. Patients had a better overall perception of intensive case management compared with standard case management, but no significant differences were noted in perceived quality of care. Patients with female case managers had more positive perceptions of the quality of the care they received than those with male case managers. Several clinical and social variables were strongly associated with perceived quality of care but less so with overall perception of case management. CONCLUSIONS: Patients' general perceptions of intensive case management seemed more favorable than patients' general perceptions of standard case management, but no difference was noted in their perceptions of quality of care.

Background The comparative outcome of psychosis in British Whites and UK African-Caribbeans is unclear. Some report that African-Caribbeans have worse outcome, whereas others claim better symptomatic outcome and a more benign course. Aims To compare the course, outcome and treatment of psychosis in African-Caribbeans and British Whites in a large multi-centre sample. Method A secondary analysis of 708 patients with research diagnostic criteria-defined psychosis from a 2-year, randomised controlled trial of case management. Outcome measures (hospitalisation, illness course, self-harm, social disability and treatment received) were adjusted for socio-economic and clinical differences between groups at baseline using regression analysis. Results African–Caribbeans were less likely to have a continuous illness and to receive treatment with antidepressants or psychotherapy. Conclusions The outcome of psychosis is complex but differs between UK African–Caribbeans and British Whites. This may reflect risk factors that increase the rate of psychosis in UK African–Caribbeans. Treatment differences require further investigation.

Objectives To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case managementDesign Randomised controlled trial with two year follow up.Setting Four inner city community mental health services.Participants 708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group.Intervention Intensive case management (caseload 10-15 per case manager) for two years compared with standard case management (30-35 per case manager).Main outcome measure Physical assault over two years measured by interviews with patients and case managers and examination of case notes.Results No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86).Conclusions Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care.

Identifying the burden of care on relatives of the mentally ill remains an integral part of research in community psychiatric services. The present study aimed to assess the level and extent of burden on relatives in South Verona (northeast Italy). The South Verona catchment area provides a comprehensive, community-based psychiatric service with minimal reliance on the hospital. Patients were selected from the South Verona Psychiatric Case Register and 40 of their relatives were interviewed using structured assessments measuring objective burden, patient behaviour, coping strategies, satisfaction and needs for services. Both positive and negative aspects of burden were apparent, 92% of relatives continued to maintain contact with friends/relatives, 72% had no change to their family income, and 52% could manage any household disruptions during a crisis. The main negative effects for relatives included reduced leisure activities (57%) and psychological problems (67%). The greatest burden was on relatives of patients who were male (P = 0. 016), unemployed (P = 0.013) and diagnosed with psychosis (P = 0. 041). The implications of employment for patients and its association with lower levels of caregiver burden are discussed.

ResumenIdentificar la carga de los cuidados sobre los familiares del enfermo mental es una parte integral de la investigación en los servicios psiquiátricos comunitarios. El presente estudio tenía el propósito de evaluar el nivel y el alcance de la carga sobre los familiares en el sur de Verona (noreste de Italia). El área de captación del sur de Verona proporciona un servicio psiquiátrico comunitario amplio con dependencia mínima del hospital. Se seleccionó a los pacientes a partir del Registro de Casos Psiquiátricos del sur de Verona y se entrevistó a 40 de sus familiares utilizando evaluaciones estructuradas que medían la caiga objetiva, el comportamiento del paciente, las estrategias de afrontamiento, la satisfacción y las necesidades de servicios. Se pusieron de manifiesto tanto los aspectos positivos como negativos de la caiga: el 92% de los familiares continuaban manteniendo contacto con amigos o familiares, el 72% no habían experimentado cambios en sus ingresos familiares y el 52% podían resolver cualquier perturbación en la casa durante una crisis. Los efectos negativos principales para los familiares incluían una reducción de las actividades de ocio (57%) y problemas psicológicos (67%). La carga mayor se ejercía sobre los familiares de los pacientes varones (P = 0,016), sin empleo (P = 0,013) y diagnosticados con psicosis (P = 0,041). Se comentan las implicaciones del empleo para los pacientes y su asociación con niveles inferiores de caiga del cuidador.

BACKGROUND:Whilst it is commonly believed that black and ethnic minority (B&EM) people living in the UK experience social disadvantage compared with the white British (WB) population, no study has specifically addressed this issue in patients with severe mental illness. We sought to test the hypothesis that B&EM patients experience more negative life events than their WB counterparts, and to examine the extent to which they attribute these events to discrimination.METHOD:Thirty-four WB, 78 African Caribbean (AC) and 35 other ethnic minority patients with psychotic illnesses, defined using Research Diagnostic Criteria, were asked to complete a Racial Life Event Questionnaire examining life events and perceptions of discrimination at baseline and 12 and 24 months later.RESULTS:African Caribbean patients experienced more 'Financial' life events across the study period, otherwise there were no significant differences between patient groups in number of life events experienced. The B&EM group collectively (n = 113), however, were significantly more likely than the WB group (n = 34) to attribute 'Assault', and 'Legal' life events to discrimination. The AC patient group were significantly more likely than the other two ethnic groups to attribute the 'Financial' and 'Health' life events they experienced to discrimination. The B&EM group was also significantly more likely, and particularly the AC patient group, to report that members of their own ethnic group are adversely affected by discrimination. Further analyses showed skin colour rather than ethnicity or nationality to be the major contributing factor to perception of discrimination; thus, the Irish (n = 11) had similar scores to the WB while Africans (n = 16) scored like the ACs.CONCLUSION:Our study shows that B&EM patients do not experience significantly more life events than WB patients; however, their perception of these events is clearly different, and significantly more often attributed to racism. It is reasonable to suppose that patients may be disinclined to utilise services they believe to be prejudiced against them on the basis of their skin colour, and service providers need to be aware of this in order to create health care services that B&EM patients feel confident to use.

Major advancement in Italian mental health care came with Franco Basaglia’s movement to eliminate the marginalisation of the mentally ill from the rest of society. Basaglia’s movement sought alternative structures to the mental asylum by reintegrating the mentally ill into the community. Legislation in 1978 (Law 180) formalised this endeavour by closing mental hospitals within a short time period. The unequal spread of Law 180 resulted in a number of formidable problems, both in political and economic terms. These issues, together with the important implications for families, and the introduction of workers’ co-operatives for the mentally ill are discussed.