Sir: Sashidharan's article on institutional racism in British psychiatry (Psychiatric Bulletin, July 2001, 25, 244-247) failed to mention a major issue that in my experience is crucial to this debate. Black and other ethnic minorities are more likely than the general population to be poor and socially disadvantaged and live in areas that generate high psychiatric morbidity, but where mental health services are likely to be similarly impoverished and deprived. This alone may account for much that is objectionable and countertherapeutic in the experience of Black psychiatric patients.

We recently demonstrated the importance of inequality in a randomised controlled trial of community care for recently discharged patients in Brent and Westminster (Reference Tyrer, Evans and GandhiTyrer et al, 1998). This study showed that although community care reduced admissions to hospital compared to hospital-based care, this only made a worthwhile impact where there were adequate numbers of hospital beds.

As Sashidharan points out, it is undeniable that many Black people experience psychiatric services as noxious and alienating. However, he is selective in focusing almost exclusively on the providers of psychiatric services in searching for the causes and remedies.