The experience of psychiatrists managing Chinese patients in Merseyside

The Chinese community in the UK has existed since the latter half of the 1800sand traditionally has been perceived as insular and self sufficient (Lynn, 1982). In the 1960s and '70s, there was a large influx of Chinese into the UK to work in catering businesses. Many of the children of this generation were born in this country; with this group now in their early adulthood, there is more integration into the in digenous population. However, there is still an impression that Chinese psychiatric patients are under-represented in the services, but as yet, there has been little psychiatric research carried out among the Chinese in the UK. This study examined briefly the level of contact with, and difficulties encountered in, managing Chinese patients by psychiatrists in Merseyside.

The Chinese community in the UK has existed since the latter half of the 1800sand traditionally has been perceived as insular and self sufficient (Lynn, 1982). In the 1960s and '70s, there was a large influx of Chinese into the UK to work in catering businesses. Many of the children of this generation were born in this country; with this group now in their early adulthood, there is more integration into the in digenous population. However, there is still an impression that Chinese psychiatric patients are under-represented in the services, but as yet, there has been little psychiatric research carried out among the Chinese in the UK. This study examined briefly the level of contact with, and difficulties encountered in, managing Chinese patients by psychiatrists in Merseyside. i

The study
All consultants and senior registrars (including those in honorary posts) in the Mersey region were sent a questionnaire, which was completed and returned over a two-month period between June and August 1990.
The questionnaire contained 12 items which addressed the following areas: (1) The subspeciality of the respondent.
(2) The number of Chinese patients under the respondent's care and whether this was con sidered to be more/same/less than would be expected. (3) Do Chinese patients pose greater management problems? If so, whether these are due to cultural/language/social difficulties, (4) Do language difficulties prevent a significant number of Chinese patients from using the services? (5) Is interviewing through a non-medical in terpreter generally satisfactory? If so, whether they are easy to find. (6) Is there sufficient information available about the Chinese culture? (7) Would there be a place for a team familiar with the Chinese culture to manage Chinese psychiatric patients?

Findings
One hundred and twenty-two questionnaires were sent out: there were 93 replies (76% response rate) with five undelivered. Of these, 72 were consultant replies: adult general/forensic/alcohol and substance abuse psychiatry (n = 43); psychogeriatrics (n= II); and child/mental handicap psychiatry (n = 18). Of the consultants, 29% had Chinese patients under their care at the time of the survey; among the adult psychiatrist's group, 40% had Chinese patients but only two consultants had more than five patients. Most (72%) thought that this under-represented the actual numbers (none considered the numbers to be an over-representation).
With consultants and senior registrars considered together, 47% thought that Chinese patients posed greater management difficulties (compared to 26% who disagreed) but under a half of these thought that the difficulties were actually major. If only those con sultants with Chinese patients under their care were considered (total number was 21), the 47% rose to 62%. A large number (49%) made no reply when asked what they considered the difficulties may be due to, many commenting that they had had insuf ficient experience. Of those who did reply, some twothirds (which includes 54% of those with Chinese patients in their care), thought the difficulties were due to language problems in contrast to the remain ing third (12% of those with Chinese patients) who considered cultural/environmental factors to be more important. Forty-three per cent thought lan guage difficulties prevented service utilisation in a significant number, with 14% disagreeing. Again, when only those with Chinese patients were con sidered, 57% thought it did cause problems in using psychiatric facilities. Interpreters were difficult to find for 57% of those who actually had Chinese patients, and 67% of them said that the service pro vided by interpreters was generally unsatisfactory. The majority of those replying (46%, with 47% making no reply), thought there was insufficient in formation on the Chinese culture. Of those replying when asked about the feasibility of a 'Chinese team', about similar numbers were for and against such an idea, but several commented on the need for a Community psychiatric nurse working either full-or part-time with Chinese patients.
At the time of the questionnaire, four of the 18 consultants in child psychiatry or mental handicap and none of the psychogeriatricians had Chinese patients in their care. In general, the results were similar for the different subspecialty groups but there were a few differences. The psychogeriatricians con sidered Chinese patients to pose greater problems in management (yes:no ratio of 55%:9%), whereas the results for the adult psychiatry and the child/mental handicap psychiatry groups were less clear (42%: 35% and 39%:28% respectively). When those with Chinese patients currently under their care were con sidered, the figures for the latter two groups changed to 65%:35% and 50%:50% respectively. Within the child/mental handicap psychiatry group, 33% con sidered non-medical interpreters to be satisfactory and 23% thought they were unsatisfactory. For the other two groups, the differences were unequivocal (47%:17% and 64%:9%).

Comment
The study was a brief, non-standardised survey which has obvious limitations. However, the re sponse of 76% was good and is likely to be a fairly accurate reflection of the experience of managing Chinese patients in the Mersey region, from the per spective of psychiatrists. Whether these findings are applicable to other regions is not known.
Overall, 29% had care of Chinese patients but the numbers were low; in addition many questions were not answered as the respondents considered them selves to have had insufficient experience of Chinese patients. This is consistent with reports (Chan, 1986) that found a tendency for the greater part of the Chinese community in the UK to be scattered. Chinatowns and their surrounding areas may have a significant number of Chinese residents but they are primarily foci for social activities and employment. In the Mersey region, there is a relative concentration of Chinese people in the south-central catchment areas of Liverpool. The majority of the respondents expected more Chinese psychiatric patients from their estimate of the size of the population in their areas. Whether this is due to a lower prevalence of psychiatric morbidity or an under-utilisation of the services, is not clear. A recent study of Chinese pri mary care patients in Manchester (Pan & Goldberg, 1990) suggests the latter but further fundamental research needs to be done. The results of the 1991 Li census should be available in the next few years, pro viding accurate demographic data for the different ethnic groups and this should facilitate the task.
Language difficulties were perceived to be more important than cultural/environmental factors in leading to management problems and service underutilisation; interpreters do not appear to be a satis factory solution to this. These trends were more apparent with those who had Chinese patients under their care; presumably, their opinion approximates better to the actual situation. Whether the use of interpreters with basic psychiatric knowledge is the answer no-one knows, but there remains the problems of the difficulties encountered in using the existing services. Many thought information on Chinese culture was lacking and the production of an information pack may be a simple initial step in addressing this issue.
In the new world of 'purchasers' and 'providers', it is expected that ethnic groups will be one of the areas monitored in respect to the delivery and uptake of services. The employment of community nurses fluent in Chinese and familiar with the culture would be a viable and effective first step to overcoming some of the problems encountered in managing Chinese psychiatric patients. Community nurses would be effective in dealing with the scattered nature of the population and their role would include: aiding accurate diagnosis, monitoring and working with the patient in the context of the family.