Roasting Roast Breadfruit Psychosis

Some of the fundamental flaws in their argument have been well flagged by the invited commenta tors. Nevertheless, it is worthwhile to raise other issues that were not given an airing. A significant number of Black immigrants of West African origin, for example Nigerians, also come into contact with psychiatric services in south-east London where one of the authors works. Analysis of the prevalence of severe mental illness among this group is essential to the corroboration of their argument. For it can be argued that recognisably foreign accents and the lack of representation of their cultural traditions in 'Black British' cultural discourse makes this


Lewisham & Guy's Mental Health Trust, 151 Blackfriars Road. London SEI 8EL
Sir: Hickling & Hutchinson (Psychiatric Bulletin, March 1999, 23, 132-134) present valuable insights on the political and moral importance of 'race' in the construction of 'psychosis' in Black Caribbean people in the UK. The invited commentaries (Psychiatric Bulletin. March 1999, 23. 135-138) seem to miss the message partly because their authors fail to comprehend a fundamental point (made in the paper) namely 'reluctance in psychiatry to explore the validity of diagnosis itself, preferring instead to dwell in the dubious succour of standardised diagnostic instruments . . .'.
In the nineteenth century. Black slaves who absconded were sometimes diagnosed as suffer ing from 'drapetomania' which 'manifests itself by an irrestrainable propensity to run away' (Cartwright, 1851 (Psychiatric Bulletin, March 1999, 23, 132-134). was extremely distasteful. The article appeared to have been based purely on speculation, with no evidence offered for the strong views it contained. Very few Black people would fail to be offended by the oft-repeated suggestion that they really would rather be White. Whatever the inherent causes, and like it or not there are 3.5 million non-Western people in Britain, psychiatrists, entrusted as they are with people's mental well-being, and self-esteem, are obliged, like all other doctors, to carry out their duties in a manner that is free of all bias.
What is perhaps more surprising, is that the respected Psychiatric Bulletin could publish such offensive material (inviting commentaries from African and Asian psychiatrists does not make it alright). Large institutions should renew their commitment to promoting tolerance and harmony among society's diverse cultures. The

Reliability and validity of HoNOS
Sir: We looked in vain for evidence of the statement by Chaplin & Perkins (Psychiatric Bulletin. January 1999, 23, 20-21) that their study had assessed the reliability and validity of the pre-final version of the Health of the Nation Outcome Scales (HoNOS).The first claim relates to a comparison of the scores of 32 (out of 248) patients interviewed either by a psychologist, psychiatrist or by a nurse. What they call a lack of reliability seems to be large difference in the man total scores (15.6 and 6.4 respectively). In a second comparison involving only eight patients, similar mean total scores (13.75 and 14.25) were obtained by nurses rating independently of each other. It is impossible to interpret these figures without knowing, in substantial detail, how the study was carried out.
In the equivalent study of the pre-final HoNOS during the field trials (further details available from the authors upon request), there was a small by significant difference between nurses (n=399) and psychiatrists (n=60), probably reflecting differences between the settings (acute longer term and community) where the ratings took place there was a much larger difference between clinicians and social workers, which appeared to be associated with different rating thresholds, indicating as other studies have done a problem of calibration between professions.
So far as we can tell, no trial of Validity' was carried out by the authors.
A further incidental but important point relates to terminology. The formulation "HoNOS rated half with hallucinations. . ." is inadmissible. HoNOS is not a person. The clinicians rated HoNOS. We do strongly agree with the recom mendation that training should be supplemented by supervision, as emphasised in the HoNOS documentation. JOHN  Sir: In response to the correspondence from Wing & Lelliott, I would like to make the following comments. HoNOS ratings were introduced as a routine measure of outcome in our service in 1995. An evaluation of their utility was consid ered necessary in order to assess their ability to measure change in our service which solely consists of people with severe and enduring psychiatric disability. Two senior staff members attended a training day organised by the Royal Collegeof Psychiatrists and then trained all other senior team members. These senior profes sionals then trained professionals in all other areas of the service in the use of the scales and supervised the completion of the initial forms.
The scales were tested for reliability in only a minority of the patients as Wing & Lelliott commented. To do so on a larger group would not have been possible without additional funding. Ratings by different professionals were all made in the same setting (long-term) so could not explain the differences. The study did not explicitly test validity as Wing & Lelliott rightly state. However, some of the results were very surprising. The scales recorded zero on 6% of the patients which suggested a total absence of disability. In this group, the patients were reassessed by senior professionals who knew them well to confirm the clinical impression that they were indeed significantly disabled. This suggested that in this small group of patients that HoNOS lacked face validity. The most important finding of the study was that the different disciplines may have extremely different rating styles, a potential problem which can be addressed by multi-disciplinary group ratings.  (Psychiatric Bulletin. January 1999, 23, 46-48) raises a number of questions. National Schizophrenia Fellowship members recognise that police are in the front-line, not through choice but as a result of the resource and planning failing associated with care in the community. They remain the only service that can be relied upon to turn up at any time of the day or night when called.
However, the Police Complaints Authority and Metropolitan Police Commissioner Sir Paul Condon, among others, now recognise what the National Schizophrenia Fellowship has been saying for years, that police training in dealing Correspondence