Department of Psychiatry, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London
Department of Psychiatry, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London, and Department of Epidemiology and Public Health, University College London and the Royal Free Medical School,london
Department of Psychiatry, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London
Department of Medicine, Royal Free and University College London Medical School
Department of General Practice and Primary Care, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London
Department of Human Science and Medical Ethics, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London
Department of Psychiatry, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London
Department of Health, Institute of Community Health Sciences, Barts and The London, Queen Marys School of Medicine and Dentistry, University of London, London UK
Correspondence: Professor Stephen Stansfeld, Department of Psychiatry, Barts and The London, Queen Marys School of Medicine and Dentistry, Queen Mary, University of London, Medical Sciences Building, Mile End Road, London E1 4NS, UK. Tel: +44 (0)207 882 7727; fax: +44 (0)207 882 7924; e-mail: s.a.stansfeld{at}qmul.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To examine whether ethnic differences in prevalence of psychological distress in adolescents are associated with social deprivation.
Method A cross-sectional questionnaire survey was used to assess 2790 male and female pupils, aged 1114 years, from a representative sample of 28 east London secondary schools.
Results Rates of psychological distress were similar to rates in UK national samples in boys and girls. Bangladeshi pupils, although highly socially disadvantaged, had a lower risk of psychological distress (OR=0.63, 95% CI 0.40.9). Non-UK White girls had higher rates of depressive symptoms (OR=1.54, 95% CI1.12.2).
Conclusions High rates of depressive symptoms in non-UK White girls may be related to recent migration. Low rates of psychological distress in Bangladeshipupils in this sample relative to White pupils, despite socio-economic disadvantage, could be associated with cultural protective factors that require further investigation.
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INTRODUCTION |
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METHOD |
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Ethnicity and cultural indicators
Ethnicity was self-rated by the adolescents using an adaptation of the
Census 2001 questions (Office for National
Statistics, 2001). Black children included those who classified
themselves as Black African, Black British, Black Somali and Black
AfricanCaribbean; small numbers precluded analysing these groups
individually. The mixed ethnicity group included White and Black
Caribbean; White and Black African; White and Black; White and Asian; and
mixed other. The other group included Chinese and
Vietnamese, among others. Country of birth, main languages spoken at home,
religion and its observance, and length of time in the UK were collected by
child self-report in the questionnaire.
Socio-demographic factors
Previous research suggests that the use of multiple indicators of
socio-economic status collected from adolescents can reliably indicate
household socio-economic status (Rogers
et al, 1995; Health
Education Authority, 1997). In the questionnaire, socio-economic
indicators included parental employment status, household crowding (>1.5
persons/room) and family car ownership. In addition, eligibility for free
school meals was obtained from school records. We selected eligibility for
free school meals as our main socio-economic adjustment variable because it is
known to be a reliable indicator of socio-economic status in UK studies of
young people, and it was also the indicator on which we had the most complete
data (Sammons et al,
1997).
Main outcome measures
Data were collected by questionnaire on mental and physical health, health
behaviours, height, weight and socio-demographic factors. The following
outcomes were included in the analyses reported in this paper.
Mental health
Child mental health was measured using the self-report Strengths and
Difficulties Questionnaire (SDQ; Goodman,
1997; Goodman et al,
1998) which is a widely used psychometrically valid instrument for
assessing psychological morbidity in UK children. A total difficulties score
was derived by adding the scores of each of four sub-scales (emotional
symptoms, conduct problems, peer problems and hyperactivity), producing a
total score ranging from 0 to 40. In a nationally representative sample of
adolescents (aged 1115 years), the 1999 British Child and Adolescent
Mental Health Survey, the overall prevalence of psychiatric morbidity was
11.2% (12.8% boys, 9.6% girls aged 1115 years), established using
multiple methods (Meltzer et al,
2000;
http://www.sdqinfo.com).
A score of 18 was chosen as the threshold for a high scorer on
the child self-completion version of the SDQ because this gave prevalence
figures in the national data that were equivalent to the 9.5% prevalence found
using multi-modal assessments (i.e. including data from parents and teachers)
at national level (for children aged 515 years). We applied the same
threshold to our data. The SDQ has been used in Bangladeshi adolescents before
(Mullick & Goodman, 2001)
and thus has validity in this group. The SDQ was supplemented by the brief and
reliable 13-item Short Moods and Feelings Questionnaire (SMFQ;
Angold et al, 1995) to
measure core depressive symptoms. A threshold of 8 or more was chosen to
define high scorers. This threshold yielded a positive predictive value of 80%
and a negative predictive value of 68% in the original validation against the
Diagnostic Interview Schedule for Children Depression Scale
(Angold et al,
1995).
Procedure
Data collection
Copies of the questionnaire were group administered to the pupils, who
completed them individually in classrooms under the supervision of researchers
who answered pupils questions and checked questionnaires for missing
data. Parents were informed by letter of the study, and passive consent (with
active opt-out) was used. Pupils gave written consent to participation in the
study. The study protocol was approved by the East London and the City Local
Research Ethics Committee.
Statistical analysis
All analyses were weighted to take account of unequal probabilities of
selection. As the sample selection used a stratified cluster design with
pupils clustered within schools, standard errors and 95% confidence intervals
for means and proportions were calculated using the survey estimation (svy)
commands available in STATA (StataCorp,
1999).
Odds ratios and corresponding 95% confidence intervals were calculated using the STATA logistic regression command with the cluster option specified. Three sets of logistic regression analyses were conducted:
These analyses were carried out for boys and girls combined and all models were adjusted for year group, gender and an interaction term between gender and year group. This interaction was included because the SDQ and SMFQ scores increased with age in girls but decreased in boys.
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RESULTS |
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Gender differences in psychological distress
Both psychological distress and depressive symptoms increased with age in
girls and decreased in boys (Table
1). In year 7 psychological distress scores were similar for boys
and girls, but by year 9 boys had lower scores than girls. A similar pattern
was seen for depressive symptoms, except that girls constituted a higher
proportion of the cases at year 7 as well as year 9
(Table 1).
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Comparison with national data
Scores on the SDQ in our cohort were compared with national data from the
1999 British Child and Adolescent Mental Health Survey
(Meltzer et al, 2000)
and the Health of Young People 199597 survey
(Prescott-Clarke & Primatesta,
1998). Based on the self-reported SDQ data from the 1999 survey
and self-reported data in our survey, using the same threshold of 18 for high
scorers in both studies, the proportion of high scorers on the SDQ was similar
in boys in our sample (9.3%, 95% CI 712) and in boys the 1999 British
Child and Adolescent Mental Health Survey sample (9.4% of boys aged
1115 years). Rates were also similar for girls, with slightly higher
rates of 11.3% (95% CI 1013) in our sample being SDQ high scorers,
compared with 9% of girls in the 1999 survey
(Meltzer et al,
2000). The proportion of high scorers among girls in our survey
was higher than the proportion of high scorers among girls in the Health of
Young People study (7% in girls aged 1012 years and 6% in girls aged
1315 years in the latter), although rates were similar in boys in both
studies (11% in boys aged 1012 years and 9% in boys aged 1315
years in the Health of Young People survey;
Prescott-Clarke & Primatesta,
1998). In the Health of Young People study the SDQ was
parent-reported rather than self-reported and the threshold for high scorers
was 17.
Ethnic differences in rates of psychological distress
The largest ethnic groups were Bangladeshi (25%), White UK (21%) and Black
(20%). All ethnic groups experienced high levels of familial social
disadvantage compared with the national average, but this was most evident in
the Bangladeshi group (Table
2). Rates of psychological distress on the SDQ varied modestly by
ethnic group (Table 3). This
was similar for the SMFQ, except that higher rates of depressive symptoms on
the SMFQ were found in non-UK White girls, who were largely of Irish, Turkish
or Greek origin.
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Contrary to our expectations, psychological distress and depressive symptoms had little consistent association with social disadvantage using the indices of parental unemployment, lack of car ownership, household overcrowding or eligibility for free school meals (Table 4).
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Odds ratios for SDQ high scores were statistically significantly lower among Bangladeshi pupils compared with the White UK group adjusting for gender, year group and the interaction of gender and year group (Table 5). This lower risk remained after further adjustment for socio-economic status in terms of eligibility for free school meals. The low risk of psychological distress in Bangladeshi pupils might be due to a preference for expressing psychological distress in a somatic idiom rather than through emotional expression. However, the rates of reported somatic symptoms did not differ by ethnicity.
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Non-UK White pupils had a higher risk of depressive symptoms on the SMFQ than White UK pupils adjusting for gender, year group, the interaction of gender and year group and socio-economic status, and although not significant, the odds ratio for a high SDQ score was also raised in this group (Table 5). It seemed possible that this might relate to refugee status. We examined the year of entering the UK as a marker for recent migration and possible refugee status or asylum-seeking. Overall, 9% of pupils had entered the UK in the previous 5 years, but this proportion was higher in non-UK White pupils (26%) and Black pupils (19%). There was poorer mental health among more recent entrants than among the rest of the sample. Among non-UK White pupils, adjustment for recent migration reduced the risk of psychological distress on the SDQ from 1.36 (95% CI 0.82.3) to 1.19 (95% CI 0.72.0) and on the SMFQ from 1.54 (95% CI 1.12.2) to 1.25 (95% CI 0.91.8). Another possibility was that household composition might explain the high risk of psychological distress. We found that rates of psychological distress were similar in pupils from two-parent and mother-only families, and that the increased risk of depressive symptoms in the non-White UK pupils was not explained by differences between single-parent or two-parent household composition (results not reported).
Eligibility for free school meals was not associated with increased risk of a high SDQ score or with risk of depressive symptoms after adjustment for ethnicity. This weak association of socio-economic status with SDQ and SMFQ did not appear to differ by ethnic group (significance of interaction term for eligibility for free school meals by ethnic group, P=0.52).
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DISCUSSION |
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Socio-economic position and psychological distress
Somewhat surprisingly, there was no association between indices of social
disadvantage and psychological distress. In contrast, national data in the
Health of Young People study showed a social gradient of high scores in
parent-reported SDQ by social class of head of household
(Prescott-Clarke & Primatesta,
1998). The lack of effect of socio-economic position within our
cohort may reflect lack of variability within it, given that every ward in the
three boroughs lies in the bottom quintile of the governments index for
deprivation (Department of Environment,
Transport and the Regions, 2000). Measures of socio-economic
position may not be equally indicative of social disadvantage across ethnic
groups (Davey Smith, 2000),
although we found a lack of association across all ethnic groups, including
White UK pupils. Lack of variation in socio-economic status and the
possibility of area effects on psychological distress, even for those of more
advantaged social position, may explain the apparently small effects of social
disadvantage. Child psychiatric disorder also showed no social gradient
related to poverty among Native Americans in the Great Smoky Mountains Study,
although there was such a gradient in White children
(Costello et al,
1997). The authors argued that the effects of poverty might have
been mitigated by protective aspects of community or family life.
Limitations of the study
The SDQ is a well-accepted screening instrument for adolescent mental
ill-health, and the self-report version has been validated in a community and
clinic sample (Goodman et al,
1998). In many studies it is used in a multi-method version
incorporating parental and teacher versions of the questionnaire, to provide
an overall prevalence score using an algorithm. The major limitation of our
study was the reliance on self-reported assessment of psychological distress
without triangulation by parental and teacher accounts and validation by a
psychiatric assessment (Goodman et
al, 2000). The sensitivity of the self-report version of the
SDQ is low in other samples (15.9%), although it is slightly higher for
depressive disorders (33.3%) and anxiety disorders (22.1%). Thus, we might not
have identified all cases of psychological distress. Moreover, we did not
assess the validity of the thresholds for psychological distress on the SDQ or
SMFQ in this study population. In unravelling differences in rates of
psychological distress between ethnic minorities, it would be very informative
to have standardised interview-based measures of psychological distress. This
is a goal for this study in future data collection.
Part of the difference in rates of high SDQ scores between the Health of Young People survey and our study in girls may be methodological. In the former survey parents completed the SDQ on behalf of their children, and might have underreported problems (Prescott-Clarke & Primatesta, 1998). In our survey the pupils completed their own SDQ, which might have led to higher rates of reporting problems. Self-reports of emotional disorders with the SDQ in children aged 11 years upwards are as useful as teacher data, but not as useful as parent data, and are of less predictive value for conduct and hyperactivity disorders than parent or teacher data (Goodman et al, 2000).
The cross-sectional nature of our study means we cannot be certain of the direction of association. Having insufficient numbers in the various Black categories meant merging Black children from very different cultures into a single group. There were also relatively small numbers in the Pakistani and Indian groups. This was a further limitation, and more research is needed to examine psychological distress in these groups. Although the study lacked sufficient power to detect differences between the smaller ethnic groups, this was not the case for the Bangladeshi and White UK groups. As 12% of pupils were absent at the time of data collection, and as rates of psychological distress might have been higher among absentees, our estimates of psychological distress may underestimate the true prevalence. In general, there was a high rate of absence from schools, much of which could not be easily accounted for.
Depressive symptoms in non-UK White pupils
Non-UK White pupils had a higher risk of depressive symptoms relative to
White UK pupils. This increased risk was diminished after adjustment for
recent migration, suggesting that the excess risk for psychological distress
might relate to stressors associated with migration. These might include
traumatic experiences prior to migration, separation from parents and friends
and difficulties adjusting to a new, alien environment
(Bhugra & Jones, 2001).
Psychological distress in Bangladeshi pupils
Despite their high levels of social disadvantage, Bangladeshi pupils
relative to White UK pupils were at decreased risk of psychological distress
on the SDQ even after adjustment for gender, year group, the interaction of
gender and year group, and socio-economic status. Lower rates of psychological
distress were also found in Bangladeshi girls (but not boys) in the British
Child and Adolescent Mental Health Survey
(Meltzer et al,
2000), suggesting that this is not an isolated finding. Why should
Bangladeshi children have lower rates of psychological distress, when they
live in conditions of social deprivation and Bangladeshi adults have high
rates of physical illness (Bhopal et
al, 1999)? One explanation could be that instruments such as
the SDQ do not identify the idioms of psychological distress as effectively in
Bangladeshi pupils as they do in pupils from other ethnic groups
(Bhui et al, 2003).
However, the SDQ has been used successfully to identify psychological distress
in children in Bangladesh (Mullick &
Goodman, 2001), and we did not find higher rates of somatic
symptoms in Bangladeshi pupils who might have had a tendency to somatise
emotional symptoms, as has been suggested in south Asian adults
(Rack, 1982). High levels of
family support and high ethnic density in the east London Bangladeshi
population may be protective factors for mental health, but further research
is needed to explore this (Halpern &
Nazroo, 2000; Sproston &
Nazroo, 2002). Research is also needed on cultural identity, the
impact of religious belief and observance and the impact of culture on health
behaviour in relation to psychological distress.
It may be that the mental health effects of living in an area with high levels of deprivation are counterbalanced by ethnically related protective factors (Costello et al, 1997). In east London these factors might include high levels of family support, religious belief, strong cultural identity and cohesion. If any of these factors are protective of mental health in the face of social adversity, there may be implications for the prevention of psychological distress in adolescents.
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Clinical Implications and Limitations |
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Limitations
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ACKNOWLEDGMENTS |
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Received for publication October 10, 2003. Revision received March 24, 2004. Accepted for publication March 31, 2004.
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