Incidence,Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review

Abstract

French

Objective

Black communities are increasingly concerned about psychosis, a worry echoed by provincial health-care systems across Canada. Responding to the lack of evidence on psychosis in Black communities, this scoping review examined the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received, and stigma faced by individuals with psychosis.

Method

To identify studies, a comprehensive search strategy was developed and executed in December 2021 across 10 databases, including APA PsycInfo, CINAHL, MEDLINE and Web of Science. Subject headings and keywords relating to Black communities, psychosis, health inequalities, Canada and its provinces and territories were used and combined. The scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA-ScR) reporting standard.

Results

A total of 15 studies met the inclusion criteria, all of them conducted in Ontario and Quebec. Results highlight different disparities in psychosis among Black communities. Compared to other Canadian ethnic groups, Black individuals are more likely to be diagnosed with psychosis. Black individuals with psychosis are more likely to have their first contact with health-care settings through emergency departments, to be referred by police and ambulance services, and to experience coercive referrals and interventions, and involuntary admission. Black individuals experience a lower quality of care and are the ethnic group most likely to disengage from treatment.

Conclusion

This scoping review reveals many gaps in research, prevention, promotion and intervention on psychosis in Black individuals in Canada. Future studies should explore factors related to age, gender, social and economic factors, interpersonal, institutional and systemic racism, and psychosis-related stigma. Efforts should be directed toward developing trainings for health-care professionals and promotion and prevention programs within Black communities. Culturally adapted interventions, racially disaggregated data, and increased research funding are needed.

Keywords

psychosis Black communities Canada health disparities

Introduction

In Canada, 4% of the population will experience a first episode of psychosis at some point in their lives.¹ Schizophrenia—the most common psychotic disorder—affects approximately 1% of Canadians and has increased by an average of 3% annually from 2002 to 2016.² People with psychosis face various health disparities, including a mortality rate 2.8 times higher than the general population.² Psychotic symptoms, whether derived from affective or non-affective disorders or induced by substance abuse, constitute one of the most distressing mental illnesses for the people experiencing it and for their loved ones.^3-5 Symptoms of delusions, hallucinations and disorganized speech and behaviour, common in psychosis, lead to fear and hopelessness in families of those who experience the illness. In particular, the first episode of psychosis is a significant moment of stress and distress for people with psychosis and their families and friends.³

In Canada, there are growing concerns within Black communities because they perceive psychosis as being increasingly diagnosed in Black youth.^6-8 This sentiment is echoed within Canadian provincial health-care systems, as emerging Black adults with psychotic symptoms often arrive at hospitals in acute crisis.^8,9 Despite these observations, studies of the prevalence of psychosis in Black communities remain rare and primarily examine disparities in first episodes of psychosis (e.g., incidence, diagnostic and quality of care). Current scientific knowledge of psychosis does not provide a clear picture of its incidence, prevalence, mortality rate and experiences of families among Black communities in Canada. In addition, little is known about the average age of onset of the first episode, the nature of the care provided (e.g., voluntary and forced), its quality and its adaptation to cultural issues, among others. American-based studies showed significant racial disparities in various aspects of psychosis.^10-13 For example, Black individuals were found to be five times more likely to be diagnosed with psychosis, had a greater risk of being misdiagnosed, were less likely to adhere to treatment, and were more likely to have interactions with law enforcement and be involuntarily hospitalized.^10-12,14-17

The Present Study

In the USA and England, several reviews have been conducted on various aspects surrounding psychosis in Black communities and other racialized communities, including pathways of care for first episodes of psychosis,^18,19 discrimination as a risk factor for psychotic symptoms,²⁰ and course and outcome of psychosis.²¹ However, no systematic or scoping reviews have been conducted in Canada on aspects surrounding psychosis in Black communities. A systematic review on race, ethnicity and duration of untreated psychosis included two studies conducted in Canada, but no analysis on racial issues. Notably, all aspects related to race as a social construct, including racial background, racial discrimination and prejudices in health services, differential treatment in care and impacts of racial discrimination on health care seeking in racialized communities, could be conducted by country due to the limited data.²²

Several studies conducted in recent years in Canada have shown significant racial disparities in various mental health disorders.^23-28 Studying the medical, social and racial issues surrounding psychosis in Black communities in Canada is of particular importance to guide future research, improve clinical interventions, adapt care and services and develop trainings to destigmatize the illness within the Black communities. This is essential for those who experience psychosis and for their families and loved ones. The lack of information on such topics highlights the importance of the present study, a scoping review designed to identify studies conducted on psychosis in Black communities in Canada. The scoping review model was preferred to present an overview of the literature that is currently insufficiently rich to address research questions about specific issues related to psychosis among Black individuals in Canada. Through this scoping review, we also sought to examine the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received and the stigma faced by those who experience psychosis.

Method

This scoping review follows guidance provided initially by Arksey and O’Malley²⁹ and then updated by Peters et al.³⁰ The PRISMA extension for scoping reviews, Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA-ScR), was used to report its findings.³¹

Studies Identification

An experienced research librarian (PRL) drafted, developed and implemented a search strategy to find pertinent published articles in APA PsycInfo (Ovid), Canadian Business & Current Affairs (ProQuest), Canadian Periodical Index (Gale OneFile), CINAHL (EBSCOhost), Cochrane CENTRAL (Ovid), Embase (Ovid), Érudit, MEDLINE (Ovid), Repère and Web of Science (Clarivate). The strategy was informed by previous reviews conducted among Black communities,^32-37 on mental health and psychosis^38-41 as well as on health inequalities more generally.^42-44 In addition, search lines relating to Canada and its provinces and territories were devised and used in combination with the three concepts mentioned. The final search strategy included relevant subject headings and keywords. The strategy for MEDLINE (Ovid) was peer-reviewed by another research librarian following the Peer-Review of Electronic Search Strategy guideline.⁴⁵ The final strategy was executed on 20 and 21 December 2021. The search did not use any database limits related to language or to date. However, results from some databases were limited to those published in scholarly journals (these limits are indicated in the full strategy). The complete search strategy is available in Appendix 1. Citations found through the database searches were imported into Covidence^TM, an online tool used to manage various steps of a systematic review's screening phases. Duplicate references were identified and removed once imported into Covidence^TM. Additional duplicates were identified and excluded while screening references.

Steps for Selection

Once references were imported into Covidence^TM, duplicates were identified and removed. Screening of both the title-abstract and the full text of articles was completed by three groups of two authors (SEF, HP, FMB, DGD, APG and MS). All conflicts at both screening phases were resolved by three authors (ED, WPD and JMC).

Selection Criteria

Articles that met the following criteria were included: (a) related to the nature, prevalence, risk and protective factors related to psychosis in Black communities in Canada; (b) conducted on Black individuals in Canada; (c) written in English or French; and (d) employing quantitative data or mixed-methods studies. As the scoping review aims to present an overview of the literature on psychosis among Black individuals in Canada, we included all forms of psychosis and explained them when relevant (e.g., affective and non-affective psychoses and substance-induced psychosis). The papers that did not meet these conditions were excluded from the review.

Data Extraction

Data from the 15 retained articles were extracted by three groups of authors working in pairs (SEF, HP, FMB, DGD, APG and MS) using Microsoft Excel. Each member of the three groups worked collaboratively, each extracting data and comparing their findings before presenting it in a unique table. The information extracted included the name of authors, year of publication, study purpose and design, sample characteristics and main outcomes of the study. The latter included the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received and stigma faced by those experiencing psychosis. Data extracted are presented in Table 1. Then, we used a critical meta-narrative approach to extract narratives from the data and synthesize them. It consisted of using an inductive approach to identify and regroup convergent themes and compare results for each theme to present integrated conclusions from the included studies.^46-48

Table 1.

Characteristics of Included Studies and Main Findings.

Authors	Year published	Title	Study purpose	Study design	Sample characteristics	Main findings
Adeponle et al.	2012	Using the cultural formulation to resolve uncertainty in diagnoses of psychosis among ethnoculturally diverse patients	To examine the impact of using cultural formulation when reassessing diagnosis in out-patients at a cultural consultation service (CCS) in Montreal, Canada.	Quantitative Black individuals defined based on self-identification found in case notes.	n = 323 Age: 19% under 24, 31% between 25 and 34, 29% between 35 and 44 and 45% over 45 years old. Mean age: 36 years old Black individuals: n = 58 (18%) Of these Black individuals, 41 (71%) were from sub-Saharan Africa, and 17 (29%) were from the Caribbean	There was no significant difference between different racial and ethnic groups in terms of psychotic disorder reassessment. However, patients who were not Black were more likely to receive a different diagnosis during the reassessment than they had at intake compared to Black patients (OR = 3.72, 95% CI = 1.03–13.41).
Anderson et al.	2013	Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis	To evaluate determinants of pathways to care and how this affects mental health service engagement.	Quantitative Black individuals identified based on region of origin and according to the Statistics Canada definitions of population group.	n = 324 Age: 14–30 years old Median age: 22.6 years old Black individuals: n = 13%	Compared to White individuals, Black individuals did not significantly differ in terms of predictors of contact in the prodrome stage (OR = 0.90, 95% CI = 0.38–2.13), first contact being with emergency service (OR = 1.225, 95% CI = 0.54–2.73) or odds of referral source being emergency services (OR = 2.15, 95% CI = 0.82–5.62). Black individuals did not differ from White individuals either in terms of predictors of number of total contacts (OR = 0.93, 95% CI = 0.45–1.90), police/ambulance contact (OR = 1.98, 95% CI = 0.87–4.50) or referral delay (exp (B) = 0.63, 95% CI = 0.32–1.25). However, Black individuals had over twice the risk of disengaging from services compared to White individuals (hazard ratio (HR) = 2.10, 95% CI = 1.19–3.70).
Anderson et al.	2015	Pathways to first-episode care for psychosis in African-, Caribbean-, and European-origin groups in Ontario	To identify differences in the pathway to care and duration of untreated psychosis between people of Black African, Black Caribbean, and White European origin experiencing first-episode psychosis.	Quantitative Black individuals defined as: Black African and Black Caribbean.	n = 171 Black African: n = 41 Black Caribbean: n = 40 White European: n = 90	Black African participants were significantly more likely to have a first contact with the emergency department compared to Europeans (OR = 3.78, 95% CI = 1.31–10.92). There were no other significant differences between the groups for police involvement (OR = 0.94, 95% CI = 0.44–1.97), general practitioner involvement (OR = 0.70, 95% CI = 0.29–1.70), inpatient referral (OR = 2.04, 95% CI = 0.94–4.44), total contact (exp (B) = 0.83, 95% CI = 0.65–1.06), duration of untreated psychosis (DUP) (exp (B) = 1.10, 95% CI = 0.60–2.03) or referral delay (exp (B) = 0.97, 95% CI = 0.52–1.81). Compared to Europeans, Black Caribbeans individuals had significantly lower odds of general practitioner involvement (OR = 0.17, 95% CI = 0.07–0.46) and significantly increased odds of inpatient referral (OR = 3.33, 95% CI = 1.46–7.60). There was no significance difference between the two groups for first contact with emergency department (OR = 2.42, 95% CI = 0.85–6.69), police involvement (OR = 0.88, 95% CI = 0.42–1.87), total contacts (exp (B) = 0.77, 95% CI = 0.60–0.99), DUP (exp (B) = 1.49, 95% CI = 0.82–2.69) and referral delay (exp (B) = 1.55, 95% CI = 0.84–2.83).
Anderson et al.	2015	Incidence of psychotic disorders among first-generation immigrants and refugees in Ontario	To study the prevalence of schizophrenia and schizoaffective disorders in first-generation immigrants and refugees in Ontario, Canada.	Quantitative Unspecified definition for Black people but grouped/categorized into (a) West Africa; (b) East Africa; (c) Central Africa; and (d) South Africa.	n = 4,284,694 West Africa group: n = 5,348, 29.7% refugees East Africa group: n = 21,117, 63.2% refugees Central Africa group: n = 676, 39.5% refugees South Africa group: n = 2,776, 4.2% refugees Age: 14–40 years old Sample grouped into (a) general population; (b) immigrants; and (c) refugees Subgroups are categorized into different world regions, such as America, Caribbean, Africa, Asia, Middle East and Oceania	First generation refugees from East Africa are more vulnerable to psychotic disorders relative to the general population in Ontario (incidence rate ratio (IRR) = 1.95, 95% CI = 1.44–2.65), as well as immigrants from West Africa (IRR = 1.66, 95% CI = 0.84–3.28), though only the first result is statistically significant. Refugees from South Africa also have a large incidence rate (IRR = 3.01, 95% CI = 0.24–38.5), although this was not significant. Refugee status had a significant association with an incidence rate per 100,000 person-years, as refugees had a higher risk of having a psychotic disorder than both immigrants and the general population (IRR = 1.27, 95% CI = 1.04–1.56).
Anderson et al.	2017	Examining the impact of migrant status on ethnic differences in mental health service use preceding a first diagnosis of schizophrenia	To examine the effects of ethnicity and migrant status on use of health services before being diagnosed with schizophrenia or schizoaffective disorder for the first time.	Quantitative Place of origin was used to define ethnicity. African individuals included individuals from African countries except from North Africa. We count these individuals as being Black.	n = 18,080 African: n = 312 Age: 14–35 years old	Compared to the general population, African individuals did not have significantly increased odds of accessing care through a family physician or a psychiatrist (OR = 1.11, 95% CI = 0.89–1.40; OR = 1.01, 95% CI = 0.80–1.27), which was also true when compared to Europeans (OR = 1.14, 95% CI = 0.85–1.52; OR = 0.87, 95% CI = 0.65–1.18). In terms of intensity of family physician contact, the African group had significantly lower rate ratios compared to the general population and to the European group (RR = 0.78, 95% CI = 0.68 = 0.91; RR = 0.77, 95% CI = 0.64–0.92). This was also true for intensity of emergency room contact, but only when compared to the general population (RR = 0.87, 95% CI = 0.81–1.01; RR = 0.95, 95% CI = 0.81–1.12).
Archie et al.	2010	Ethnic diversity and pathways to care for a first episode of psychosis in Ontario	To evaluate how care methods to access early intervention (EI) services in Ontario differ between various ethnic groups.	Quantitative Black individuals were defined as being from African descent.	n = 200 Black individuals: n = 31 Age: 16–50 years old	There were no significant differences in terms of health seeking actions between different ethnic groups (c² = 8.877, df = 6, P = 0.181). Black participants were less likely than Asian and “other” ethnicity groups (not including White individuals) to use ER services as their first point of contact (Black: 22.2%, Asian: 41.7%, other: 52.4%, White: 23.9%, P = 0.023). No significant ethnic differences in the last service contacted were observed in the proportion of participants who required ER services or hospitalization. The odds ratio of using ER services as first point of contact was not significantly different between the White and Black ethnic groups (OR = 1.11, P = 0.857).
Jarvis et al.	2005	The role of Afro-Canadian status in police or ambulance referral to emergency psychiatric services	To investigate the relationship between racial status and admission to hospitals for psychotic disorders. Specifically studying the percentage and the likelihood of Black Canadian psychosis patients to be referred to emergency psychiatric services through police or ambulance, rather than through other available means.	Quantitative Ethnicity was estimated through patients’ medical chart. Black individuals were defined as Afro-Canadians, most of whom were immigrants from Caribbean and Africa.	n = 351 Mean age: 44 years old (SD = 16.24) Afro-Canadians: n = 37 (11%), of which 31 were immigrants (84%)	A total of 73% of Afro-Canadian psychosis patients (27 out of 37) were referred to hospitals by police or ambulance. In contrast, only 48% of Euro-Canadian (96 out of 207) and 50% of Asian Canadian (29 out of 62) psychosis patients were referred through police or ambulance. When Black patients in Canada experienced psychosis, they were more likely to be brought into hospital through police or ambulance (B = 1.1, 95% CI = 1.26–6.62; P = 0.01). Being non-Black was a significant predictor of change in psychosis diagnosis (adjusted OR = 3.72, P = 0.045).
Jarvis et al.	2011	High rates of psychosis for Black inpatients in Padua and Montreal: different contexts, similar findings	To examine whether Black patients have higher rates of assigned diagnosis of psychosis compared to their non-Black counterparts in different settings (Padua, Italy vs. Montreal, Canada).	Quantitative Ethnicity was determined by patient chart or self-declaration. Black individuals defined as: Black migrants (in Padua), Black Canadians or Black migrants from Caribbean or Africa (in Montreal).	n = 3,332 Italy n = 2,932 Canada n = 400 Black participants from Italy: n = 41 Black participants from Canada: n = 42	In both sites (Italy and Canada), Black patients were diagnosed with psychosis at a higher rate when compared to the other three racial groups (White native-born, White migrants and non-White non-Black migrants). In Montreal, 81% of Black patients were diagnosed with psychosis, whereas only 48.2%, 40.4% and 53.3% of native-born White, White migrant and non-White non-Black migrant patients had a psychosis diagnosis, respectively. This was statistically significant (c² = 20.48, df = 3, P < 0.05). In Padua, 75.6% of Black patients were diagnosed with psychosis, whereas only 46.1%, 44.3% and 47.9% of native-born White, White migrant and non-White non-Black migrant patients had a psychosis diagnosis, respectively, which were also significant differences (c² = 14.40, df = 3, P < 0.05). Logistic regression showed that race was a significant predictor of being diagnosed as psychotic, even after controlling for sex and age. Being Black was significantly associated with receiving a psychosis diagnosis. Compared to other ethnic groups, Black participants had significantly higher odds of being diagnosed as psychotic. They were between 3 and 4 times more likely to be diagnosed as psychotic: Black participants versusnative-born White (Canada: OR = 4.20, 95% CI = 1.77–9.90; Italy: OR = 3.68, 95% CI = 1.79–7.58), Black versusWhite migrants (Canada: OR = 3.02, 95% CI = 1.17–7.82; Italy: OR = 3.96, 95% CI = 1.77–8.82), Black versusnon-White non-Black migrants (Canada: OR = 3.59, 95% CI = 1.48–8.71; Italy: OR = 3.18, 95% CI = 1.48–8.71).
Knight et al.	2021	Ethnoracial differences in coercive referral and intervention among patients with first-episode psychosis	The purpose of this study was to assess if patients with first-episode psychosis (FEP) were at an increased risk to be coercively referred to psychiatric services or coercively intervened by psychiatric services than non-Black patients with FEP.	Quantitative Black individuals were defined as being from Caribbean or African descent.	n = 208 Age: 16–40 years old Mean age: 22.9 years old Black individuals: n = 42	Out of all groups, Black patients that had experienced first-episode psychosis (FEP) had the highest chances of being referred via coercion compared to White patients who had lower risks (c² = 9.24, df = 2, P = 0.010). Additionally, Black individuals with FEP were more likely to experience any coercive intervention that included legal and medical measures, compared to White and non-Black visible minority groups (c² = 9.21, df = 2, P = 0.010). Black patients experiencing FEP had a higher risk of experiencing legal coercive interventions compared to the other two groups (c² = 10.92, df = 2, P = 0.004). Being Black (OR = 2.72, 95% CI 1.11–6.63, P = 0.028) increased the likelihood that a coercive intervention would be used. Additionally, being Black (OR = 3.01, 95% CI 1.23–7.35, P = 0.016) increased the risk of coercive legal interventions.
Maraj et al.	2015	Symptom profiles and explanatory models of first-episode psychosis in African-, Caribbean- and European-origin groups in Ontario	To explore differences between Black Caribbean, Black African, and White European individuals in terms of symptoms of psychosis and explanatory models for the illness.	Quantitative. Black individuals defined based on self-report.	n = 171 Age: 17–41 years old. Mean age: 24.8 years old (SD = 5.0) Black African: n = 41 Black Caribbean: n = 40	Black Caribbean participants were less likely to have a diagnosis of affective psychosis (OR = 0.29, 95% CI 0.10–0.81). In terms of symptoms, they also had lower odds compared to White European participants of reporting speaking incomprehensibly (OR = 0.36, 95% CI 0.14–0.90). In addition, Black African participants had higher odds compared to White Europeans of reporting persistent aches or pains (OR = 2.92, 95% CI 1.32–6.50). In terms of explaining the origin of their mental illness—and compared to White Europeans—Black Africans had lower odds of reporting hereditary factors (OR = 0.41, 95% CI 0.19–0.89), substance use (OR = 0.29, 95% CI 0.13–0.67) or themselves (OR = 0.41, 95% CI 0.19–0.89), as responsible for their condition. There were no significant differences here between Black Caribbean and White European participants.
Nikolitch et al.	2018	Adherence to follow-up in first-episode psychosis: ethnicity factors and case manager perceptions	To identify the degree of quality of follow-up depending on patient ethnicity in a population of minority patients who had experienced their first episode of psychosis. Moreover, the researchers wanted to determine how case managers would perceive their ethnic minority patients in terms of their patient's adherence to their medication, appointments, degree of insight, cooperation with the treatment team and familial involvement.	Mixed methods Black individuals identified based on chart reviews and case manager questionnaires.	n = 163 Mean age: 22.6 years old (SD = 4.9) Black participants: n = 25%	Black patients were 24% less likely to have received a good, effective follow-up (P = 0.04) compared to White patients (exp (B) = 0.22, adjusted χ 21 = 4.3, P = 0.04). This demonstrates that Black Canadians have discrepancies in receiving a good follow-up after a first episode of psychosis. Black patients were also less likely to attend appointments than White patients. There were no significant differences in case manager perceptions in terms of how they perceived visible minority groups adhering to appointments, adhering to medications, insight or family involvement.
Rodrigues et al.	2020	Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: a retrospective cohort study using health administrative data	The study had two primary goals. The first was to determine the risk of involuntary hospitalization in young first-generation people who belong to a minority ethnic group with early psychosis. The second was to understand the role of ethnicity and refugee status on the risk of involuntary admission among a subsample that consisted of first-generation migrants.	Quantitative Black individuals defined as: Caribbean and African which include people from sub-Saharan Africa (ex, Kenya, Ethiopia, Ghana, Nigeria and Zimbabwe).	n = 15,844 African participants: n = 405 (mean age 25.1; 34% female and 66% male; 203 on the schizophrenia spectrum; 202 diagnosed with psychosis) Caribbean participants: n = 303 (mean age 25; 34% female and 66% male; 137 on the schizophrenia spectrum; 166 diagnosed with psychosis)	Migrants from the European, African, Caribbean and East Asian groups had the highest risk of involuntary admission compared with the general population. Migrants from the Caribbean and African groups had the highest risk of involuntary admission (RR = 1.58, 95% CI = 1.37–1.82; RR = 1.52, 95% CI = 1.34–1.73, respectively). The risk of involuntary admission within the migrant group was highest among African and Caribbean ethnic minority groups relative to the European migrants (African: RR = 1.24, 95% CI = 1.04–1.48; Caribbean: RR = 1.29, 95% CI = 1.07–1.56). Only the Caribbean cohort had a higher risk of involuntary admission when compared with the European group (RR = 1.32, 95% CI = 1.09–1.60) when accounting for the migrant class. Overall, classification as a refugee had a 16% increased risk in involuntary admission (RR = 1.16, 95% CI = 1.02–1.32). The groups that were most likely to be admitted involuntarily were African and Caribbean, with 52% and 58% increased risks of involuntary admission, respectively. Refugee status among the migrant group from the Caribbean had a 72% increased risk of first involuntary admission compared with Caribbean immigrants (RR = 1.72, 95% CI = 1.15–2.58).
Rotenberg et al.	2017	The role of ethnicity in pathways to emergency psychiatric services for clients with psychosis	To determine the method by which participants arrived at a mental health emergency department and to determine if and how frequency of involuntary detention varies for ethnic minority individuals with psychosis (under the Ontario mental health act (MHA)). Finally, the researchers wanted to identify which factors predicted which participants were involuntarily represented under the MHA, and which protective factors could help influence care pathways.	Quantitative Black individuals were defined as African or Caribbean.	n = 765 Age (mean) = 38.01 Black African participants: n = 99 Black Caribbean participants: n = 141	Black African and Black Caribbean origin clients are 2.20 (P = 0.01) and 1.63 (P = 0.084) times more likely, respectively, to be presented to the emergency department involuntarily when compared to White North American clients. Black African clients have an increased chance of being presented to the ER by police or ambulance compared to White North American clients (OR = 2.00, 95% CI 1.10–3.64). Black Caribbean clients were also more likely than White North American clients to be presented to the ER by police or ambulance (OR = 1.51, 95% CI, 0.88–2.62). Overall, Black psychosis patients have an increased risk of experiencing negative pathways to emergency psychiatric.
Rotenberg et al.	2019	The role of ethnicity in involuntary psychiatric admission in Toronto, Canada in clients presenting with psychosis	The purpose of the study was to determine if patients from different ethnic groups presenting with psychosis are more likely to be admitted (as a whole) and more likely to be admitted as an involuntary patient under the MHA.	Quantitative Black people are defined as either Black Caribbean or Black African.	n = 711 305 individuals admitted Of those: 48 Black African, 53 Black Caribbean A total of 166 were admitted involuntarily Of those: 28 Black African, 28 Black Caribbean	The study found no significant differences in being admitted or being admitted involuntarily while presenting with psychosis based on the ethnicity of the clients.
Van der Ven et al.	2012	Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec	To explore differences in severity and nature of symptoms of FEP according to ethnic group and migrant status through the use of the cultural consultation services.	Quantitative Black people defined according to Statistics Canada 2006 Census: “African and Afro-Caribbean, including sub-Saharan Africa and the West Indies”.	n = 289 Reference group n = 145, age (mean, SD) = 23.4 (4.0) African and Afro-Caribbean n = 39, age (mean, SD) = 22.8, 4.3	Black individuals were more likely to be referred from the emergency department compared to Middle East and North African groups (c² = 14.8, df = 5, P = 0.01) but not compared to the reference group (White English or French Canadians with Canadian-born parents). General psychopathology subscale score of the reference group compared to the other groups showed higher mean total SANS and general psychopathology (PANSS subscale) scores only for Black individuals (F = 2.817, df = 5/288, P = 0.02; F = 3.485, df = 5/288, P = 0.005, respectively). The alogia subscale score of the SANS scores showed a higher mean for the Black people group compared with the reference group (F = 7.671, df = 1/183, P = 0.006). Black individuals differed from the reference group on the uncooperativeness, poor attention and preoccupation items (F = 8.909, df = 1/183, P = 0.003; F = 9.625, df = 1/183, P = 0.002; F = 12.065, df = 1/183, P = 0.001, respectively) of the PANSS general psychopathology items. There were no differences in age of onset of psychosis or any of the other listed demographic variables between groups.

Note. OR = odds ratio; CI = confidence interval; SANS = Scale for the Assessment of Negative Symptoms; PANSS = Positive and Negative Syndrome Scale.

Results

Of the 5,656 imported into Covidence^TM, 2,416 were identified as duplicates and removed. Of the 3,240 studies identified, 3,153 were excluded at the title-abstract phase, leaving 87 full text articles to screen. A total of 72 of these references were excluded because 1. the sample did not include Black individuals in Canada; 2. the studies had unsuitable research designs (e.g., conference abstracts and reviews); or 3. they did not assess psychosis. A total of 15 studies were retained for extraction and inclusion in this review. More information about this process is found in the PRISMA flow diagram presented in Figure 1.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA) flow diagram of the scoping review search process.

Characteristics of Studies

A total of 15 studies were included in the present scoping review (see Table 1 for detailed information). There was only one mixed-methods study⁴⁹ and 14 quantitative studies.^50-63 Eight studies were conducted in Ontario, the most populous province in Canada, which contains more than half of the country's Black population.^{51,52,54,57,58,60,61,63} Seven studies were conducted in Montreal (Quebec),^{49,50,53,55,56,59,62} including one that was set in both Montreal (Canada) and Padua (Italy).⁵⁶ The studies were published between 2005 and 2021.

Targeted Populations

Of the 15 studies, five focused primarily on Black individuals,^{52,55,56,59,60} while three focused on immigrants, refugees and migrants,^51,62,63 and seven others focused on diverse ethnic populations.^{49,50,53,54,57,58,61}

Summary of Data

Incidence and prevalence. Two studies explored the incidence and prevalence of psychotic disorders and found that Black individuals are more likely to be diagnosed with psychosis compared to other Canadian ethnic groups.^51,56 The first found that (in Ontario) first-generation refugees from East Africa are at a significantly higher risk of having a psychotic disorder compared to the general population (incidence rate ratio (IRR) = 1.95, 95% confidence interval (CI) 1.44–2.65).⁵¹ A study researched the prevalence of psychosis, comparing how proportions of diagnosis differed between Black and non-Black patients of two cities (Montreal, Canada and Padua, Italy).⁵⁶ It found that, in both sites, Black patients were diagnosed with psychosis more compared to other racial groups (Canada: c² = 20.48, df = 3, P < 0.05; Italy: c² = 14.40, df = 3, P < 0.05). In both Canada and Italy, Black participants were more likely than native-born White participants to receive a diagnosis of psychosis (Canada: odds ratio (OR) = 4.20, 95% CI = 1.77–9.90; Italy: OR = 3.68, 95% CI = 1.79–7.58). This was also true compared to White migrants (Canada: OR = 3.02, 95% CI = 1.17–7.82; Italy: OR = 3.96, 95% CI = 1.77–8.82) and compared to non-White and non-Black migrants (Canada: OR = 3.59, 95% CI = 1.48–8.71; Italy: OR = 3.18, 95% CI = 1.48–8.71). Overall, race was a significant predictor of diagnosis, even when controlling for various sociodemographic factors.

Diagnosis of non-affective versus affective psychosis. A brief report by Maraj et al.⁶⁰ found that Black Caribbean participants were less likely to have a diagnosis of affective psychosis (OR = 0.29, 95% CI 0.10–0.81) compared to White European participants.

Access to Care

Pathways to care. Three studies researched how individuals accessed care and sought help.^52,53,63 The first one by Anderson et al.⁵² found that Black African participants had increased odds of having a first contact through the emergency department (OR = 3.78, 95% CI 1.31–10.92). They also found that Black Caribbean individuals, compared to White Europeans, had increased odds of referral from an inpatient unit to early intervention services (OR = 2.04, 95% CI = 0.94–4.44), decreased odds of having general practitioner involvement on the pathway to care (OR = 0.70, 95% CI = 0.29–1.70) and fewer total contacts (exp (B) = 0.83, 95% CI = 0.65–1.06). Another study found that, in terms of access to care through a family physician for a mental health reason, the African group did not significantly differ from the general population or to the White European group (OR = 1.11, 95% CI 0.89–1.40; OR = 1.14, 95% CI 0.85–1.52).⁶³ The results were also similar for access to care through a psychiatrist (OR = 1.01, 95% CI 0.80–1.27; OR = 0.87, 95% CI 0.65–1.18) and for access to care through the emergency department (OR = 1.12, 95% CI 0.89–1.41; OR = 0.98, 95% CI 0.73–1.32). However, these results contrasted with those found by Anderson et al.⁵² Finally, in their 2013 study on determinants of negative pathways to care, Anderson et al.⁵³ found that Black individuals were twice as likely than White individuals (among others) to have been referred by emergency services following an episode of psychosis (OR = 2.15, 95% CI = 0.82–5.62), although this result was not statistically significant. Similarly, they were not significantly more likely to be referred through police and ambulance services compared to other ethnic groups (OR = 1.98, 95% CI = 0.87–4.50). Black participants were not significantly less likely to have had medical contact during their prodrome stage compared to Asian and “other” groups (OR = 0.90, 95% CI = 0.38–2.13). These results echoed those of Anderson et al.⁶³ but contradicted those from another study published by Anderson et al.⁵²

Health seeking. In terms of help seeking, Archie et al.⁵⁴ found no significant differences between help-seeking actions and various ethnic groups (c² = 8.877, df = 6, P = 0.181). However, Black (22.2%) and White (23.9%) individuals were less likely to access care through an emergency room as a first point of contact in pathways to care compared to Asian individuals (41.7%) and other ethnic groups (52.4%) studied (P = 0.023).

Coercive referrals and interventions and involuntary admission. Five studies examined the impact of ethnicity and race on the experience of coercive referrals and interventions, and on the experiences of involuntary admission of patients with first-episode psychosis.^{55,58,59,61,62} Jarvis et al.⁵⁵ found that Black patients in Montreal were more likely to be brought to the hospital by police or paramedics when experiencing psychosis (B = 1.1, 95% CI = 1.26–6.62, P = 0.01). Black patients were also treated as having more abnormal behaviours and more psychotic symptoms compared to other groups. These results were echoed by Van Der Ven et al.,⁶² whose findings showed that Black participants were more likely to be referred to the emergency department compared to Middle East and North African individuals, (c² = 14.8, df = 5, P = 0.01). However, Black participants were not more likely to be referred to the emergency department when compared to White English or French Canadians with Canadian-born parents. Similarly, Knight et al.⁵⁹ found that Black patients (of either African or Caribbean descent) experiencing first-episode psychosis were more likely to be referred and treated via coercion than non-Black patients (c² = 9.24, df = 2, P = 0.010; c² = 9.21, df = 2, P = 0.010). Indeed, Black patients were at an increased risk of being referred for care by police or paramedics, or by court order (OR = 2.72, 95% CI = 1.11–6.63, P = 0.028) and at an increased risk for legal coercion with court involvement (OR = 3.01, 95% CI = 1.23–7.35, P = 0.016). In addition, the study by Rotenberg et al.⁶¹ found that individuals of Black African and Black Caribbean origins were more likely to be presented to the emergency department involuntarily when compared to White North American patients (OR = 2.20, P = 0.01; OR = 1.63, P = 0.084). Black African and Black Caribbean participants also had an increased chance of being brought to the emergency department by police or ambulance services compared to White North American participants (OR = 2.00, 95% CI = 1.10–3.64; OR = 1.51, 95% CI = 1.10–3.64). A later study by Rodrigues et al.⁵⁷ presented results that aligned with Rotenberg et al.,⁶¹ finding that individuals from the Caribbean (Caribbean individuals may include individuals who do not define themselves as Black, such as those from Cuba, Porto-Rico) and African groups had the highest risk of being involuntarily admitted (RR = 1.58, 95% CI = 1.37–1.82; RR = 1.52, 95% CI = 1.34–1.73, respectively). This was also true when examining risk of involuntary admission within the subgroup of the first-generation individuals, where the risk for African and Caribbean groups was higher than for European migrants (African: RR = 1.24, 95% CI = 1.04–1.48; Caribbean: RR = 1.29, 95% CI = 1.07–1.56). After accounting for migrant class in their model, only the Caribbean group had a higher risk of involuntary admission compared with the European group (RR = 1.32, 95% CI = 1.09–1.60).

Finally, one study explored the impact of ethnicity on the risk of involuntary admission for psychosis.⁵⁷ This study found no significant differences in being admitted voluntarily or being admitted involuntarily while presenting with psychosis based on the ethnicity of patients.⁵⁷

Clinical Presentation and Symptoms

Two studies explored possible differences in clinical presentation of first-episode psychosis. The first focused on ethnicity and migration status.⁶² It found that the general psychopathology subscale score of the reference group showed a higher mean total on the Scale for the Assessment of Negative Symptoms (SANS) and general psychopathology (Positive and Negative Syndrome Scale (PANSS) subscale) scores compared to Black individuals (F = 2.817, df = 5/288, P = 0.02; F = 3.485, df = 5/288, P = 0.005, respectively). The alogia subscale score of the SANS scores showed a higher mean for the Black participants’ group compared with the reference group (F = 7.671, df = 1/183, P = 0.006). Black individuals differed from the reference group on the uncooperativeness, poor attention and preoccupation items (F = 8.909, df = 1/183, P = 0.003; F = 9.625, df = 1/183, P = 0.002; F = 12.065, df = 1/183, P = 0.001, respectively) of the PANSS general psychopathology items. There were no differences in age of onset of psychosis or any of the other listed demographic variables between groups. The second study, which was mentioned earlier, found that Black Caribbean participants had lower odds compared to White European participants of reporting speaking incomprehensibly as a symptom (OR = 0.36, 95% CI 0.14–0.90).⁶⁰ It also found that Black African participants had higher odds of reporting persistent aches or pains compared to White Europeans (OR = 2.92, 95% CI 1.32–6.50).

Explaining Symptoms

The study conducted by Maraj et al.⁶⁰ also looked at explanatory models. They found that in terms of explaining the origin of their mental illness, Black Africans had lower odds of reporting hereditary factors (OR = 0.41, 95% CI 0.19–0.89), substance use (OR = 0.29, 95% CI 0.13–0.67) or themselves (OR = 0.41, 95% CI 0.19–0.89), as responsible for their condition (compared to White Europeans). There were no statistically significant differences between Black Caribbean and White European participants.

Diagnosis

The study by Adeponle et al.⁵⁰ was the only one to research the impact of using a more culturally adapted interview to diagnose psychosis in individuals. Looking at patients of ethnic minority and immigrant backgrounds, they found that when reassessing patients with the cultural formulation interview, being non-Black (as compared to being Black) was associated with increased odds of receiving a different diagnosis than what had been given to them at intake (OR = 3.72, 95% CI = 1.03–13.41).

Treatment

Quality of health care. A single study explored quality of health care among Black first-generation immigrants compared to the general population.⁶³ It found that Black immigrants from Africa did have a significantly lower intensity of care by a family physician compared to both the general population and the White European group (RR = 0.78, 95% CI 0.64–0.91; RR = 0.77, 95% CI 0.64–0.92). The Black African group had a significantly lower intensity of care through a psychiatrist compared to the general population, but this decrease was not significant when compared to the White European group (RR = 0.87, 95% CI 0.76–0.99; RR = 0.95, 95% CI 0.81–1.12). This was also the case for intensity of care through the emergency department (RR = 0.84, 95% CI 0.74–0.96; RR = 0.95, 95% CI 0.81–1.12). Finally, for inpatient status at the index diagnosis of psychosis, there were no significant differences between the African group and any of the reference groups or adjusted models.

Disengagement from treatment. A single study explored disengagement from treatment among Black individuals.⁵³ This study researched disengagement from services and found that Black participants were the ethnic group most likely to disengage from psychosis services compared to Asian and other ethnic groups (OR = 2.10).

Duration of treatment. Similarly to disengagement from treatment, only a single study looked at duration of treatment. Anderson et al.⁵² did not find a significant difference in duration of untreated psychosis between groups. Two other studies, one conducted in Ontario⁵⁴ and one conducted in Quebec,⁶² also found no differences in duration of untreated first psychosis episode according to ethnic background.⁵⁴

Follow-up. A single study explored the role of ethnicity in adherence to follow-up.⁴⁹ This mixed methods study focused on the quality of follow-up, in addition to interviewing case managers to research their perception of their patients’ adherence to various aspects of their treatment. They found that Black participants were 24% less likely to receive an effective follow-up compared to White participants (P = 0.04).

Discussion

Summary of Findings

The purpose of this review was to identify studies conducted on psychosis in Black communities in Canada. We examined factors surrounding psychosis, including incidence and prevalence, access to care (pathways to care, health seeking behaviours, coercive referrals and interventions, involuntary admission, etc.) and treatment. The two studies exploring the incidence and prevalence of psychotic symptoms among Black people in Canada found that they were at higher risk in both Ontario and Quebec.^51,56 First, the Jarvis study found that Black individuals were 3.02 to 4.20 times more diagnosed with psychotic symptoms compared to White individuals born in or outside of Canada.⁵⁶ Next, a study conducted in Ontario found that Black refugees from East Africa had 95% higher incidence of psychotic symptoms compared to White people.⁵¹

The three studies that examined coercive care found that, in general, Black people are more likely to receive coercive care compared to other ethnic groups.^55,59,62 Indeed, Black individuals were more likely to be referred to emergency departments and forcibly brought in by police, ambulatory services or court order. One of the studies found that, compared to non-Black people, Black individuals were 2.72 times more likely to receive some form of coercive intervention, while they were 3.01 times more likely to receive care under a court order.⁵⁹ Additionally, of the three studies that have been conducted on involuntary admission to care,^57,58,61 two found that Black individuals were 1.24 to 2.2 times more likely to be admitted compared to other ethnic groups.^57,61 Black individuals with immigrant backgrounds were particularly at high risk.⁶¹

Findings on the increased susceptibility of Black people to receive coercive and involuntary care demonstrate three important elements. First, they attest to the lack of trust that Black people hold towards health-care services. This mistrust of health care is fuelled by racism and the colour-blind approach in mental and physical health care in Canada.^26,64 In addition, this mistrust is exacerbated by the cultural and racial inappropriateness of care.⁶⁴ Second, Mental health issues are still stigmatized in Black communities.⁶⁵ Indeed, individuals and families who experience mental difficulties may prefer to hide them and/or to pray, rather than seek professional care.⁶⁶ Families will often only resign themselves to seeking care when situations reach extreme levels of intensity or disruption. Finally, established racist structures in health care, judicial and law enforcement systems also contribute to increasing the likelihood of Black people receiving coercive and involuntary care.⁶⁴ As a result of these systems, Black individuals have decreased access to family doctors and quality health care and are more likely to be forcibly taken away by police (even when it is not justifiable), and their concerns and those of their families are not addressed by the judicial system.

The same reasons discussed above may also explain why the few studies conducted on care pathways have found that Black individuals, compared to White individuals, were up to 3.78 times more likely to receive emergency care.^52,53 Yet, no significant differences were found on care seeking between different ethnic groups.⁵⁴ Furthermore, compared to other ethnic groups, Black individuals were most likely to disengage from treatment for psychosis (OR = 2.10).⁵³ This last item also calls into question the quality of care available to Black individuals with psychosis. It is noteworthy that 14 of the 15 included articles were published since 2010, including six since 2017. This suggests an increased awareness and interest in disaggregating data by race. However, this observation must be considered with caution as all of these studies are mainly from researchers from two institutions in Toronto and Montreal. In addition, other aspects remain to be examined as many aspects are still unexplored, and gaps need to be addressed.

Observed Gaps and Future Research

The results showed that there are significant gaps in research on psychosis in Black communities in Canada. Although Black communities in Ontario and Quebec make up three quarters of the Black population in Canada, it is important to note that no studies on psychosis among Black people have been identified in other provinces. Nevertheless, there is a growing presence of Black communities in the provinces of Alberta, New Brunswick, Manitoba and British Columbia, and a historical presence of Black communities in Nova Scotia.⁶⁷ In fact, Black populations in some of these provinces have doubled in the last 10 years.⁶⁸ In addition, all of these studies come mainly from two teams: one in Montreal with the psychiatry team at McGill University affiliated primarily with the Jewish General Hospital;^{49,50,53,55,56,59,62} and a team in Ontario with majority connections to CAMH.^{51,52,54,57,58,60,61,63} No studies have been identified in large cities with significant Black populations, such as Halifax, Edmonton, Calgary, Ottawa-Gatineau or Winnipeg.

Furthermore, we did not identify any studies conducted solely on Black individuals. The fact that the studies were conducted among multiple communities prevented us from exploring intrinsic differences within Black communities and to observe their specific needs. Instead, in all studies, Black people were studied as a monolithic group and differences in gender, age and ethnicity, and socioeconomic conditions were not analysed. As well, few studies analysed migration status specifically among Black communities, which can play an important role in the treatment of psychosis and related elements. The small sample of Black people in the studies also prevented this type of analysis. In fact, with the exception of three population-based studies,^53,57,63 the others generally had a sample size of less than 100 Black individuals. In addition to these three studies, two others used data reported by Immigration, Refugees and Citizenship Canada on the geographic origin of individuals to determine that they are Black rather than usingself-reported racial identity.^57,63 The last study that used self-reported data also used country of origin as a measure of ethnic origin.⁵³ A recently published article showed that in three cases, this approach is an inaccurate way to identify Black people in health research in Canada.⁶⁹

Future studies should be conducted on all these factors, including age of first psychotic episode in Black populations and substance-induced psychosis. These factors can play an important role in prevention and in the involvement of families and communities in the care of Black people experiencing psychosis.

Another gap in studies has been the identification of Black people. Often, the region of origin (Africa and/or the Caribbean) was used to label individuals as Black when, in fact, about half of the people in the Caribbean do not consider themselves to be Black.⁶⁹ This problem is present across all research on the health of Black communities in Canada and deserves to be considered to ensure that individuals studied and identified as Black are indeed Black.³⁷ Finally, it is also important to conduct more research on chronic forms of psychotic disorders since the vast majority of the studies are conducted on the first episode of psychosis. There is a need for data on the continuity and quality of care, the quality of life, comorbidities, coercive referrals and interventions and other aspects in Black individuals with chronic psychotic disorders.

Limitations

As noted in the previous section, there is a dearth of information on various aspects surrounding psychosis in Black communities in Canada. This review on the incidence, prevalence, diagnosis (including cultural adaptability) and care (quality, disengagement) of psychosis in Black communities in Canada remains exploratory. In addition, although comprehensive and exhaustive, the search strategy and the list of databases used might not have identified all relevant studies published. For example, grey literature was not included, which may also have led to potentially useful results. Furthermore, because this was a scoping review, the quality of studies included was not assessed, which might have further reduced the number of included articles. Finally, none of the included studies were conducted exclusively among Black individuals. Thus, only comparisons between different ethnic groups were conducted, and no studies examined intrinsic differences within Black communities and the intersectionality of risk factors (e.g., gender, age, education, sexual orientation and occupation), which limits the generalization of our conclusions. Several important aspects deserve to be examined, such as the average age at first episode of psychosis, substance-induced psychosis and family and community involvement in the care of Black people.

Conclusions

This review examined different aspects surrounding psychosis in Black communities in Canada based on available data. Most importantly, it reveals many gaps in research on psychosis in Black communities as Black people are not only treated, medicated and served forcibly but also forcibly taken by police and paramedics, and hospitalized through court decisions every day. To date, no studies have analysed issues related to psychosis among Black individuals while solely focusing on issues related to age, gender and other social and economic factors. Similarly, few have examined the understanding of psychosis in Black communities, their beliefs, fears, stigmas and needs in terms of education, training, promotion and prevention programs. In addition, few have studied strategies for supporting Black people with psychosis and their families. Considering these gaps, research funds dedicated to the study of psychosis in Canada should dedicate a portion of funding to the study of psychosis in Black communities to encourage researchers to focus on this area of research. Scientific journals should also encourage researchers to disaggregate data by ethnicity and race and to analyse basic intersectional aspects such as gender and age. New research should address the issues surrounding psychosis in Black communities by establishing a complex framework of analysis that considers the different forms of racial discrimination these communities face at interpersonal, institutional and structural levels that impact their health, their ability and behaviours to seek care, their need of early detection, their interactions with care services and the treatments they receive as well as their effectiveness.⁷⁰ Finally, universities, hospitals and health-care settings have to implement training that can help to develop antiracist practices and care for Black individuals.^71,72

Supplemental Material

sj-docx-1-cpa-10.1177_07067437231178957 - Supplemental material for Incidence, Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review

Supplemental material, sj-docx-1-cpa-10.1177_07067437231178957 for Incidence, Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review by Jude Mary Cénat, Élisabeth Dromer, Wina Paul Darius, Rose Darly Dalexis and Sarah Elizabeth Furyk, Hannah Poisson, Farid Mansoub Bekarkhanech, David Guangyu Diao, Andi Phaelle Gedeon, Muhammad S. Shah, Patrick R. Labelle, Emmanuelle Bernheim, Cary S. Kogan in The Canadian Journal of Psychiatry

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Public Health Agency of Canada, (grant number 1920-HQ-000053).

ORCID iD

Jude Mary Cénat

Supplemental Material

Supplemental material for this article is available online.

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