The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(10) 713-731© The Author(s) 2023
Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437231178957TheCJP.ca | LaRCP.ca
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.
Résumé
Introduction: Les communautés noires s’inquiètent de plus en plus de la psychose, un souci auquel font écho les systèmes de santé provinciaux du Canada. En réponse à l’absence de données probantes sur la psychose dans les communautés noires, cet examen de la portée a examiné l’incidence et la prévalence de la psychose, l’accès aux soins (trajectoires de soins, renvois coercitifs et interventions, etc.), les traitements reçus et les stigmas auxquels font face les personnes souffrant de psychose.
Méthodes: Pour identifier les études, une stratégie de recherche exhaustive a été mise au point et exécutée dans 10 bases de données en décembre 2021, notamment APA PsycInfo, CINAHL, MEDLINE et Web of Science. Les sujets et les mots clés liés à la psychose, aux communautés noires, aux inégalités en santé, au Canada et à ses provinces et territoires ont été utilisés et combinés. L’examen de la portée a été mené conformément aux Normes standardisés du PRISMA-ScR.
Résultats: Au total 15 études ont satisfait aux critères d’inclusion, toutes menées en Ontario et au Québec. Les résultats révèlent les différentes disparités liées à la psychose dans les communautés noires.
Comparées à d’autres groupes ethniques canadiens, les personnes noires sont plus susceptibles de recevoir un diagnostic de psychose. Les personnes noires souffrant de psychose sont plus susceptibles d’avoir un premier contact avec les établissements de santé par la voie des services d’urgence, en étant référés par les services de police et d’ambulance, et en faisant l’expérience des décisions et interventions coercitives, et de l’hospitalisation involontaire. Les personnes noires reçoivent une qualité de soins inférieure et sont le groupe ethnique le plus susceptible d’abandonner les traitements.
Conclusions: Cet examen de la portée révèle de nombreux écarts dans la recherche, la prévention, la promotion, et l’intervention en psychose chez les personnes noires du Canada. Les futures études devraient explorer les facteurs liés à l’âge, au genre, aux facteurs économiques et sociaux, au racisme interpersonnel, institutionnel et systémique, et aux stigmas liés à la psychose. Les efforts devraient être concentrés sur l’élaboration de formations de professionnels de la santé et la promotion de programmes de prévention au sein des communautés noires. Des interventions culturellement adaptées, des données désagrégées par par l’origine raciale et un financement de la recherche accru sont nécessaires.
Keywordspsychosis, Black communities, Canada, health disparities
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 nonaffective 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
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.
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
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 psychosis38-41 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 CovidenceTM, an online tool used to manage various steps of a systematic review’s screening phases. Duplicate references were identified and removed once imported into CovidenceTM. Additional duplicates were identified and excluded while screening references.
Once references were imported into CovidenceTM, duplicates were identified and removed. Screening of both the titleabstract 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).
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 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
Of the 5,656 imported into CovidenceTM, 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.
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.
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
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 sociodemo-graphic 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.
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
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).
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.
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).
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).
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.
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.
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.
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
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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).
Jude Mary Cénat https://orcid.org/0000-0003-3628-6904
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1 School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
2 Interdisciplinary Centre for Black Health, University of Ottawa, Ottawa, Ontario, Canada
3 University of Ottawa Research Chair on Black Health, University of Ottawa, Ottawa, Ontario, Canada
4 Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
5 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
6 Faculty of Arts & Science, McGill University, Montreal, Quebec, Canada
7 Library, University of Ottawa, Ottawa, Ontario, Canada
8 Faculty of Law, Civil Law Section, University of Ottawa, Ottawa, Ontario, Canada
9 Canada Research Chair on Mental Health and Access to Justice, University of Ottawa, Ottawa, Ontario, Canada
Corresponding Author:Jude Mary Cénat, PhD, School of Psychology, University of Ottawa, 136 Jean-Jacques-Lussier, 4017, Vanier Hall, Ottawa, Ontario, Canada K1N 6N5.Email: jcenat@uottawa.ca