Atherosclerotic renovascular disease.

the patients are more likely to present symptoms somatically."8 Another found that this failure applied to anxiety but not to depression. 19 An alternative explanation is that general practitioners recognise signs of mental illness but think it inappropriate to treat or refer patients and leave this to other agencies. Such behaviour may not be confined to general practitioners born and trained in Britain. Those trained in the Indian subcontinent and practising in Britain are less likely than their British counterparts to think it appropriate for patients toconsult with family problems and may overtly or tacitly discourage patients with such problems from attending.20 Psychiatry has low status within medical education in India,2" and one study has shown that general practitioners in India can identify only a quarter of probable cases of psychiatric morbidity.22 A widespread view is that much illness, particularly mental illness, remains managed within the Asian family. No attempt has been made to test this idea, although the belief affects action: general practitioners, for example, are inhibited from referring Asian patients to district nursing services.23 Nevertheless, some evidence supports the idea. Bengali children referred to a child psychiatry service in east London presented a narrower range ofproblems than white children.' This may indicate Asian patients' unwillingness to proceed to further treatment, especially that requiring admission to hospital, which is seen as a mark of serious illness.62425 Referral to a psychiatrist may affect marriage prospects.26 Some patients may be shielded from medical care more than others. Studies of general practitioner consultation rates suggest that contact is particularly inhibited for women,7-9 who seem to be uncertain of expectations in a doctor-patient relationship,27 especially when the general practitioner is a man.28 Many requests to a phone-in advice service for ethnic minorities were from women with severe life crises who were seeking the help of a woman doctor.29 An additional reason for low presentation rates for mental illness is that ideas of psychological causation of illness are poorly understood within Asian cultures."24 3031 Moreover, treatment by general practitioners for conditions such as depression and anxiety has become commonplace only in the last generation, and it is hardly surprising if older Asians behave differently in seeking help for such conditions.32 Patients may sidestep conventional medical services and prefer to approach hakims or other alternative healers, but there is little evidence that this happens on a major scale.2 33 34 Mentally ill British Asians may, however, travel to Asia for treatment: almost a quarter of those from one sample who had visited the subcontinent had visited an Asian healer while they were there.33 Although British Asians may thus show both genuinely low rates of mental illness and a tendency to underreport mental illness, their prevalence of mental illness will probably gradually reach national levels, both overall and for particular diagnoses. In the meantime Asian patients may need encouragement to express their emotional problems in psychological terms and doctors need to develop a greater sensitivity in recognising them. BERNARD INEICHEN Senior Research Fellow, Newham Health Authority, London E13 ODZ