Social inequality, not genetics, is the driving force behind the higher rates of mental illness recorded among Black communities in the UK, according to a leading psychiatrist.
Dr Lade Smith CBE, president of the Royal College of Psychiatrists, said that a wealth of evidence now shows that disparities in mental health outcomes are rooted in social and economic disadvantage. She pointed to deprivation, discrimination, early childhood trauma and other forms of socioeconomic hardship as the key factors that increase the risk of mental illness across all groups, but which disproportionately affect Black communities.
Systemic inequalities that fuel poor mental health
Research consistently links poverty, unemployment, poor housing, social isolation and a lack of opportunity to worse mental health outcomes. Dr Smith has previously warned that people from Black, Asian and minority ethnic (BAME) backgrounds face a “triple whammy” of blows to their mental health: the disproportionate impact of the COVID-19 pandemic, the fallout from events such as the murder of George Floyd, and ongoing institutional racism within the NHS. These pressures compound the effects of everyday discrimination and racial bias, which are themselves recognised as direct stressors that can trigger or worsen mental illness.
Early life adversity – including neglect, trauma and exposure to deprivation – has lasting psychological effects that extend into adulthood, increasing the likelihood of mental health problems, social exclusion and contact with the criminal justice system. Individuals who enter the criminal justice system are themselves more likely to experience mental ill-health, often because of the same underlying social disadvantages.
Lessons from the Valdo Calocane case
The case of Valdo Calocane, who killed three people in Nottingham in June 2023, illustrates how systemic failures and racial considerations can interact with mental health care. Calocane, who has schizophrenia, had been sectioned four times before the attacks and had repeatedly misled healthcare professionals about his condition and medication. A review by the Care Quality Commission (CQC) identified a “series of errors, omissions and misjudgments” in the care provided to him by Nottinghamshire Healthcare NHS Foundation Trust. Risk assessments minimised key details, his family’s concerns were poorly handled, and his discharge planning was inadequate. He was discharged back to his GP in September 2022 – nine months before the killings and on the same day an arrest warrant was issued for assaulting a police officer – without consultation with his family, GP or the police, despite his lack of engagement with services. Healthcare workers had effectively “lost” him.
Evidence presented at the public inquiry into the attacks, chaired by Her Honour Deborah Taylor, revealed that in 2020 mental health professionals had decided not to detain Calocane after a violent incident, citing research on the “over-representation of young black men in custody”. They opted instead for the “least restrictive” approach – a community treatment plan – with potential hospital admission only if it failed. Dr Smith and others have pointed out that such decisions, while well-intentioned, can reflect a system that fails to address the underlying social inequalities that drive mental illness, while also risking inadequate care for individuals who need it.
Disparities in diagnosis and detention
People from Black, Asian and minority ethnic backgrounds are more likely to be diagnosed with severe mental illness and are detained under the Mental Health Act at disproportionately high rates. They are also more likely to experience racism within the NHS. These disparities are not explained by any biological or genetic difference, but by the social and structural conditions in which people live.
Calocane pleaded guilty to three counts of manslaughter on the grounds of diminished responsibility – a defence under Section 2 of the Homicide Act 1957 that reduces murder to voluntary manslaughter when a defendant proves they had an “abnormality of mental functioning” from a “recognised medical condition” that substantially impaired their ability to understand their conduct, form rational judgments or exercise self-control. Because he was convicted of manslaughter rather than murder, the judge had discretion over sentencing and imposed a hospital order for treatment rather than a life sentence. The Court of Appeal upheld the sentence in May 2024, stating that Calocane was “in the grip of a severe psychotic episode” and that schizophrenia was the sole identified cause.
Victims’ families have expressed profound anger at the outcome. Emma Webber, mother of Barnaby Webber, said the families were “robbed of justice” because Calocane never faced a murder trial. Other relatives called the result a “miscarriage of justice” and argued that Calocane “got away with murder”. They have repeatedly called for a public inquiry into the deaths and the systemic failures that preceded them.
The public inquiry is examining Calocane’s interactions with health services and police over the three years before the attacks, and will consider whether wider social and racial factors played a role. Dr Smith said the evidence is now overwhelming that these disparities are not inevitable, but are the product of inequality that can and must be addressed.
