The study was conducted at the Second Psychiatric Clinic of Athens University Medical School in Attikon General Hospital which had recently opened. This unit does not accept involuntary admissions. Our sample comprised of 153 in-patients admitted consecutively via the emergency department of the hospital from April 2008 to December 2009. The emergency department is on call twice a week (Mondays and Thursdays), covering the area of Attica, with another large psychiatric hospital which assesses requests for involuntary admissions. Attica is the most densely populated geographical area in Greece, including Athens where half of the residents in Greece live. The age of patients ranged from 19 to 59 years old; 81 were males and 72 females. They were designated as Greek (N = 90) or non-Greek (N = 63) if both their parents were either Greek or non-Greek respectively. Patients from mixed-ethnicity marriages were excluded from the study. All patients fulfilled the DSM-IV-TR criteria for schizophrenia and other psychotic disorders (schizoaffective and delusional). Admission of patients was made on a voluntary basis alone. No restraint, enforced medication or seclusion was used for any of the patients.
Based on the relevant literature we checked for several confounding variables, including length of stay, age, legal status upon admission, substance misuse upon admission, prior substance misuse and smoking status on admission.
Each patient received an initial diagnosis and admission approval by the two psychiatrists responsible for the emergency department on the day of admission. Overall, 18 trained psychiatrists participated in this study. The on call psychiatrists were aware that their clinical judgments would be used in a study about medication prescribing. They were blind to the fact that the study explored ethnic bias in clinical practice. All psychiatrists were of Greek nationality with both parents Greek.
The social and psychological functioning of patients was assessed by the Global Assessment of Functioning (GAF) scale. GAF is widely used in mental health practice and has established good validity [14
]. Moreover, because GAF is meant to assess patients' functioning and not their psychiatric symptoms, the brief psychiatric rating scale-extended version (BPRS-E) [16
] was also used to assess symptom severity on admission and discharge. The BPRS comprises of 24 symptom constructs, each rated on a 7-point scale of severity. This rating scale been used extensively with populations with severe and persistent mental problems and has established sound reliability and validity
Medication (types and doses of drugs) upon admission was determined by the two psychiatrists that had agreed to admit each patient. GAF and BPRS-E ratings upon admission were conducted by the same two psychiatrists. Medication on discharge as well as GAF and BPRS ratings on discharge were determined by the responsible attending psychiatrist which was one of the two psychiatrists that had admitted the patient.
Ethical approval for this research was granted by the Attikon University General Hospital ethics Committee and consequently by the Attikon General Hospital Scientific Committee. Written informed consent was obtained by the patients. Overall, data were gathered by the medical and nursing files of the Department as well as the attending psychiatrist and nursing staff.
Prescribing practice was compared between the groups with reference to 5 factors:
1. Polypharmacy was defined as the concurrent treatment with more than one psychiatric medication (as opposed to treatment with one or more antipsychotic agents [17
] employed in most other studies). Thus, in our study it consisted simply in the sum, in absolute number, (rather than rated in doses, usually sum of individual % of the maximum dose allowed) of the different drugs given in each of the following categories: FGAs, SGAs, mood stabilizers, SSRIs-SNRIs and benzodiazepines. If in one category more than one drug was given, this would also be counted (two mood stabilizers, one SGA and two different benzodiazepines would make up 5 in our score). In Greece, antipsychotic polypharmacy is very widespread and is a product of poor yet well-meant and standard practice. Thus we figured that elevated use of antipsychotic polypharmacy in non-Greeks would be difficult to associate with intended racial behavior. The latter might be better assessed by the measure adopted in our study, especially as Greek psychiatrists are well aware of the negative short and long terms consequences of polypharmacy,
2. Use of FGAs (yes/no)
3. Use of SGAs (yes/no)
4. Use of mood stabilizers (yes/no)
5. Use of SSRI-SNRI. (Yes/no)
6. Use of benzodiazepines (Yes/no)
Thus, we compared six outcomes related to prescribing and six scale outcomes; differences in BPRS-E and GAF on admission, on discharge and on improvement as rated by each scale (that consisted of the mean differences in ratings-discharge mean minus admission mean for each ethnic group).
In total we tested for twelve two-tailed experimental hypotheses. Based on the literature we expected to find some evidence of negative ethnic bias towards the ethnic minority group members in terms of one or more categories tested.