Post on 02-May-2023
Originally published in: Emma Warnock-Parkes, Susan Young & Gisli
Gudjonsson (2010) Cultural sensitivity in forensic services: findings from
an audit of South London forensic inpatient services, The Journal of
Forensic Psychiatry & Psychology, 21:1, 156-166, DOI:
10.1080/14789940903202179
Cultural sensitivity in forensic services: findings from an audit of South London forensic inpatient services
Emma Warnock-Parkes a, Susan Young
b & Gisli
Gudjonsson b
a The Centre for Anxiety Disorders and Trauma, The Maudsley Hospital , London , UK
b Department of Forensic Mental Health Science, Institute of Psychiatry, London, UK Published online: 25 Sep 2009.
RESEARCH ARTICLE
Cultural sensitivity in forensic services: findings from an audit of South London forensic inpatient services Emma Warnock-Parkes
a*, Susan Young
b and Gisli Gudjonsson
b
aThe Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, London, UK;
bDepartment of
Forensic Mental Health Science, Institute of Psychiatry, London, UK
(Received 8 August 2007; final version received 22 July 2009)
This paper summarises the key findings from an audit using the Cultural
Sensitivity Audit Tool for Mental Health Services (The Sainsbury Centre
for Mental Health, 2001) to evaluate the views of service-users and staff in
a South London Forensic Inpatient Service. Forty-one service-users and 47
members of staff working in the service took part in the audit. Staff
completed the tool as a questionnaire, and service-users were interviewed.
The majority of staff believed that black and minority ethnic patient groups
were over-represented in the service, and many attributed this to
misunderstandings of culture. Staff identified gaps in their training on race
and culture; none of the staff believed they had received all the training
required. Nevertheless, service-users highlighted culturally sensitive and
effective aspects of the service, and many believed their cultural needs were
understood. Given this disparity, the authors question whether the large
emphasis on the cultural sensitivity of services is something service-
providers are more concerned about than our service-users; and whether a
greater focus on service quality, of which cultural sensitivity is one aspect,
would be more helpful.
Introduction
The representation of black and minority ethnic groups in mental health services has
been documented to be significantly disproportionate to the ethnic profile of the
country at large (National Institute for Mental Health in England: NIMHE, 2003). The
area has become one of controversy: possibly due to the findings that people from
black and minority ethnic groups differ in the following respects from fellow white
service-users: they are more likely to be admitted to and over-represented in inpatient,
secure and prison settings (British Psychological Society, 1998; Department of
Corresponding author. Email: emma.warnock-parkes@slam.nhs.uk
DOI: 10.1080/14789940903202179 http://www.informaworld.com
Health, 1992, 1999a; Maden, Friendship, McClintock, & Rutter, 1999); more likely to
be compulsorily admitted and more than six times more likely to be sectioned
(Department of Health, 2000; Morgan et al., 2005); more likely to have an inpatient
diagnosis of schizophrenia (Bhugra et al., 1997); less likely to be registered with a
General Practitioner (Koffman, Fulop, & Pashley, 1997); less likely to be referred to
psychology services (BPS, 1998); less likely to be treated with psychotherapy or
antidepressants (McKenzie et al., 2001); and less likely to be prescribed newer
atypical antipsychotic medications (Wang, West, Tanielian, & Pincus, 2000).
However, a recent paper found no differences in the quality of prescribing between
black and white patients (Connolly & Taylor, 2008). It has been argued that some
documented differences in representation could be related to higher rates of psychosis
in certain ethnic groups (Bebbington et al., 1994), and it is observed that there might
be more exposure to risk factors that could lead to the development of mental illness
(Lewis, Croft-Jeffreys, & David, 1990). Although, as Singh and colleagues (Singh,
Greenwood, White, & Churchill, 2007) suggest, this area of research is ‘politically
charged and ethically contentious requiring a cautious and balanced approach to
research and interpretation of data’ (p. 103). Unfortunately, studies are often fraught
with methodological problems that limit their findings (Bhui et al., 2003).
Partly following such research, a number of governmental papers have been
published making recommendations for the treatment of black and minority ethnic
groups, including: the National Service Framework for mental health (Department of
Health, 1999b); a report titled Engaging and Changing (Patel, Winters, Bashford, &
Bingley, 2003) and Delivering Race Equality in Mental Health Care (DRE:
Department of Health, 2005). At a local level, the Race Relations [Amendment] Act
(Stationary Office, 2000) placed a general duty on all public authorities to eliminate
unlawful racial discrimination, promote equality of opportunity, and promote good
relations between people of different racial groups. In May 2002, the South London
and Maudsley (SLAM) NHS Trust published its first Race Equality Scheme as
required by the Race Relations Act (SLAM NHS Trust, 2002a). Six functions were
identified at this time: (1) clinical service provision; (2) employment; (3) patient and
public involvement; (4) education and training;
(5) research and development and (6) non-clinical support services.
When the RES was published, clinical service provision and employment were
prioritised as the first part of this work. Thus, in order to examine the clinical
service provision and evaluate the effectiveness of the South London Southwark
Forensic Service in meeting the needs of ethnic minority service-users, this service
conducted an audit of the cultural knowledge and practice adopted within the
service, from both a staff and service-user perspective. The aims of this audit were
to assess the views of staff and service-users on the ethnic diversity, accessibility
and cultural sensitivity of the service.
Method The service
At the time of the audit, the Southwark Forensic Inpatient Service (‘the service’)
included two units for male mentally disordered offenders and patients who are
difficult to manage in general psychiatric settings. One was a 29-bedded inpatient
forensic service providing care and treatment in conditions of medium security, and
the second was a 15-bedded open Forensic Rehabilitation Unit.
Participants
Participants were 41 patients and 47 members of staff working in the service.
Participation in the audit was voluntary.
Exclusions included service-users who were too unwell to participate (i.e., actively
psychotic as assessed by nursing staff) and individuals with moderate learning
disabilities who could not comprehend the questions. Unfortunately, due to a lack of
funding, interpreters could not be provided to aid completion of the questionnaires, so
individuals without an adequate understanding of English were excluded.
Measures
The Cultural Sensitivity Audit Tool for Mental Health Services (The Sainsbury
Centre for Mental Health, 2001) was devised for independent use by mental health
services to identify areas of good practice and those for improvement. It places
particular emphasis on the experiences of the people using and working in services.
The tool consists of two interview schedules:-
The Staff Interview Schedule consisting of 67 questions split into six domains: (1)
demographics; (2) communication; (3) the availability of staff to work with clients;
(4) knowledge and views of cultural and ethnic issues;
(5) training regarding cultural issues and (6) the cultural appropriateness of day
centres, hospital wards and residential settings. For this audit, the latter section was
applied to the mental health hospital ward.
The Service-User Interview Schedule consisting of 71 questions split into seven
domains: (1) demographics; (2) accessibility of services; (3) language and
interpreters; (4) general service use issues; (5) availability of appropriate staff; (6)
availability of ethnically specific services and (7) service-users’ views on the cultural
appropriateness of mental health services.
The tool has been reviewed by Mckenzie (2002) who noted that there was
insufficient information on the tool’s development and there were no data presented
on the reliability and validity of the tool. A review of the literature does not reveal
evidence of any subsequent validation with regard to this tool. However, in spite of
the lack of validity, and absence of other instruments that address specific issues of
cultural sensitivity in mental health services, this current study represents a
preliminary attempt to audit issues relevant to cultural sensitivity in forensic services.
Procedure
Copies of the Staff Interview Schedule, together with a consent form and information
sheet, were internally distributed to all staff employed in the service. These were then
returned anonymously in internal envelopes to a researcher.
The Service-User Interview Schedule was administered by a researcher as a semi-
structured interview. All individuals who met the inclusion criteria were approached
and invited to participate. Each participant was required to provide written informed
consent before completing the interview. Interviews took approximately 30 minutes to
complete, and were conducted in clinic rooms on the units.
Data were analysed using descriptive statistics or qualitative thematic analysis. For
the latter analysis, instructions were devised on how respondents’ qualitative
comments were organised into themes and a second researcher was asked to analyse
the data using these instructions. Overall, there was a high level of agreement between
the two researchers, and any discrepancies were discussed and the comment was
subsequently allocated to a theme once an agreement had been made.
Results
Due to the volume of results the key outcomes are briefly summarised (the full audit
is available on request from the authors). As some participants chose not to respond to
particular questions, there are a number of missing responses. Missing data are noted
where relevant throughout the results. Percentages are calculated on the total number
of participants, unless otherwise stated.
Characteristics of staff and service-user respondents
A total of 47 staff, representing all members of the multidisciplinary team, and 41 all
male service-users, completed the audit. Table 1 shows the characteristics of
respondents.
Staff perceptions Ethnicity and representation of service-users
The majority of staff (28, 60%; missing data – two) thought that black and minority
ethnic patient groups were over-represented in the service compared to the local area.
Of that group most (20, 71%) believed, this
Table 1. The demographic characteristics of staff and service-user respondents (number and percentage).
Staff respondents, Service-user
respondents,
n = 47 (%) n = 41 (%)
Gender
Male 20 (43) 41 (100)
Female 27 (57) 0 (0)
Ethnicity subgroups
White background 27 (57) 15 (37)
African/Caribbean 15 (32) 19 (46)
Mixed race 3 (6) 5 (12)
Indian/Asian 2 (4) 1 (2)
Black other 0 (0) 1 (2)
Religion
Christian 33 (70) 27 (66)
Atheist/no religion 10 (21) 9 (22)
Muslim 1 (2) 2 (5)
Hindu 1 (2) 1 (2)
Other 2 (4) 2 (5)
reflected a misunderstanding of culture and ethnicity, and the ways in which people
express themselves.
Cultural appropriateness of the service
The majority of staff (40, 85%; missing – four) believed that the food available on the
unit fulfilled cultural and religious requirements of the service-users. Only a third of
staff (15, 32%; missing data – eight) stated that culturally appropriate personal care
products were available in the service.
The majority of keyworker staff (10 of the 13 keyworkers that commented – 77%)
reported that service-users were rarely given the option of having a keyworker of the
same ethnicity, although the same percentage of staff stated that a culturally
appropriate member of staff is usually available on the ward, if required.
Just under half of staff respondents (20, 43%; missing data – three) stated that the
team in which they work had attempted to improve its cultural sensitivity and
examples were given relating to: staff development (e.g., training), clinical practice
(e.g., care plans), diverse recruitment, ward-based factors and events (e.g., organising
culturally appropriate social events) and displaying culturally relevant literature on the
wards.
Communication
Less than half of the staff (22 respondents; 47%; missing data – four) reported to have
access to written information for service-users available in different languages.
However, approximately half of staff respondents (24, 51%) had required interpreter
services in the past.
Staff knowledge, skills and training
A majority of staff (28, 60%; missing data – 4) were aware of external services for
people from black and minority ethnic communities and half of these staff (14, 50%
of the 24 staff) members had referred service-users onto such services.
Just less than half of the staff respondents (23, 49%) stated that they had a
moderate-to-high level of knowledge of the Trust’s anti-discrimination policies. A
majority of staff (34, 73%) stated that they had some knowledge and skills but that
these were ‘not adequate’, indicating they lacked confidence in their knowledge and
skills. Only one-quarter of staff (12; 26%) stated that their knowledge and skills were
‘adequate’. Half of staff respondents (23, 49%; missing data – three) stated they had
attended ‘no training’ regarding ethnic and cultural issues.
Service-user perceptions of the service Impact of ethnicity on diagnosis and treatment
A majority of service-users (31; 80%; missing data – two) stated that they did not
think the treatment they received was different from other people because of their
ethnicity and/or gender. Furthermore, just over half of service-users (21, 51%) stated
that there would not have been any differences in their treatment and diagnosis if they
had been in contact with a member of staff who better understood their experiences as
a member of a particular ethnic group. Most service-users (29; 71%; missing data –
one) believed that staff understood their cultural needs, with 13 (32%) reporting that
these needs were understood ‘very well’, and 16 (40%) ‘fairly well’.
The cultural appropriateness of the service
A majority of service-users stated that they had appropriate places to worship if
required (29, 71%; missing data – five), and were happy with the levels of privacy
they received on the unit (34, 83%; missing data – three). Only half of service-users
(20, 49%; missing – eight) stated that culturally appropriate personal care products
were available.
The majority of service-users (29, 71%), did not express a preference for a
keyworker of the same ethnic background.
A majority of service-users (29, 71%; missing data – one) were unaware of local
services provided specifically for people from black and minority ethnic backgrounds,
and only six service-users could identify any local community services by name.
Communication
A majority of service-users (17, 41%) stated that they preferred to talk about mental
health issues in English, and a majority of service-users (33, 80%) reported to
understand ‘everything’ or ‘most’ of what the staff said to them.
Discussion
The majority of staff respondents (60%) believed that black and minority ethnic
groups were over-represented in the service compared with the local area. As a crude
method of exploring the representation of ethnic groups in the service compared to
local demographics, comparison with the 2001 census data (see Gardener &
Connolly, 2005) and the ethnicity data for the London Borough of Southwark (SLAM
NHS Trust, 2002b) suggests that a greater proportion of the patient respondents to this
audit were from African-Caribbean and mixed race backgrounds than reside in the
local community. This apparent over-representation of black and minority ethnic
groups in this service is consistent with previous research and audits in inpatient and
secure settings (BPS, 1998; Browne, 1995; Department of Health, 1999a; Southwark
Community Health Council, 1999). Staff attributed this over-representation to
misunderstandings of culture and ethnicity, and the ways in which people express
themselves, which is consistent with the published literature (Bhugra, 2002;
McGoldrick & Giordano, 1996).
Strikingly, a majority of service-users did not think the treatment they received
was affected by their ethnicity, or that their treatment would have been different if
they had contact with staff who better understood their experiences as a member of a
particular ethnic group. Indeed, the majority of service-users did not express a
preference to have an ethnically matched keyworker. This is interesting given that the
ethnic profile of staff respondents was somewhat more white-dominated than that of
the service-users (this finding is reflective of the diversity of Southwark NHS
employees more generally: SLAM NHS Trust, 2002a). Furthermore, a high
proportion of service-users (71%) believed that staff understood their cultural needs.
Thus, the majority of service-users did not report experiencing the differential
treatment that has been reported for black and minority ethnic groups in inpatient
mental health services (BPS, 1998; Mckenzie et al., 2001; Wang et al., 2000).
In terms of the cultural appropriateness of the service, the overall majority of
service-users commented that appropriate services were provided in terms of levels of
privacy, food and places to worship. The availability of culturally appropriate
personal care products was the only area that was highlighted as needing attention.
These findings prompt an
interesting question: are we as staff putting too much emphasis on services being
culturally sensitive when the service is successfully meeting the majority of the needs
of our service-users? Indeed, in a recent paper, Singh (2007) acknowledges the
importance of being culturally sensitive, but warns about the dangers of treating
patients as groups rather than individuals, observing that this is what racists
themselves do, and highlighting that cultural factors are only a part of a patient’s
formulation and care plan.
Despite a majority of service-users concluding that the service on the whole met
their cultural needs overall, the staff lacked confidence in their knowledge and skills
with regards to race and culture, and none of the staff believed they had received all
the training they required. It would also seem from the results that although
interpreters had been used, staff had not attended training on using interpreters. Of
note, published literature discusses the limitations of accurately assessing, diagnosing
and treating people with mental health problems without a detailed understanding of
their cultural background (Bell, Halligan, & Ellis, 2003; Leeser & O’Donohue, 1999;
Rhi, 2001). However, evidence of the effectiveness of training on service delivery is
still needed (Bhui, Warfa, Edonya, McKenzie, & Bhugra, 2007). Further, given that
this was not a problem for our service-users, perhaps staff can overestimate the level
of knowledge and skills that is required to provide a service that meets a variety of
cultural and ethnic needs. Of relevance, in a paper looking at lessons from public
inquiries on institutional racism, Singh (2007) makes reference to the limitations of
relying on training as a key recommendation in dealing with inequality of treatment in
the NHS.
In terms of information about services, the lack of information available in
different languages was highlighted in this audit, as has been the case in past service
evaluations (Fassil, 1996). The majority of staff did report knowledge of local service
provision for black and minority ethnic communities, despite the majority of service-
users being unaware of these services. The importance of forging links with
community groups outside of inpatient services for ‘effective change to be made
inside’ is highlighted by the National Institute for Mental Health in England (NIMHE,
2003: 63). However, no service-users mentioned this as being a limitation of the
service.
The study has a number of limitations. First, no record was made of the number of
staff or service-users who did not complete the questionnaires. Therefore, there may
be a response bias in favour of people who wished to express their views; especially
since two white female members of staff, who would not have matched most of the
service-users, conducted the interviews. Second, as service-users were interviewed by
a researcher, it is possible that they were more favourable in their responses than they
might have been if completing a questionnaire anonymously. This potential bias and
imbalance of power would have been better addressed if service-users had conducted
the interviews themselves; the authors recommend this to be considered in future
similar studies. Third, due to resource issues, the interview was completed by staff as
a self-administered questionnaire, which may have contributed to missing data.
Alternatively, this might indicate that staff were reluctant to be forthcoming about
themselves and their views. Fourth, in spite of the audit-evaluating aspects of culture
and ethnicity in the service, financial resources were not available to use an interpreter
to complete the service-user interviews. Thus, only service-users proficient in English
were able to participate which could have biased the findings. Fifth, the measure used
has no published reliability and validity data (McKenzie, 2002). The way questions
were worded could also have focused on highlighting areas of cultural insensitivity,
rather than encouraging expression of cultural sensitivity. Finally, we did not
breakdown responses by ethnicity and so it is hard to say which ethnic groups
responded in which direction.
Conclusions
The findings of the study reveal ethnic diversity within the service. With such
diversity comes a variety of needs, and services have a responsibility to meet these
needs. Interestingly, the audit appears to have found that service-users on the whole
are happy with the cultural appropriateness of the service they receive. The
assumption of a cultural sensitivity audit tool is that there are important cultural issues
and needs not being adequately addressed in health services. This study actually
suggests that this may not be the case: that most service-users in this service do not
receive differential treatment as a result of their ethnic background. This leads to an
interesting question: are we placing too much emphasis on cultural sensitivity, when
this is something that our service-users do not necessarily see as a problem? As Singh
argues
‘By focusing inappropriately on culture and ethnicity at the expense of sound clinical
judgement, we risk offering poorer rather than better care to patients from minority
ethnic groups’ (2007: p. 364).
Acknowledgements
The authors thank all the staff and participants from all the units involved. We would also like
to thank the reviewers of the paper for their helpful comments and suggestions on improving
it.
References
Bebbington, P.E., Feeney, S.T., Flannigan, C.B., Glover, G.R., Lewis, S.W., & Wing, J.K.
(1994). Inner London collaborative audit of admissions in two health districts. II Ethnicity
and the use of the Mental Health Act. British Journal of Psychiatry, 165, 743–749.
Bell, V., Halligan, P., & Ellis, H. (2003). Beliefs about delusions. The Psychologist, 16, 418–
422.
Bhugra, D. (2002). Ethnic factors and service utilization. Current Opinion in Psychiatry, 15,
201–204.
Bhugra, D., Leff, J., Mallett, R., Der, G., Corridan, B., & Rudge, S. (1997). Incidence and
outcome of schizophrenia in whites, African-Caribbeans and Asians in London.
Psychological Medicine, 27, 791–798.
Bhui, K., Stansfeld, S., Hull, S., Priebe, S., Mole, F., & Feder, G. (2003). Ethnic variations in
pathways to and use of specialist mental health services in the UK: Systematic review.
British Journal of Psychiatry, 182, 105–116.
Bhui, K., Warfa, N., Edonya, O., McKenzie, K., & Bhugra, D. (2007). Cultural competence in
mental health care: A review of model evaluations. BMC Health Services Research, 7, 15–
25.
British Psychological Society (BPS). (1998). Services to black and minority ethnic people. A
guide for commissioners of clinical psychology services. Briefing paper number 16.
Leicester: BPS.
Browne, D. (1995). Sectioning: The black experience. In S. Fernando (Ed.), Mental health in
a multi ethnic society: A multidisciplinary handbook. London and New York: Routledge.
Connolly, A., & Taylor, D. (2008). Ethnicity and quality of antipsychotic prescribing among
in-patients in south London. The British Journal of Psychiatry, 193(2), 161–162.
Department of Health. (1992). Services for people from Black and ethnic minority groups –
issues of race and culture: A discussion paper. London: Department of Health and Home
Office.
Department of Health. (1999a). A systematic review of research relating to the Mental Health
Act 1983. London: Department of Health.
Department of Health. (1999b). National service framework for mental health: Modern
standards and service models. London: Department of Health.
Department of Health. (2000). An analysis of the use of Part II of the Mental Health Act.
London: RCP.
Department of Health. (2005). Delivering race equality in mental health care: An action plan
for reform inside and outside services and the Government’s response to the Independent
inquiry into the death of David Bennett. Retrieved July 7, 2008, from
http://www.dh.gov.uk/Publications AndStatistics/
Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidance
Article/fs/en?CONTENT_ID=4100773&chk=grJd1N
Fassil, J. (1996). Primary health care for black and minority ethnic people. A consumer
perspective. Leeds, UK: NHS Ethnic Health Unit.
Gardener, D., & Connolly, H. (2005). Who are the other ethnic groups? London: Office for
National Statistics.
Koffman, J., Fulop, N.J., & Pashley, D. (1997). Ethnicity and use of acute psychiatric beds:
One-day survey in North and South Thames regions. British Journal of Psychiatry, 171,
238–241.
Leeser, J., & O’Donohue, W. (1999). What is a delusion? Epistemological dimensions.
Journal of Abnormal Psychology, 108, 687–694.
Lewis, G., Croft-Jeffreys, C., & David, A. (1990). Are British psychiatrists racist?
British Journal of Psychiatry, 157, 410–415.
Maden, A., Friendship, C., McClintock, T., & Rutter, S. (1999). Outcome of admission to a
medium secure unit 2. Rule of ethnic origin. British Journal of Psychiatry, 175, 313–316.
McGoldrick, M., & Giordano, J. (1996). Overview: Ethnicity and family therapy. In M.
McGoldrick, J. Giordano, & J.K. Pearce (Eds.), Ethnicity and family therapy. London:
Guilford Press.
McKenzie, K. (2002). Reviews: Cultural sensitivity audit tool for mental health services.
Psychiatric Bulletin, 26, 239–240.
McKenzie, K., Samuel, C., Van Horn, E., Tattan, T., Van Os, J., & Murray, R. (2001).
Comparison of the outcome and treatment of psychosis in people of Caribbean origin
living in the UK and British whites. British Journal of Psychiatry, 179, 160–165.
Morgan, C., Mallett, R., Hutchinson, H., Bagalkote, K., Morgan, P., Kearon, P., et al. (2005).
Pathways to care and ethnicity. I: Sample characteristics and compulsory admission.
British Journal of Psychiatry, 186, 281–289.
National Institute for Mental Health in England. (2003). Inside outside: Improving mental
health services for black and minority ethnic communities in England. London:
Department of Health Publication.
Patel, K., Winters, M., Bashford, J., & Bingley, W. (2003). Engaging and Changing:
Developing effective policy for the care and treatment of black and minority ethnic
detained patients. London: Department of Health and National Institute for Mental Health
in England.
Rhi, B.Y. (2001). Culture, spirituality and mental health. Psychiatric Clinics of North
America, 24, 509–580.
Singh, S.P (2007). Institutional racism in psychiatry: Lessons from inquiries.
Psychiatric Bulletin, 31, 363–365.
Singh, S., Greenwood, N., White, S., & Churchill, R. (2007). Ethnicity and the Mental Health
Act (1983): A systematic review. British Journal of Psychiatry, 191, 99–105.
South London and Maudsley (SLAM) NHS Trust. (2002a). Race equality scheme (RES).
Retrieved April 5, 2006, from http://www.slam.nhs.uk/news/boardmin/
docs/23sept03/Racequalityscheme.doc
South London and Maudsley (SLAM) NHS Trust. (2002b). Race equality scheme (RES).
Retrieved April 5, 2006, from http://www.slam.nhs.uk/news/boardmin/
docs/30apr02/ethnicitydatasouth wark.doc
Southwark Community Health Council. (1999). Racialism in our mental health services? A
report on a conference organised by Southwark Community Health Council.
Stationary Office. (1999). Race Relations (Amendment) Act 2000: Chapter 34. Retrieved
May 6, 2006, from http://www.opsi.gov.uk/acts/acts2000/00034–a.htm The Sainsbury Centre
for Mental Health. (2001). The cultural sensitivity audit tool for
mental health services. Retrieved April 2, 2006, from www.scmh.org.uk
Wang, P.S., West, J.C., Tanielian, T., & Pincus, H.A. (2000). Recent patterns and predictors
of antipsychotic medication regimens used to treat schizophrenia and other psychotic
disorders. Schizophrenia Bulletin, 26, 451–457.