I read with great interest Lelliot et al's (2001) survey of patients from an inner-London health authority in medium secure psychiatric care. In particular, the authors set out to compare Black and White patients and found statistical differences which they dismiss. The scores on the Health of the Nation Outcome Scales and compound variables of clinical behaviour and social function differed between Black and White patients, but Lelliot et al comment that these may not be clinically significant.

If statistically significant findings on scales used in the study need not be explained, then the instruments cannot be considered valid to address the third aim of the study, to compare Black and White patients. Black patients were significantly less morbid on a number of clinical, social and behavioural variables, including affective symptoms, activities of daily living, problems with living skills, relationship problems and other mental or behavioural problems of self-harm and overactive and aggressive behaviour. Why should Black patients with less severe psychopathology or aggressive behaviour continue to find themselves in medium secure units?

There are two possible explanations. One is non-engagement with treatment options in less secure environments. It is known that Black patients are more likely to abscond from in-patient units (Reference Falkowski, Watts and FalkowskiFalkowski et al, 1990) and that they are increasingly dissatisfied with each consecutive in-patient admission (Reference Parkman, Davies and LeeseParkman et al, 1997).

An alternative explanation is that Black patients are perceived to be more dangerous despite lower ratings of psychopathology (Reference Cope, Bluglass and BowdenCope, 1990; Reference Lewis, Croft-Jeffreys and DavidLewis et al, 1990). Lelliot et al unfortunately dismiss important findings as clinically insignificant. These very findings warrant further research and exploration and such work may well deliver a better understanding of why Black people are over-represented in secure psychiatric facilities.