Professor Tyrer's editorial (Reference Tyrer2005) is welcome and long overdue. He highlights a serious inequality between the contributions of authors from the industrialised and non-industrialised world. What Professor Tyrer failed to discuss is a more deeply imbedded problem of the institutionalised racism that lies at the heart of the conceptual systems we use in psychiatry. This is, of course, an understandably even harder and more painful issue for our profession to face; it is, however, necessary that we examine the potential for the concepts that we use to be inherently discriminatory.

For example, is the consistently higher rate of diagnosis of schizophrenia in second-generation British-Carribean people a result of incorrect diagnosis, or the potential for a reductionistic biomedical model of mental health to label whole communities as ‘mad’ with the resulting stigma these communities then suffer (as well as masking from us the impact of social issues such as immigration and racism)? Another example relates to the concept of depression, which is meaningless in some cultures. What impact does imposing a meaningless diagnosis have on someone's willingness and motivation to engage with services? This obviously has the potential to discriminate in a subtle way against whole communities on their ability to develop meaningful relationships with their treating psychiatrists.

We should not be surprised that there are inherently racist concepts embedded in our ‘institutionalised’ ways of thinking about mental health problems, how to conceptualise them, what to do about them, and what value system we take into our daily practice. Mental health ideology and technology have developed not as the result of the discovery of testable physical pathology, but through a system of consensus resulting from powerful psychiatrists' interpretation of the existing evidence. These psychiatrists have carried their own cultural assumptions (derived from the dominant Western culture) without apparently being aware of this, and developed a system thinking and acting for psychiatrists based on these Western cultural ideals. Thus, from its conception, modern psychiatry has been imposing these Western, culturally constructed ideas on communities who have very different models for understanding mental health problems and what to do about them.

Sadly, I am not sure how ready our profession is to engage in some self-reflection and a thorough re-examination of these issues. I guess that may be just too painful; however, if we do not do this, we will not get rid of the scourge of institutional racism from our profession.