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Ethnic inequalities have been demonstrated in severe mental illness experiences and outcomes. There is a long-standing literature on the higher incidence of schizophrenia and bipolar disorder particularly in African and Caribbean populations, but more generally in migrants and South Asians to a lesser extent. There are variations in pathways to care with greater coercive care and compulsory treatment in African and Caribbean patients that are not always explained by substance misuse or levels of violence and criminality. These findings have been sustained for a number of years but uncertainty about causation, the reading of the evidence and uncertainties and disputes, and how to intervene to prevent inequalities. One of the challenges has been disputes amongst professional networks, disciplines as well as within and across service user groups about causation and priority. Some have argued universal interventions are better, to improve healthcare of all parties. Others say that targeted interventions should be tested for better outcomes.  A substantial amount of evidence exists in practice and also in pilot studies on targeted interventions. Some of the disputed explanations for inequalities include social exclusion, poverty deprivation, ethnicity, urban life leading to higher incidence of psychosis as well resource strain in local services clustering with deprivation and ethnicity, leading to poorer service experience. Other sources of dispute include the nature of structural disadvantage and discrimination as applied to age, gender and ethnicity and whether societal disadvantage enters into the institutions and, therefore, into individual practice. Racism specifically has led to significant dispute by academics, clinicians, commissioners, policy makers and government, and even patient groups. There are quite different and contrasting ways of reading the evidence, conflating political ideologies and opinions with the evidence-leading to paralysis of any proposed actions. Over time, psychiatry has moved to a better neuroscientific and biomarker based understanding of causation and potential intervention. Is it possible that biomarkers for psychosocial adversity in general and racism in particular could be found to demonstrate differences across ethnic groups, not only in the total dose of psychosocial adversity but also in the responsivity to similar levels of adversity, given the historical legacies of disempowerment and identity politics are argued by social scientists to have a cumulative effect. I hope to present the challenges of work in this area but also potential solutions based on better research taking advantage of the revolution in neuroscientific and biomarker based research with some examples. I hope to provoke some thought about new research lines and potential collaborations.

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