Ethnicity and detention: are Black and minority ethnic (BME) groups disproportionately detained under the Mental Health Act 2007?

A co-produced service evaluation of ethnic minority community service user experiences of a specialist mental health service during the COVID-19 pandemic

BACKGROUND

For ethnic minority communities in the UK, the COVID-19 pandemic amplified existing health inequalities and created other consequential disadvantages like increased vulnerability to COVID-19, higher rates of hospital admissions, increased mortality and poorer mental health outcomes. While longer-term impacts of COVID-19 are considered, it is crucial for NHS mental health services to understand the specific barriers and needs of ethnic minority communities to provide consistent and equitable access to mental health services. These aspects were the focus of a service evaluation of a Sussex-wide mental health service conducted in co-production with experts-by-experience, public members, health professionals and researchers from ethnic minority communities.

METHODS

Co-designed creative workshops (n = 13) and semi-structured qualitative interviews (n = 13) were used to explore experiences of accessing specialist mental health services during the COVID-19 pandemic. Participants were: Sussex Partnership NHS Foundation Trust (SPFT) service users recruited between October 2021 and January 2022; aged 16+; from ethnic minority community backgrounds. Data was analysed using Thematic Analysis.

RESULTS

The analysis yielded five overarching themes contextualising service users' experiences: (1) limited awareness of SPFT mental health services; (2) effects of COVID-19 in gaining access to SPFT; (3) SPFT reaching out to ethnic minorities; (4) being supported, 4a) hiding my mental health status from friends and families, 4b) lack of ethnic diversity in services, and 4c) better provision of information and support services, (5) relationship between childhood experiences and current mental health. These findings led to seven key recommendations for future service developments within SPFT.

CONCLUSIONS

Although this evaluation was set in the context of COVID-19, findings have highlighted specific mental health service needs for ethnic minorities that are applicable beyond the confines of the pandemic. Many benefited from online sessions seen as more inclusive. Mental health advocates, outreach and joint working with communities could help further reduce stigmatising attitudes and improve engagement with mental health services. Improved service awareness of the impact of childhood or historical traumas experienced by ethnic minority communities on current mental health, the role of cultural awareness training and availability of culturally adapted therapies is also needed. Many service improvement recommendations provided could impact all service users.

Codesigning a systemic discharge intervention for inpatient mental health settings (MINDS): a protocol for integrating realist evaluation and an engineering-based systems approach

INTRODUCTION

Transition following discharge from mental health hospital is high risk in terms of relapse, readmission and suicide. Discharge planning supports transition and reduces risk. It is a complex activity involving interacting systemic elements. The codesigning a systemic discharge intervention for inpatient mental health settings (MINDS) study aims to improve the process for people being discharged, their carers/supporters and staff who work in mental health services, by understanding, co-designing and evaluating implementation of a systemic approach to discharge planning.

METHODS AND ANALYSIS

The MINDS study integrates realist research and an engineering-informed systems approach across three stages. Stage 1 applies realist review and evaluation using a systems approach to develop programme theories of discharge planning. Stage 2 uses an Engineering Better Care framework to codesign a novel systemic discharge intervention, which will be subjected to process and economic evaluation in stage 3. The programme theories and resulting care planning approach will be refined throughout the study ready for a future clinical trial. MINDS is co-led by an expert by experience, with researchers with lived experience co-leading each stage.

ETHICS AND DISSEMINATION

MINDS stage 1 has received ethical approval from Yorkshire & The Humber-Bradford Leeds (Research Ethics Committee (22/YH/0122). Findings from MINDS will be disseminated via high-impact journal publications and conference presentations, including those with service user and mental health professional audiences. We will establish routes to engage with public and service user communities and National Health Service professionals including blogs, podcasts and short videos.

TRIAL REGISTRATION NUMBER

MINDS is funded by the National Institute of Health Research (NIHR 133013) https://fundingawards.nihr.ac.uk/award/NIHR133013. The realist review protocol is registered on PROSPERO.

PROSPERO REGISTRATION NUMBER

CRD42021293255.

Racial and Ethnic Inequities in Inpatient Psychiatric Civil Commitment

OBJECTIVE

Involuntary psychiatric treatment may parallel ethnoracial inequities present in the larger society. Prior studies have focused on restraint and seclusion, but less attention has been paid to the civil commitment system because of its diversity across jurisdictions. Using a generalizable framework, this study investigated inequities in psychiatric commitment.

METHODS

A prospective cohort was assembled of all patients admitted to an inpatient psychiatric unit over 6 years (2012-2018). Patients were followed longitudinally throughout their admission; raters recorded legal status each day. Sociodemographic and clinical data were collected to adjust for confounding variables by using multivariate logistic regression.

RESULTS

Of the 4,393 patients with an initial admission during the study period, 73% self-identified as White, 11% as Black, 10% as primarily Hispanic or Latinx, 4% as Asian, and 3% as another race or multiracial. In the sample, 28% were involuntarily admitted, and court commitment petitions were filed for 7%. Compared with White patients, all non-White groups were more likely to be involuntarily admitted, and Black and Asian patients were more likely to have court commitment petitions filed. After adjustment for confounding variables, Black patients remained more likely than White patients to be admitted involuntarily (adjusted odds ratio [aOR]=1.57, 95% confidence interval [CI]=1.26-1.95), as were patients who identified as other race or multiracial (aOR=2.12, 95% CI=1.44-3.11).

CONCLUSIONS

Patients of color were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalization, and Black patients and patients who identified as other race or multiracial were particularly vulnerable, even after adjustment for confounding variables.

Involuntary psychiatric hospitalizations in Israel 2001-2018 and risk for immigrants from different countries

Since 2000, the Israeli mental health system has undergone a reduction in hospital beds, initiation of community-based rehabilitation, and transfer of governmental services to health maintenance organizations. This study examined trends, predictors and outcomes of involuntary psychiatric hospitalizations (IPH), in particular for immigrants. All first psychiatric hospitalizations of adults, 2001-2018, in the National Psychiatric Case Registry were used. Involuntary and voluntary hospitalizations were analyzed by demographic and clinical characteristics, and age-adjusted rates calculated over time. Multivariate logistic regression models were used to investigate IPH predictors and first IPH as a risk factor for one-year suicide after last discharge, and a Cox multivariate regression model to examine its risk for all-cause mortality. Among 73,904 persons in the study, age-adjusted rates of IPH were higher between 2011 and 2015 and then decreased slightly until 2018. Ethiopian immigrants had the highest risk for IPH, immigrants from the former Soviet Union a lower risk, and that of Arabs was not significantly different, from non-immigrant Jews. IPH was not significantly associated with one-year suicide or all-cause mortality. These findings demonstrate the vulnerability of Ethiopian immigrants, typical of disadvantaged immigrants having a cultural gap with the host country and highlight the importance of expanding community mental health services.

Evidence for interventions to promote mental health and reduce stigma in Black faith communities: systematic review

PURPOSE

There are significant documented inequalities for the Black community in the UK in relation to mental health care. Research has also indicated that cultural difference exists in pathways into, and engagement with, mental health services. To reduce inequalities and improve engagement with mental health services, it is important that professionals utilise culturally appropriate community networks to increase mental health awareness and reduce stigma. This systematic review considers research in Black faith settings, with two linked aims to review the evidence for the effectiveness of (i) mental health interventions, and (ii) other health stigma interventions as the latter have been implemented in Black faith settings. The review identified 'active ingredients' of interventions for this population that can be applied in future work. The authors seek to draw from the mental health and wider health stigma literature to inform the design of the ON TRAC project, a collaborative partnership between King's College London, South London and Maudsley NHS Foundation Trust and Black faith community groups in Southwark and Lambeth, London, in this currently under-researched area.

METHODS

A systematic search of ten major medical and social sciences databases was conducted in 2019, for studies on mental health or other health stigma interventions in Black faith settings. PRISMA guidelines were followed and search terms and search strategy ensured all possible studies were identified for review.

RESULTS

The review identified sixteen studies for inclusion. Ten were quantitative studies, four qualitative studies and two systematic reviews. Active ingredients of interventions included utilisation of 'bottom up' development of approaches and mental health champions. Multiple factors were found to influence effective implementation. Co-production and partnership working are key to ensure that an acceptable and accessible intervention is agreed.

CONCLUSION

Evidence for the effectiveness of interventions focused on mental health awareness and stigma reduction in the Black faith community is limited due to the low quality of studies. This review sheds light on the lessons learnt and necessary key requirements for interventions that can guide future projects.

STUDY REGISTRATION

PROSPERO registration number: CRD42018110068.

The relationship between ingroup identity and Paranoid ideation among people from African and African Caribbean backgrounds

OBJECTIVES

People from ethnic minority groups experience higher rates of paranoid delusions compared with people from ethnic majority groups. Identifying with social groups has been shown to protect against mental health symptoms; however, no studies have investigated the relationship between social identification and paranoia in ethnic minority populations. Here, we investigated the association between British identification and paranoia in a sample of people from African and African Caribbean backgrounds living in the United Kingdom. We also assessed the role of potential mediating (self-esteem and locus of control) and moderating (contact with White British people) factors.

DESIGN

Cross-sectional quantitative survey design.

METHODS

We recruited 335 people from African and African Caribbean backgrounds who completed online self-report measures of identification with Great Britain, self-esteem, locus of control, positive and negative contact with White British people, and paranoia.

RESULTS

A parallel moderated mediation model indicated that British identification was associated with lower paranoia when participants experienced primarily positive contact with White British people. British identification was associated with higher paranoia when participants had primarily negative contact with White British people. Both effects were mediated by changes in locus of control, but self-esteem was not implicated in either pathway.

CONCLUSIONS

Identification with the majority culture is associated both positively and negatively with paranoid beliefs depending on the types of social interactions people experience. The findings have implications for preventative social prescribing initiatives and for understanding the causes of the high rates of psychosis in ethnic minority populations.

PRACTITIONER POINTS

People from African and African Caribbean backgrounds experience high rates of paranoia, which may stem from social causes such as lack of belonging and negative social experiences. Among people from African backgrounds living in the UK, British identification is associated with lower paranoia when people's social experiences with White British people are positive and higher paranoia when their social experiences with White British people are negative. It is recommended that social interventions designed to reduce paranoia in vulnerable groups foster positive social contact and community belonging, which should enhance feelings of personal control. Understanding the complex interplay between social identity and social contact in the development of paranoia may help therapists and researchers better understand the phenomenology and risk factors of paranoid symptomology.

Ethnicity and impact on the receipt of cognitive-behavioural therapy in people with psychosis or bipolar disorder: an English cohort study

OBJECTIVES

(1) To explore the role of ethnicity in receiving cognitive-behavioural therapy (CBT) for people with psychosis or bipolar disorder while adjusting for differences in risk profiles and symptom severity. (2) To assess whether context of treatment (inpatient vs community) impacts on the relationship between ethnicity and access to CBT.

DESIGN

Cohort study of case register data from one catchment area (January 2007-July 2017).

SETTING

A large secondary care provider serving an ethnically diverse population in London.

PARTICIPANTS

Data extracted for 30 497 records of people who had diagnoses of bipolar disorder (International Classification of Diseases (ICD) code F30-1) or psychosis (F20-F29 excluding F21). Exclusion criteria were: <15 years old, missing data and not self-defining as belonging to one of the larger ethnic groups. The sample (n=20 010) comprised the following ethnic groups: white British: n=10 393; Black Caribbean: n=5481; Black African: n=2817; Irish: n=570; and 'South Asian' people (consisting of Indian, Pakistani and Bangladeshi people): n=749.

OUTCOME ASSESSMENTS

ORs for receipt of CBT (single session or full course) as determined via multivariable logistic regression analyses.

RESULTS

In models adjusted for risk and severity variables, in comparison with White British people; Black African people were less likely to receive a single session of CBT (OR 0.73, 95% CI 0.66 to 0.82, p<0.001); Black Caribbean people were less likely to receive a minimum of 16-sessions of CBT (OR 0.83, 95% CI 0.71 to 0.98, p=0.03); Black African and Black Caribbean people were significantly less likely to receive CBT while inpatients (respectively, OR 0.76, 95% CI 0.65 to 0.89, p=0.001; OR 0.83, 95% CI 0.73 to 0.94, p=0.003).

CONCLUSIONS

This study highlights disparity in receipt of CBT from a large provider of secondary care in London for Black African and Caribbean people and that the context of therapy (inpatient vs community settings) has a relationship with disparity in access to treatment.

Mental health in hospital emergency departments: cross-sectional analysis of attendances in England 2013/2014

Objective

To describe the population of patients who attend emergency departments (ED) in England for mental health reasons.

Methods

Cross-sectional observational study of 6 262 602 ED attendances at NHS (National Health Service) hospitals in England between 1 April 2013 and 31 March 2014. We assessed the proportion of attendances due to psychiatric conditions. We compared patient sociodemographic and attendance characteristics for mental health and non-mental health attendances using logistic regression.

Results

4.2% of ED attendances were attributable to mental health conditions (median 3.2%, IQR 2.6% to 4.1%). Those attending for mental health reasons were typically younger (76.3% were aged less than 50 years), of White British ethnicity (73.2% White British), and resident in more deprived areas (59.9% from the two most deprived Index of Multiple Deprivation quintiles (4 and 5)). Mental health attendances were more likely to occur ‘out of hours’ (68.0%) and at the weekend (31.3%). Almost two-thirds were brought in by ambulance. A third required admission, but around a half were discharged home.

Conclusions

This is the first national study of mental health attendances at EDs in England. We provide information for those planning and providing care, to ensure that clinical resources meet the needs of this patient group, who comprise 4.2% of attendances. In particular, we highlight the need to strengthen the availability of hospital and community care ‘out of hours.’

"Crazy person is crazy person. It doesn't differentiate": an exploration into Somali views of mental health and access to healthcare in an established UK Somali community

Background

Mental health conditions have been shown to disproportionately affect those from Black, Asian and Minority Ethnic (BAME) communities. Somali communities globally have relatively high levels of mental illness, but low levels of mental health service use, with numerous barriers to care identified.

This study was conducted in an established UK Somali community in the South West of England and aimed to explore community beliefs and views about the causes of mental illness, treatment for mental illness, and access to medical services in general. Participants were asked about how mental health and illness are understood and conceptualised, along with the cultural meaning of mental illness and its manifestations in relation to men, women and young people.

Design

Using a community-based participatory research design, in partnership with local Somali community organisations, the research team conducted four focus groups with a total of 23 participants aged over 18. Open-ended questions were used to facilitate discussion. Transcripts were analysed thematically.

Results

The participants discussed the role of migration and associated stress from the civil war and how that could contribute to mental illness.

Participants tended to view the symptoms of mental illness as physical manifestations such as headaches and to describe a strong community stigma where those with mental health conditions were viewed as “crazy” by others. Barriers to accessing healthcare included language barriers, waiting times and a mistrust of doctors. Various ideas for improvements were discussed, including ideas to reduce stigma and ideas for community initiatives.

Conclusion

Cultural considerations and reducing stigma are vital in improving understanding of mental illness and improving access to mental health services, along with building relationships and trust between the Somali community and health care workers.

"Crazy person is crazy person. It doesn't differentiate": an exploration into Somali views of mental health and access to healthcare in an established UK Somali community

BACKGROUND

Mental health conditions have been shown to disproportionately affect those from Black, Asian and Minority Ethnic (BAME) communities. Somali communities globally have relatively high levels of mental illness, but low levels of mental health service use, with numerous barriers to care identified. This study was conducted in an established UK Somali community in the South West of England and aimed to explore community beliefs and views about the causes of mental illness, treatment for mental illness, and access to medical services in general. Participants were asked about how mental health and illness are understood and conceptualised, along with the cultural meaning of mental illness and its manifestations in relation to men, women and young people.

DESIGN

Using a community-based participatory research design, in partnership with local Somali community organisations, the research team conducted four focus groups with a total of 23 participants aged over 18. Open-ended questions were used to facilitate discussion. Transcripts were analysed thematically.

RESULTS

The participants discussed the role of migration and associated stress from the civil war and how that could contribute to mental illness. Participants tended to view the symptoms of mental illness as physical manifestations such as headaches and to describe a strong community stigma where those with mental health conditions were viewed as "crazy" by others. Barriers to accessing healthcare included language barriers, waiting times and a mistrust of doctors. Various ideas for improvements were discussed, including ideas to reduce stigma and ideas for community initiatives.

CONCLUSION

Cultural considerations and reducing stigma are vital in improving understanding of mental illness and improving access to mental health services, along with building relationships and trust between the Somali community and health care workers.

Length of stay among multi-ethnic psychiatric inpatients in the United Kingdom

BACKGROUND

Disproportionate rates of psychiatric admissions and length of stay (LOS)¹ have been repeatedly observed among Black and Minority Ethnic (BME)² groups with severe mental illness (SMI), specifically those of Black Caribbean heritage. Commensurate understanding of the mechanisms underlying this observation remains poorly understood, warranting further attention.

METHOD

A quasi-experimental retrospective cohort design was used to examine 11,617 psychiatric inpatient admissions in London, U.K. Variations in LOS across four ethnic groups (i.e., Black Caribbean, Black African, White British, and Asian) were recorded. Multivariate logistic regression was then used to determine the extent to which demographic (age, marital status, gender, homeless at admission), clinical (primary diagnosis, substance misuse), and behavioral variables (violent behavior, deliberate self-harm, victimization) explained any observed differences across ethnic groups.

RESULTS

Univariate analyses revealed that while Black Caribbean and African minority group admissions were significantly more likely to be a longer (>28 days) than shorter (≤28 days) LOS, White British admissions demonstrated the opposite association. After adjusting for demographic, clinical, and behavioral factors, the multivariate logistic regression only partially explained the association between Black Caribbean and African admissions and longer LOS compared to White British admissions. The regression model explained approximately 18% of the observed variance in LOS.

CONCLUSIONS

These findings indicate that additional variables, such as treatment, system related, and discrimination-based factors, should be examined to better understand the complex relationship between BME groups and LOS in order to improve the experience and outcomes of these vulnerable psychiatric populations.

Understanding increasing rates of psychiatric hospital detentions in England: development and preliminary testing of an explanatory model

BACKGROUND

The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.

AIMS

To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.

METHOD

Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.

RESULTS

Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.

CONCLUSIONS

Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Investigating police officers' perceptions of their role in pathways to mental healthcare

In the United Kingdom, one-in-four individuals with mental health problems access mental healthcare with police involvement. However, little is known about police officers' perceptions of their role in pathways to services. The aim of this study was to examine UK police officers' views and experiences of their involvement in mental healthcare, focusing on decision-making in emergency situations. Using volunteer sampling, we recruited 15 police officers from a large metropolitan conurbation in the North West of England. Semi-structured interviews, including a vignette depicting a mental health emergency, were used to elicit data. Interviews were transcribed verbatim and analysed at the manifest level using thematic analysis, yielding three main themes: 'Doing What's Right', 'Challenges of Working Together' and 'Training versus Experience'. Our findings indicate that, while police officers believe they have a duty of care to protect people in mental health emergencies, they sometimes lack relevant knowledge, skills and confidence in decision-making. Challenges associated with multi-agency working were also perceived as impeding officers' ability to effectively manage these emergencies. Our findings suggest that strengthening multi-agency working and improving training might positively influence police officers' views of their role and maximise their contribution to improving emergency mental healthcare.

Plant Fetish: A Creative Challenge to Mental Health Stigma

People of BAMME (Black, Asian, Minority, and Migrant ethnic) heritage in the UK experience various anomalies when engaging with mental health services. Typically concentrated at secondary and secure levels of care, these discrepant experiences interact with a reticence to uptake mental health support at the primary care level. Official, national anti-stigma campaigns often reproduce messages that do not connect with BAMME communities, raising questions about how best to challenge stigma in this context. This research paper describes a case study of an alternative means to address stigma, drawing from a dramatic comedy performance, Plant Fetish, written and performed by an artist who carries a diagnosis of complex post-traumatic stress disorder (Complex PTSD). The study comprised of an individual interview with the artist, audience feedback, and a group discussion conducted after the show. Data were subject to interpretative phenomenological analysis. Findings are discussed in relation to the importance of using creativity to increase public awareness of mental health and inform efforts to reduce stigma. We conclude that such approaches show promise and merit further exploration in a context of growing discursive interest in mental health amidst acknowledged deficiencies of contemporary anti-stigma efforts, especially as they apply to BAMME people, their families, and their communities.

A comparison of long-term medium secure patients within NHS and private and charitable sector units in England

BACKGROUND

In England, forensic psychiatric hospital services are provided at three security levels: high, medium and low. All are publicly funded and similarly regulated, but medium and low secure services are provided in the private and charitable (PCS) sector as well as the National Health Service (NHS). Originally, medium secure hospital services were conceived as for up to 2 years' inpatient stay, but numbers of longer stay patients have been rising. Little is known about their characteristics or whether they differ between NHS and PCS settings.

AIMS

To describe and compare characteristics of long-stay patients in NHS and in PCS medium security hospital units.

METHODS

Data were extracted from clinical records in 14 NHS and 9 PCS hospital units for all patients fulfilling criteria for long stay: having been in high security for more than 10 years or medium security for more than 5 years or in a mix of both for more than 15 years in total.

RESULTS

178 NHS and 107 PCS patients were eligible for inclusion, respectively, 16 and 22% of the total patient populations in these settings. The mean length of stay in a medium or high secure setting was similar: 163 and 164 months. Characteristics of the patients, however, differed between unit type. NHS services admitted more patients from prison and PCS services more from other hospitals. NHS services included a lower proportion of patients with personality disorder or intellectual disability. 'Challenging behaviour' was more prevalent in PCS; a history of absconding was found more often among NHS patients.

CONCLUSIONS

The two systems of service appear to be used differently. More research is needed to explain why patients apparently without behavioural disturbances remain in specialist secure facilities for such a long time and whether their needs are truly being met in the least restrictive environment possible.

Reasons behind the rising rate of involuntary admissions under the Mental Health Act (1983): Service use and cost impact

There has been a significant rise in the use of the Mental Health Act (1983) in England over the last 10 years. This includes both health-based Place of Safety detentions and involuntary admissions to NHS mental health facilities. Although these trends should clearly inform the implementation of mental health care and legislation, there is currently little understanding of what caused these increased rates. We therefore sought to explore potential underlying reasons for the increase in involuntary admissions and Place of Safety detentions and to ascertain the associated service costs. We extracted publicly available data to ascertain the observed number of involuntary admissions (Section 2 or 3) and health-based Place of Safety detentions in England between 1999/2000 and 2015/2016. A simple regression analysis then enabled us to compare observed admission rates with predicted rates, between 2008/2009 and 2015/2016. This prediction model was based on observed figures before 2008. We then generated a costing model for these rates and compared admission costs to alternative interventions. Finally, we added relevant covariates to the prediction model, to explore potential relationships with observed rates. Since 2008/2009, there has been a marked increase in the number of involuntary admissions (38%) and Place of Safety detentions (617%). The analysis revealed that for involuntary admissions, the period of greatest increase occurred after 2012, two years after austerity measures were implemented. For Place of Safety detentions, substantial rises were seen from 2008/2009 to 2015/2016, coinciding with the economic recession. The rise in Place of Safety detentions may have been worsened by a reduction in mental health bed availability. During the study period, involuntary admissions are estimated to have cost the English NHS £6.8 billion; with a further £120 million spent on Place of Safety detentions. This is approximately £597 million greater than predicted, had involuntary admissions continued to change at pre-2008 rates. We conclude that the rise in involuntary admissions, and to a lesser extent Place of Safety detentions, were associated with three specific impactful events: the economic recession, legislative changes and the impact of austerity measures on health and social care services. In addition to the extensive arguments presented elsewhere, there is also an urgent economic case for addressing this trend.

Late booking amongst African women in a London borough, England: implications for health promotion

The National Institute for Health and Clinical Excellence guidance is that a pregnant woman should see a midwife within the first 13 weeks into her pregnancy, in what is known as the 'booking appointment' or the 'full assessment' where she discusses with the midwife her care plan, medical and family histories and social circumstances. Significant numbers of black African women present after 13 weeks into the pregnancy. This study explores why black African women access the booking appointment after 13 weeks of pregnancy in a London borough. The study took a qualitative approach and used semi-structured interviews with 23 women who self-identified as black African migrants born in a sub-Saharan African country, and had experience of using ante-natal services in the borough. Participants discussed how their cultural understandings of pregnancy influenced timing of the booking appointment. The data was analysed using the thematic approach. Cultural, economic and political contexts within which they experienced pregnancy influenced the timing. Whilst acknowledging the benefits of early booking, this was said to be at odds with their cultural beliefs where pregnancy disclosure within 13 weeks was considered inappropriate. Lack of information about the booking appointment and unresolved immigration issues led to perceptions that they were being brought under the Immigration Department's radar through the booking appointment. Whilst most health promotion information regarding the booking appointment is designed in a top-down fashion, health planners should also recognize ethnic diversities so as to market the booking appointment using downstream approaches that take account of the cultural, political and economic contexts in which migrants/ethnic minority populations live.

Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

AIMS

To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

METHOD

Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

RESULTS

The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

CONCLUSIONS

Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

DECLARATION OF INTEREST

None.

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data

BACKGROUND

Evidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations.

METHODS

For this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137.

FINDINGS

Our search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03-3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62-3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07-1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22-4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21-1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages.

INTERPRETATION

BAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention.

FUNDING

University College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

The physical and mental health of acute psychiatric ward staff, and its relationship to experience of physical violence

To evaluate and describe the physical and mental health of staff on acute psychiatric wards and examine whether violence exposure is linked with health status. We undertook a cross-sectional survey with 564 nursing staff and healthcare assistants from 31 psychiatric wards in nine NHS Trusts using the SF-36, a reliable and valid measure of health status and compared summary scores with national normative data. Additional violence exposure data were collated simultaneously and also compared with health status. The physical health of staff was worse, and their mental health was better than the general population. Physical health data were skewed and showed a small number of staff in relatively poor health while the majority were above average. Better physical health was associated with less time in the current post, a higher pay grade, and less exposure to mild physical violence in the past year. Better mental health was associated with being older and from an ethnic minority background. Violence exposure influenced physical health but not mental health when possible confounders were considered. Mental health was strongly influenced by ethnicity, and further research might highlight the impact on own-group ethnic density on the quality of care. The impact of staff whom are physically unwell or impaired in the workplace needs to be considered as the quality of care may be compromised despite this being an example of inclusiveness, equal opportunities employment, and positive staff motivation.

The relationship between ethnicity and service access, treatment uptake and the incidence of psychosis among people at ultra high risk for psychosis

Black ethnicity is associated with increased risk for psychosis in South London. This study explored the distribution of ethnicity among services users at ultra high risk for psychosis (UHR) and examined the influence of ethnicity on service access, treatment uptake and incidence of psychosis. The ethnic distribution of 228 people at UHR for psychosis, seen in an early detection clinical service over 10 years, was compared with 146 people with first episode psychosis from the same geographic region and census figures for the local population. Black service users were significantly over-represented in the UHR group compared to the background population (34% vs 21%; p < 0.05); but less so than in the first episode sample (58% vs 19%; p < 0.05). Within the UHR sample, there was no strong evidence of differences between ethnic groups in the types of treatment provided, nor in the rate of transition to psychosis over 2 years. The absence of differences between ethnic groups in rates of transition to psychosis raises the possibility that access to mental health care at the high risk stage might have reduced the influence of ethnicity on the incidence of psychosis in this sample. This would need to be replicated in a larger sample.

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

BACKGROUND

As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales.

METHODS

Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses.

RESULTS

Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes.

CONCLUSIONS

Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform.

TRIAL REGISTRATION

CRD42017071663.

Effect of Job Strain on Job Burnout, Mental Fatigue and Chronic Diseases among Civil Servants in the Xinjiang Uygur Autonomous Region of China

Job strain is a major concern in view of its effects among civil servants associated with job burnout, mental fatigue and chronic diseases. The objective of this study was to assess the job strain level among civil servants and examine the effect of job strain on job burnout, mental fatigue and the resulting chronic diseases. A cross-sectional study with a representative sample consisting of 5000 civil servants was conducted from March to August 2014. Using a structured questionnaire, the job strain level, job burnout and mental fatigue were measured by using the Personal Strain Questionnaire (PSQ), Maslach Burnout Inventory (MBI) and Multidimensional Fatigue Inventory (MFI-20), respectively. Overall, 33.8% of the civil servants were found to be afflicted with high and moderate job strain. The characteristics of most of the civil servants with a higher-job strain level were as follows: female, Uygur, lower educational level and job title rank, shorter working experience, married marital status, and lower income level. Civil servants suffering from chronic disease mainly had hypertension and coronary heart disease, which accounted for 18.5% of the diseases. Civil servants with a high-job strain level exhibited higher rates of burnout, mental fatigue scores and incidence of chronic diseases. There was a multiple linear regression model composed of three predictor variables in job burnout, which accounted for 45.0% of its occurrence: female gender, lower-income level, higher-job strain in civil servants, the greater the rate of job burnout was. Four factors—male gender, lower-job title rank, higher-job strain, shorter-job tenure of civil servants—explained 25.0% of the mental fatigue model. Binary logistic regression showed that intermediate-rank employees (OR = 0.442, 95% CI: 0.028–0.634; p < 0.05), job tenure of 10–20 years (OR = 0.632, 95% CI: 0.359–0.989; p < 0.05), and low-job strain (OR = 0.657, 95% CI: 0.052–0.698; p < 0.05) were all associated with significantly lower odds of chronic disease. The risk of chronic disease was higher in civil servants with high-job burnout scores and mental fatigue scores compared with civil servants with lower scores (OR = 1.139, 95% CI: 1.012–3.198; OR = 1.697, 95% CI: 1.097–2.962). These data provide evidence for the effects of job strain on job burnout, mental fatigue and chronic diseases among civil servants.

Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis

BACKGROUND

The increasing rate of compulsory admission to psychiatric inpatient beds in England is worrying. Studying variation between places and services could be key to identifying targets for interventions to reverse this trend. We modelled spatial variation in compulsory admissions in England using national patient-level data and quantified the extent to which patient, local-area, and service-setting characteristics accounted for this variation.

METHODS

This study is a cross-sectional, multilevel analysis of the 2010-11 Mental Health Minimum Data Set (MHMDS). Data from eight provider trusts were excluded, including three independent provider trusts that lacked spatial identification codes. We excluded patients detained under sections of the Mental Health Act concerned only with conveyance to, or assessment in, a registered Place of Safety, or for short-term (≤72 h) assessment only, as these do not in themselves necessarily mean that the person will be admitted to an inpatient mental health bed. MHMDS contained reasonably complete data for a limited number of patient characteristics, namely age, sex, and ethnicity; however, several patient-level variables could not be included in our analysis because of high levels of missing data. Multilevel models were applied with MLwiN to estimate variation in compulsory admission, starting with null (unconditional) models that partitioned total variance in compulsory admission between each level in the model. The primary outcome was compulsory admission to a psychiatric inpatient bed, compared with people admitted voluntarily or receiving only community-based care.

FINDINGS

Data were available for 1 238 188 patients, covering 64 National Health Service provider trusts (93%) and 31 865 census lower super output areas (LSOAs; 98%). 7·5% and 5·6% of the variance in compulsory admission occurred at LSOA level and provider trust levels, respectively, after adjusting for patient characteristics. Black patients were almost three times more likely to be admitted compulsorily than were white patients (odds ratio [OR] 2·94, 95% CI 2·90-2·98). Compulsory admission was greater in more deprived areas (OR 1·22, 1·18-1·27) and in areas with more non-white residents (OR 1·51, 1·43-1·59), after adjusting for confounders.

INTERPRETATION

Rates of compulsory admission to inpatient psychiatric beds vary significantly between local areas and services, independent of patient, area, and service characteristics. Compulsory admission rates seem to reflect local factors, especially socioeconomic and ethnic population composition. Understanding how these factors condition access to, and use of, mental health care is likely to be important for developing interventions to reduce compulsion.

FUNDING

National Institute for Health Research Health Services and Delivery Research Programme.

A Mental Health Survey of Different Ethnic and Occupational Groups in Xinjiang, China

Poor mental health has become a serious social and public health-care burden. This cross-sectional study used multistage stratified cluster random sampling to gather mental health information from 11,891 adults (18-60 years) employed in various occupations categorized according to the Chinese Standard Occupational Classification. Mental health was measured by the General Health Questionnaire, and participants exceeding the cut-off score were defined as having poor mental health. The overall prevalence of poor mental health was 23.8%. The prevalence of poor mental health was significantly higher in the Han ethnic group than Kazak ethnic group and in health-care workers, teachers, and civil servants compared to manual workers. Females (odds ratios (OR) = 1.139, 95% confidence intervals (CI): 1.012-3.198) and knowledge workers (1.697, 1.097-2.962) were risk factors for poor mental health, while Kazak ethnicity (0.465, 0.466-0.937), other minority status (non-Han) (0.806, 0.205-0.987), and working ≥15 years in the same occupation (0.832, 0.532-0.932) were protective (p < 0.05). We concluded that the general level of mental health in Xinjiang, China, is higher in the Kazak ethnic group than the Han ethnic group. The prevalence of poor mental health is higher among knowledge workers than in manual workers due to high incidences of poor mental health in civil servants, health-care workers, and teachers.

The association between continuity of care and readmission to hospital in patients with severe psychosis

PURPOSE

Providing good continuity of care to patients is considered a vital component of community mental health services, but there is limited evidence that it is associated with good outcomes. We measured service use and a multidimensional concept of continuity of care in 323 patients who were to be discharged from hospital following compulsory treatment for psychosis to investigate the association between continuity and rehospitalisation.

METHODS

We conducted a 36-month prospective cohort study of the patients recruited to the Oxford Community Treatment Order Trial (OCTET). We collected data from medical records on eight previously operationalized measures of continuity. We conducted regression analyses to determine the association between these measures and readmission to hospital, time to readmission, and the number of days spent in hospital.

RESULTS

Almost two thirds (n = 206, 63.8%) of patients were readmitted. Patients were seen frequently, with a mean of 2.9 (SD = 2.47) contacts a month throughout the follow-up. Less frequent contact was significantly associated with lower odds of rehospitalisation and fewer days in hospital. More changes in the patient's care coordinator were associated with more time in hospital. Patients who had a higher proportion of clinical correspondence copied to them spent fewer days in hospital.

CONCLUSION

Patients with severe and relapsing psychotic illness are seen frequently and consistently in community mental health services. Higher levels of patient contact could be a response to the severity of illness rather than a marker of quality of care. Using a simple linear interpretation of contact frequency as a measure of continuity of care in this patient group may be of limited value in modern services.