Ethnic minority inequalities in access to treatments for schizophrenia and schizoaffective disorders: findings from a nationally representative cross-sectional study

Understanding clozapine-related blood dyscrasias. Developments, genetics, ethnicity and disparity: it's a CIN

Clozapine remains the gold standard intervention for treatment-resistant schizophrenia; however, it remains underused, especially for some minority groups. A significant impediment is concern about propensity to neutropenia. The aim of this article is to provide an update on current knowledge relating to: the pattern and incidence of severe blood dyscrasias; the effectiveness of current monitoring regimes in reducing harm; the mechanisms of and the distinctions between clozapine-induced neutropenia and agranulocytosis; benign ethnic neutropenia; and changes to the monitoring thresholds in the USA and other international variations. These all have implications for the practical use of clozapine; specifically, how barriers to initiating, maintaining and restarting clozapine can be understood and in many cases overcome, especially for patients from minority groups, potentially with simpler approaches than the use of lithium or G-CSF.

Differences in schizophrenia treatments by race and ethnicity-analysis of electronic health records

Racial disparities in prescriptions of anti-psychotics have been highlighted before. However, (i) the evidence on other medications, including anti-depressant or mood stabilizing medications is lacking, and (ii) the role of potentially confounding factors and (iii) specificity of such disparities to schizophrenia (SCZ), are still unknown. We used electronic health records (EHRs) from 224,212 adults to estimate the odds ratios of receiving a prescription for different nervous system medications among patients with SCZ of different race/ethnicity, and analogous linear models to investigate differences in prescribed medication doses. To verify specificity of the observed patterns to SCZ, we conducted analogous analyses in depression and bipolar disorder (BD) patients. We found that Black/African American (AA) and Hispanic patients with SCZ were more likely to be prescribed haloperidol (Black/AA: OR = 1.52 (1.33-1.74); Hispanic: OR = 1.32 (1.12-1.55)) or risperidone (Black/AA: OR = 1.27 (1.11-1.45); Hispanic: OR = 1.40 (1.19-1.64)), but less likely to be prescribed clozapine (Black/AA: OR = 0.40 (0.33-0.49); Hispanic: OR = 0.45 (0.35-0.58)), compared to white patients. There were no race/ethnicity-related differences in the prescribed medication doses. These patterns were not specific to SCZ: Asian, Hispanic and Black/AA patients with BD or depression were more likely to be prescribed anti-psychotics, but less likely to be prescribed antidepressants or mood-stabilizers. In conclusion, we found racial/ethnic disparities in the medications prescribed to patients with SCZ and other psychiatric conditions. We discuss the potential implications for the quality of care for patients of diverse races/ethnicities.

Investigating the acceptability of a culturally adapted acceptance and commitment therapy group for UK Vietnamese communities: A practice-based feasibility study

Acceptance and Commitment Therapy (ACT) is an empirically supported psychotherapy that offers promise for the mental health of minoritised ethnic populations. Given the diversity of those presenting to inner-city services and barriers to accessing appropriate mental healthcare, we sought to develop a culturally syntonic ACT intervention for UK Vietnamese refugee communities in a practice-based partnership project between a National Health Service and local third-sector service in East London. The aim was to explore the feasibility, acceptability and impact of the adapted intervention to inform culturally inclusive clinical practice and future research. We outline key aspects of Vietnamese belief systems and culture, and consider how these might influence the optimisation of group-based ACT. We then present a mixed-method evaluation of the seven-session adapted ACT group for 11 participants (9 male and 5 female, aged between 44 and 73 years). Individual-level change analyses indicated clinically significant improvements in psychological flexibility for the minority of participants and a mixed pattern for impact on well-being. A thematic analysis and descriptive approach examined acceptability, feasibility and narratives of impact. Participants reported positive feedback on group experience, relevance and usefulness, and emergent themes indicate that the group facilitated key acceptance, commitment and behaviour-change processes, promoted social connections and increased engagement in meaningful life activities in relation to new perspectives and values-based action. Limitations are outlined, but overall, findings suggest preliminary support for the potential beneficial effect of the adapted ACT group as a feasible, culturally acceptable therapeutic approach for UK Vietnamese communities that is worthy of further investigation.

Racial Disparities in Clozapine Prescription Patterns Among Patients With Schizophrenia

OBJECTIVE

Previous research has suggested that demographic factors affect the likelihood of a patient with schizophrenia receiving a clozapine prescription. The authors aimed to determine the impact of race, social determinants of health, gender, rurality, and care patterns on clozapine prescription rates.

METHODS

This cross-sectional observational study used structured electronic health records data from 3,160 adult patients diagnosed as having schizophrenia between October 1, 2015, and November 30, 2021, in a multifacility health system. The social vulnerability index (SVI) was used to quantify social determinants of health. Descriptive data analysis, logistic regression, and sensitivity analysis were conducted to identify differences between patients with schizophrenia who received a clozapine prescription and those who received antipsychotic medications other than clozapine.

RESULTS

Overall, 401 patients with schizophrenia were given a clozapine prescription during the study period, and 2,456 received antipsychotics other than clozapine. Results of the logistic regression indicated that White race (OR=1.71, compared with Black race), community minority status and language SVI score (OR=2.97), and increased treatment duration (OR=1.36) were significantly associated with a higher likelihood of clozapine prescription; gender, rurality, age at first diagnosis, and ethnicity did not influence the likelihood of receiving clozapine.

CONCLUSIONS

Black patients with schizophrenia had a lower likelihood of receiving a clozapine prescription compared with White patients, even after analyses accounted for demographic variables, social determinants of health, and care access patterns. Given the effectiveness of clozapine in managing treatment-resistant schizophrenia, it is crucial for future research to better understand the factors contributing to this treatment disparity.

Ethnic differences in receipt of psychological interventions in Early Intervention in Psychosis services in England - a cross-sectional study

There is some evidence of differences in psychosis care provision by ethnicity. We investigated variations in the receipt of Cognitive Behavioural Therapy for psychosis (CBTp) and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all. We included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression analyses to examine odds ratios of receiving an intervention (CBTp, family intervention, either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload, inequalities strategies). Compared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had significantly lower adjusted odds of receiving CBTp. People of Black African, Black Caribbean, non-African/Caribbean Black, non-British/Irish White, and of "any other" ethnicity also experienced significantly lower adjusted odds of receiving family intervention. Pervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority.

Racial disparities in utilization of first-generation versus second-generation long-acting injectable antipsychotics in Medicaid beneficiaries with schizophrenia

BACKGROUND

Multiple studies report racial disparities in antipsychotic prescription patterns. This study assessed demographic and clinical factors associated with the utilization of first-generation (FG) versus second-generation (SG) long-acting injectable (LAI) antipsychotics.

METHODS

This retrospective, observational cohort analysis used claims data from the IBM MarketScan® Multi-State Medicaid database. The study included adults with an LAI claim between 01-January-2009 and 31-December-2018, an ICD-9-CM or ICD-10-CM diagnosis of schizophrenia, race recorded as Black or White, and ≥12 months of continuous enrollment before the index LAI. Descriptive analysis detailed the relationship between race and FG or SG LAI initiation. Multivariate logistic regression was used to assess potential associations with FG vs. SG LAI initiation, including clinical and demographic factors, comorbidities, and index year.

RESULTS

A total of 10,773 patients were included: 6659 (62 %) Black and 4114 (38 %) White. Black patients had a higher utilization of FG LAIs than White patients (46.8 % vs. 38.9 %) over the 10 years analyzed. Black patients were more likely to utilize FG LAIs than White patients (odds ratio: 1.47; 95 % CI: 1.34, 1.62) after controlling for index year and covariates (race, age, gender, insurance plan type, Quan-Charlson Comorbidity index score, comorbidities, prior medications). Significant predictors of FG LAI utilization were older age, type of baseline oral antipsychotic (FG vs SG), type of coverage (managed care vs fee for service), and greater comorbidity burden.

CONCLUSION

The utilization of FG LAIs was greater in Black compared to White Medicaid beneficiaries with schizophrenia over a 10-year period. These findings suggest that racial disparities exist in LAI initiation, with implications for differential quality of schizophrenia treatment.

How is ethnicity reported, described, and analysed in health research in the UK? A bibliographical review and focus group discussions with young refugees

BACKGROUND

The ethnicity data gap pertains to 3 major challenges to address ethnic health inequality: 1) Under-representation of ethnic minorities in research; 2) Poor data quality on ethnicity; 3) Ethnicity data not being meaningfully analysed. These challenges are especially relevant for research involving under-served migrant populations in the UK. We aimed to review how ethnicity is captured, reported, analysed and theorised within policy-relevant research on ethnic health inequities.

METHODS

We reviewed a selection of the 1% most highly cited population health papers that reported UK data on ethnicity, and extracted how ethnicity was recorded and analysed in relation to health outcomes. We focused on how ethnicity was obtained (i.e. self reported or not), how ethnic groups were categorised, whether justification was provided for any categorisation, and how ethnicity was theorised to be related to health. We held three 1-h-long guided focus groups with 10 young people from Nigeria, Turkistan, Syria, Yemen and Iran. This engagement helped us shape and interpret our findings, and reflect on. 1) How should ethnicity be asked inclusively, and better recorded? 2) Does self-defined ethnicity change over time or context? If so, why?

RESULTS

Of the 44 included papers, most (19; 43%) used self-reported ethnicity, categorised in a variety of ways. Of the 27 papers that aggregated ethnicity, 13 (48%) provided justification. Only 8 of 33 papers explicitly theorised how ethnicity related to health. The focus groups agreed that 1) Ethnicity should not be prescribed by others; individuals could be asked to describe their ethnicity in free-text which researchers could synthesise to extract relevant dimensions of ethnicity for their research; 2) Ethnicity changes over time and context according to personal experience, social pressure, and nationality change; 3) Migrants and non-migrants' lived experience of ethnicity is not fully inter-changeable, even if they share the same ethnic category.

CONCLUSIONS

Ethnicity is a multi-dimensional construct, but this is not currently reflected in UK health research studies, where ethnicity is often aggregated and analysed without justification. Researchers should communicate clearly how ethnicity is operationalised for their study, with appropriate justification for clustering and analysis that is meaningfully theorised. We can only start to tackle ethnic health inequity by treating ethnicity as rigorously as any other variables in our research.

Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records

BACKGROUND

Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors.

METHODS

This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription).

RESULTS

The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group.

CONCLUSIONS

Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.

Examining racial disparity in psychotic disorders related ambulatory care visits: an observational study using national ambulatory medical care survey 2010-2015

BACKGROUND

One of the most consistent research findings related to race and mental health diseases is the disproportionately high rate of psychotic disorder diagnoses among people of color, specifically people of African descent. It is important to examine if a similar pattern exists among specific psychotic disorders. We aimed to examine the racial/ethnic differences in ambulatory care visits diagnosed with schizophrenia-spectrum disorders (SSDs).

METHODS

We analyzed data from the National Ambulatory Medical Care Survey (NAMCS) 2010-2015. The study sample included physician office-based visits by individuals diagnosed with SSDs, including schizophrenia, schizoaffective, and unspecified psychotic disorder (n = 1155). We used descriptive and bivariate analysis by race/ethnicity and three multinomial logistic regression models to test the association between the SSDs and race/ethnicity, adjusting for age, gender, insurance, disposition, medication Rx, and co-morbidity, considering the design and weight.

RESULT

Of the 1155 visits for SSDs, 44.8% had schizophrenia, 37.4% had schizoaffective disorder diagnosis, and 19.0% had unspecified psychosis disorder. We found significant racial disparities in the diagnosis of SSDs. Black patients were overrepresented in all three categories: schizophrenia (24%), schizoaffective disorder (17%), and unspecified psychosis disorder (26%). Also, a notable percentage of Black patients (20%) were referred to another physician in cases of schizophrenia compared to other ethnoracial groups (p < 0.0001). Moreover, we found a significant disparity in insurance coverage for schizoaffective disorder, with a higher percentage of Black patients (48%) having Medicaid insurance compared to patients from other ethnoracial groups (p < 0.0001). Black patients had nearly twice the odds of receiving a diagnosis of schizophrenia compared to White patients [AOR = 1.94; 95% CI: 1.28-2.95; P = 0.001]. However, they had significantly lower odds of being diagnosed with schizoaffective disorder [AOR = 0.42, 95% CI: 0.26-0.68; P = 0.003]. Race/ethnicity was not associated with receiving an unspecified psychosis disorder.

CONCLUSIONS

Our results show that SSDs, more specifically schizophrenia, continue to burden the mental health of Black individuals. Validation of our findings requires rigorous research at the population level that reveals the epidemiological difference of SSDs diagnoses in different race/ethnicity groups. Also, advancing our understanding of the nature of disparity in SSDs diagnoses among the Black population requires disentangling etiologic and systemic factors in play. This could include psychological stress, the pathway to care, services use, provider diagnostic practice, and experiencing discrimination and institutional and structural racism.

Community, Hospital, and Patient Factors Contributing to Ethnoracial Disparities in Follow-Up After Psychiatric Hospitalization

OBJECTIVE

This study used an ecosocial perspective to examine ethnoracial disparities in timely outpatient follow-up care after psychiatric hospitalization in a cohort of Medicaid recipients.

METHODS

This retrospective analysis used 2012-2013 New York State Medicaid claims data for 17,488 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. Claims data were linked to other administrative data sets capturing key social conditions and determinants of mental health for non-Latinx White (White hereafter), non-Latinx Black (Black), Latinx, non-Latinx Asian/Pacific Islander (Asian/Pacific Islander), non-Latinx American Indian or Native Alaskan (American Indian or Native Alaskan), and other ethnoracial groups. Regression models were used to estimate the variations in disparities in timely follow-up care that were attributable to community, organization (i.e., hospital), and individual patient characteristics.

RESULTS

Overall, 60.1% of patients attended an outpatient mental health visit within 30 days of discharge. Compared with the rate for White patients, the attendance rates were 9.5 percentage points lower for Black patients and 7.8 percentage points higher for Asian/Pacific Islander patients. No significant difference in attendance rates was found between Latinx and White patients. Community factors, specifically urban versus rural classification and county poverty status, accounted for the greatest variation in timely follow-up care in all comparisons.

CONCLUSIONS

Efforts to increase connection to outpatient mental health follow-up care after psychiatric hospitalization should incorporate cultural and structural competencies to address social conditions and determinants of mental health that underly ethnoracial disparities.

Conceptualising mental illness among University students of African, Caribbean and similar ethnic heritage in the United Kingdom

OBJECTIVE

Students of African, Caribbean and similar ethnicity (ACE) encounter unique mental health challenges within the Western higher education system, such as feeling constrained in social spaces and perceiving greater stigma about mental health. Students of ACE are also resilient to mental health problems, such as depression, when enduring social inequality. This study aimed to conceptualise mental illness and help-seeking behaviours among university students in the United Kingdom (UK) in the context of their identity as ACE.

DESIGN

Six university students of ACE in the UK were interviewed about the meaning of mental illness, the influence of ACE culture on mental health and help-seeking by ACE students. Thematic analysis was applied from a socio-constructionist theoretical lens to interpret the interview transcripts.

RESULTS

Five main themes emerged, namely 'Perceived meanings and attitudes toward mental health problems', 'Beliefs about the non-existence of mental health problem and its spiritual attributions', 'Family dynamics and the 'silencing' of mental health problems', 'Help-seeking for mental health among people of ACE' and 'Stigma and discriminatory responses to mental health issues'. Participants expressed that mental health is an imported concept that people from ACE communities tend to shy away from. A reluctance to discuss mental health problems arose over fear of rejection from families and fear of not being understood by a mental health professional from a different cultural background.

CONCLUSION

University students of ACE and their families struggle to adopt the Western conceptualisation of mental health. Consequently, there is poor awareness of mental health issues and stigma of mental illness among university students of ACE which pose a barrier to help-seeking for mental health. The limited sample size constrains the ability to draw sound conclusions. Nonetheless, a culturally sensitive conceptualisation of mental health is needed to address poor help-seeking for mental health among people of ACE.

Ethnic differences in response to atypical antipsychotics in patients with schizophrenia: individual patient data meta-analysis of randomised placebo-controlled registration trials submitted to the Dutch Medicines Evaluation Board

BACKGROUND

Little is known about the effect of ethnicity on the response to antipsychotic medication in patients with schizophrenia.

AIMS

To determine whether ethnicity moderates the response to antipsychotic medication in patients with schizophrenia, and whether this moderation is independent of confounders.

METHOD

We analysed 18 short-term, placebo-controlled registration trials of atypical antipsychotic medications in patients with schizophrenia (N = 3880). A two-step, random-effects, individual patient data meta-analysis was applied to establish the moderating effect of ethnicity (White versus Black) on symptom improvement according to the Brief Psychiatric Rating Scale (BPRS) and on response, defined as >30% BPRS reduction. These analyses were corrected for baseline severity, baseline negative symptoms, age and gender. A conventional meta-analysis was performed to determine the effect size of antipsychotic treatment for each ethnic group separately.

RESULTS

In the complete data-set, 61% of patients were White, 25.6% of patients were Black and 13.4% of patients were of other ethnicities. Ethnicity did not moderate the efficacy of antipsychotic treatment: pooled β-coefficient for the interaction between treatment and ethnic group was -0.582 (95% CI -2.567 to 1.412) for mean BPRS change, with an odds ratio of 0.875 (95% CI 0.510-1.499) for response. These results were not modified by confounders.

CONCLUSIONS

Atypical antipsychotic medication is equally effective in both Black and White patients with schizophrenia. In registration trials, White and Black patients were overrepresented relative to other ethnic groups, limiting the generalisability of our findings.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation

PURPOSE

Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.

METHODS

A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.

RESULTS

Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.

CONCLUSIONS

The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

Comparison of Black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use

BACKGROUND

While there is increasing recognition of disparities in healthcare for Black Americans, there have been no comparisons in a nationally representative U.S. sample of Black and White adults with clinical diagnoses of schizophrenia.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we compared Black (n = 240, 36.2%) and White (n = 423, 63.8%) adults who report having been told by a physician that they have schizophrenia. Due to the large sample size, effect sizes (risk ratios and Cohen's d), rather than p-values, were used to identify the magnitude of differences in sociodemographic and clinical characteristics, including experiences of discrimination and service use. Multivariate analyses were used to identify independent factors.

RESULTS

Black individuals with diagnoses of schizophrenia reported multiple sociodemographic disadvantages, including lower rates of employment, educational attainment, income, marriage, and social support, with little difference in incarceration, violent behavior, and quality of life. They reported much higher scores on a general lifetime discrimination scale (Cohen's d = 0.75) and subscales representing job discrimination (d = 0.85), health system discrimination (d = 0.70), and public race-based abuse (d = 0.55) along with higher rates of past year alcohol and drug use disorders, but lower rates of co-morbid psychiatric disorders. Multivariable-adjusted regression analyses highlighted the independent association of Black race with measures of discrimination and religious service attendance; less likelihood of receiving psychiatric treatment (p = 0.02) but no difference in substance use treatment.

CONCLUSION

Black adults with schizophrenia report numerous social disadvantages, especially discrimination, but religious service attendance may be an important social asset.

Continuity of antipsychotic medication use among migrant and Finnish-born populations with a psychotic disorder: a register-based study

BACKGROUND

Higher incidence of psychotic disorders and underuse of mental health services have been reported among many migrant populations. This study examines the initiation and continuity of antipsychotic treatment among migrants and non-migrants with a non-affective psychosis during a new treatment episode.

METHODS

This study is based on a nationwide sample of migrants and Finnish-born controls. Participants who were diagnosed with a psychotic disorder in 2011-2014 were identified from the Care Register for Health Care (n = 1693). Information on purchases of antipsychotic drugs in 2011-2015 was collected from the National Prescription Register. The duration of antipsychotic treatment since diagnosis was estimated using the PRE2DUP model. Cox regression analysis was used to study factors that are associated with discontinuing the use of medication.

RESULTS

There were fewer initiators of antipsychotic treatment after being diagnosed with psychosis among migrants (68.1%) than among Finnish-born patients (73.6%). After controlling for sociodemographic background and factors related to the type of disorder and treatment, migrants were more likely to discontinue medication (adjusted hazard ratio 1.28, 95% confidence interval 1.08-1.52). The risk of discontinuation was highest among migrants from North Africa and the Middle East and Sub-Saharan Africa and among recent migrants. Non-use of antipsychotic treatment before being diagnosed with psychosis, involuntary hospitalization and diagnosis other than schizophrenia were associated with earlier discontinuation both among migrants and non-migrants.

CONCLUSIONS

Migrants with a psychotic disorder are less likely to continue antipsychotic treatment than non-migrants. The needs of migrant patients have to be addressed to improve adherence.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Adapting to the COVID-19 Pandemic: A Psychological Crisis Support Call Service Within a Community Mental Health Team

To mitigate potential mental health crises within a Community Mental Health Team (CMHT) the psychology department implemented a short-term, rapid access, crisis telephone support service for clients during the COVID-19 pandemic. We aimed to evaluate the feasibility and acceptability. Data was collected on who the service was offered to and whom engaged. Demographic information, referral and crisis support call information was collected from the service's electronic database. Forty-four participants were referred to the service. Seventy seven percent of participants engaged in one or more telephone sessions. Participants rated the service as highly useful, with simply 'talking to someone' seen as the most important aspect of the calls. A number of age differences were noted regarding the content that was discussed in sessions. The psychological crisis telephone support service was feasible and acceptable to service users during the COVID-19 pandemic.

Ethnic inequalities in involuntary admission under the Mental Health Act: an exploration of mediation effects of clinical care prior to the first admission

BACKGROUND

Studies show ethnic inequalities in rates of involuntary admission and types of clinical care (such as psychological therapies). However, few studies have investigated if there is a relationship between clinical care practices and ethnic inequalities in involuntary admission.

AIMS

This study investigated the impact of ethnicity and clinical care on involuntary admission and the potential mediation effects of prior clinical care.

METHOD

In this retrospective cohort study, we used data from the electronic records of the South London and Maudsley NHS Foundation Trust and identified patients with a first hospital admission between January 2008 and May 2021. Logistic regression and mediation analyses were used to investigate the association between ethnicity and involuntary admission, and whether clinical care, in the 12 months preceding admission, mediates the association.

RESULTS

Compared with White British people, higher odds of involuntary admission were observed among 10 of 14 minority ethnic groups; with more than twice the odds observed among people of Asian Chinese, of Asian Bangladeshi and of any Black background. There were some ethnic differences in clinical care prior to admission, but these had a minimal impact on the inequalities in involuntary admission. More out-patient appointments and home treatment were associated with higher odds of involuntary admission, whereas psychological therapies and having a care plan were associated with reduced odds of involuntary admission.

CONCLUSIONS

Ethnic inequalities in involuntary admission persist after accounting for potential mediating effects of several types and frequencies of clinical care. Promoting access to psychological therapies and ensuring that care plans are in place may reduce involuntary admissions.

Ethnic disparities in clozapine prescription for service-users with schizophrenia-spectrum disorders: a systematic review

Clozapine is the only licenced medication for treating treatment-resistant schizophrenia. Previous studies have suggested unequal rates of clozapine treatment by ethnicity among individuals with schizophrenia-spectrum disorders. One previous review has investigated this topic but was restricted to studies from the USA. This current review aims to synthesise the international literature regarding ethnic disparities in clozapine prescription amongst individuals with schizophrenia-spectrum disorders. We searched CINAHL, PubMed, Medline, Embase, APA PsycINFO and Open Grey and reviewed studies reporting on the proportion of service-users prescribed clozapine separately for different ethnic groups, in individuals with a primary diagnosis of schizophrenia or any schizophrenia-spectrum disorders. A narrative synthesis was conducted to integrate information from included studies. The review was registered in PROSPERO (Number: CRD42020221731). From 24 studies, there is strong, consistent evidence that Black and Hispanic service-users in the UK and the USA are significantly less likely to receive clozapine than White/Caucasian service-users after controlling for multiple demographic and clinical potential confounders. In New Zealand, Māori service-users were reported to be more likely to receive clozapine than those of White/European ethnicity. There is mixed evidence regarding Asian service-users in the UK. The mentioned disparities were observed in studies with TRS and non-TRS cohorts. The results imply that access to clozapine treatment varies among ethnic groups. These findings raise an ethical concern as they suggest a compromise of the standards of care in schizophrenia treatment practices. Interventions are needed to reduce clozapine prescribing disparities among ethnic communities.

Ethnic inequalities in clozapine use among people with treatment-resistant schizophrenia: a retrospective cohort study using data from electronic clinical records

PURPOSE

Clozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder.

METHODS

A retrospective cohort study, using information from 11 years of clinical records (2007-2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use.

RESULTS

Among 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine.

CONCLUSION

Black service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.

A Systematic Review of Inequalities in the Mental Health Experiences of Black African, Black Caribbean and Black-mixed UK Populations: Implications for Action

BACKGROUND

Measurable differences in the experience and treatment of mental health conditions have been found to exist between different racial categories of community groups. The objective of this research was to review the reported mental health of Black African-Caribbean communities in the UK, determinants of mental health, and interventions to enhance their experiences of mental health services.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was applied. To be included, papers must be published in a peer reviewed journal; report on adult populations (over 18) from any of Black African, Black Caribbean or Black mixed people in the UK; and assess (quantitative), or discuss (qualitative) mental health experiences, determinants of mental health, or interventions intended to enhance experiences of mental health services among the target population. The aims, inclusion criteria, data extraction, and data quality evaluation were specified in advance. Searches were conducted using EBSCO (PsychInfo; MEDLINE; CINAHL Plus; psychology and behavioural sciences collection). The search strategy included search terms relating to the aim. Risk of bias was assessed using a standard tool, records were organised using Endnote, and data were extracted and synthesised using Microsoft Excel.

RESULTS

Thirty-six studies were included, of which 26 were quantitative and six reported exclusively on Black participants. Black populations were less likely to access mental health support via traditional pathways due to stigma and mistrust of mental health services. Black Africans especially, sought alternative help from community leaders, which increased the likelihood of accessing treatment at the point of crisis or breakdown, which in turn increased risk of being detained under the Mental Health Act and via the criminal justice system.

DISCUSSION

Findings suggest a cycle of poor mental health, coercive treatment, stigma, and mistrust of services as experienced by Black communities. Evidence was limited by poorly defined ethnic categories, especially where Black populations were subsumed into one category. It is recommended that mental health services work collaboratively with cultural and faith communities in supporting Black people to cope with mental illness, navigate mental health pathways, and provide culturally appropriate advice. Protocol Registration Number PROSPERO CRD42021261510.

Interaction Between Race, Ethnicity, Severe Mental Illness, and Cardiovascular Disease

Severe mental illnesses, such as schizophrenia or bipolar disorder, affect ≈1% of the population who, as a group, experience significant disadvantage in terms of physical health and reduced life expectancy. In this review, we explore the interaction between race, ethnicity, severe mental illness, and cardiovascular disease, with a focus on cardiovascular care pathways. Finally, we discuss strategies to investigate and address disparities in cardiovascular care for patients with severe mental illness.

All-cause and cause-specific mortality in people with mental disorders and intellectual disabilities, before and during the COVID-19 pandemic: cohort study

BACKGROUND

People with mental disorders and intellectual disabilities experience excess mortality compared with the general population. The impact of COVID-19 on exacerbating this, and in widening ethnic inequalities, is unclear.

METHODS

Prospective data (N=167,122) from a large mental healthcare provider in London, UK, with deaths from 2019 to 2020, used to assess age- and gender-standardised mortality ratios (SMRs) across nine psychiatric conditions (schizophrenia-spectrum disorders, affective disorders, somatoform/ neurotic disorders, personality disorders, learning disabilities, eating disorders, substance use disorders, pervasive developmental disorders, dementia) and by ethnicity.

FINDINGS

Prior to the World Health Organization (WHO) declaring COVID-19 a public health emergency on 30th January 2020, all-cause SMRs across all psychiatric cohorts were more than double the general population. By the second quarter of 2020, when the UK experienced substantial peaks in COVID-19 deaths, all-cause SMRs increased further, with COVID-19 SMRs elevated across all conditions (notably: learning disabilities: SMR: 9.24 (95% CI: 5.98-13.64), pervasive developmental disorders: 5.01 (95% CI: 2.40-9.20), eating disorders: 4.81 (95% CI: 1.56-11.22), schizophrenia-spectrum disorders: 3.26 (95% CI: 2.55-4.10), dementia: 3.82 (95% CI: 3.42, 4.25) personality disorders 4.58 (95% CI: 3.09-6.53)). Deaths from other causes remained at least double the population average over the whole year. Increased SMRs were similar across ethnic groups.

INTERPRETATION

People with mental disorders and intellectual disabilities were at a greater risk of deaths relative to the general population before, during and after the first peak of COVID-19 deaths, with similar risks by ethnicity. Mortality from non-COVID-19/ other causes was elevated before/ during the pandemic, with higher COVID-19 mortality during the pandemic.

FUNDING

ESRC (JD, CM), NIHR (JD, RS, MH), Health Foundation (JD), GSK, Janssen, Takeda (RS).

Benign ethnic neutropenia: an analysis of prevalence, timing and identification accuracy in two large inner-city NHS hospitals

BACKGROUND

Benign ethnic neutropenia (BEN) is the most common cause of chronic neutropenia seen in individuals of African, Middle Eastern and West Indian descent. This phenotype is broadly defined by an absolute neutrophil counts (ANC) below 1.8 × 10⁹ cells/L in the absence of other causes, without an increased risk of infection. BEN has been implicated as a potential source of disparity in patients treated with clozapine, the antipsychotic of choice in treatment-resistant schizophrenia. Our main objective was to examine the current level of BEN recognition in a cohort of patients treated with clozapine and the potential impact of unidentified BEN on the initiation and maintenance of clozapine treatment.

METHODS

This was an observational, retrospective analysis of patients registered with clozapine haematological monitoring systems in two large mental health trusts, chosen because they serve an ethnically diverse population. The first objective was to establish certified BEN prevalence in current users of clozapine. The second objective was to explore the stage of treatment at which BEN was identified. The third objective was to evaluate the extent of unrecognised BEN in patients registered on the Central Non-Rechallenge Database (CNRD), a database for patients whose haematological parameters fall below set thresholds when receiving clozapine treatment, meaning they cannot ordinarily be prescribed clozapine again.

RESULTS

The study population comprised of 2020 patients on the clozapine register. 111 patients were monitored under BEN criteria. BEN was mostly identified after a below threshold haematological result or clozapine rechallenge (68%) compared to at clozapine initiation (32%). Eight of the 18 (42%) black patients registered on the CNRD were classified as BEN after assessment by a haematologist. Of these 8 patients, none would have met CNRD criteria again if monitored with BEN criteria at clozapine initiation.

CONCLUSIONS

Current evidence suggests that BEN remains an uncommonly recognised haematological phenotype. Improved timely identification of BEN will reduce unnecessary interruption or discontinuation of clozapine treatment. Our results suggest consideration should also be given to determining BEN status prior to initiating clozapine. Moreover, adoption of current FDA BEN monitoring criteria in the UK may further reduce clozapine discontinuation due to perceived neutropenia as drug toxicity, particularly in treatment-refractory schizophrenia patients.

Clinical ethnography in severe mental illness: a clinical method to tackle social determinants and structural racism in personalised care

Ethnic inequalities in the experiences and outcomes of severe mental illness are well established. These include a higher incidence of severe mental illnesses (psychoses), adverse pathways into and through care, including crisis care, police and criminal justice systems involvement, and care under the powers of the Mental Health Act. The situation persists despite awareness and is driven by a mixture of the social determinants of poor health, societal disadvantage and structural racism, as well as conflictual interactions with care systems, which themselves are configured in ways that sustain or deepen these inequalities. Although training and education are often proposed, this is not shown to have sustained effects. Clinical processes (interviewing/assessment/formulation/intervention) need to address systemic influences and improve the cultural precision with which care is delivered, organised and commissioned. We discuss clinical ethnography and present evidence of its value in addressing systemic as well as individual care needs for diverse communities.

Use of Health Services and Unmet Need among Adults of Russian, Somali, and Kurdish Origin in Finland

Equal access to health care is one of the key policy priorities in many European societies. Previous findings suggest that there may be wide differences in the use of health services between people of migrant origin and the general population. We analyzed cross-sectional data from a random sample of persons of Russian (n = 692), Somali (n = 489), and Kurdish (n = 614) origin and the Health 2011 survey data (n = 1406) representing the general population in Finland. Having at least one outpatient visit to any medical doctor during the previous 12 months was at the same level for groups of Russian and Kurdish origin, but lower for people of Somali origin, compared with the general population. Clear differences were found when examining where health care services were sought: people of migrant origin predominantly visited a doctor at municipal health centers whereas the general population also used private and occupational health care. Self-reported need for doctor's treatment was especially high among Russian women and Kurdish men and women. Compared to the general population, all migrant origin groups reported much higher levels of unmet medical need and were less satisfied with the treatment they had received. Improving basic-level health services would serve besides the population at large, the wellbeing of the population of migrant origin.

A description of antipsychotic prescribing patterns based on race in the inpatient behavioral health setting

BACKGROUND AND AIMS

A growing body of research shows that race contributes to disparities in mental health services utilization and influences the clinical diagnostic process. To our knowledge, no studies on current practice in the Unites States have documented whether these disparities impact the prescription of antipsychotic medications across individual patients based on race. Consequently, this study aims to describe the prescribing patterns of antipsychotic medications in the inpatient setting based on patients' race, and to explore appropriateness of therapy based on Food and Drug Administration labeling and avoidance of inappropriate polypharmacy.

METHODS

Single-centered, retrospective, chart review of 398 psychiatric patients in the inpatient setting and who had a psychiatric diagnosis that warranted a prescription for an antipsychotic medication at the time of discharge. Frequencies were computed to describe differences in demographic variables (race, health insurance type, age, and gender), medical conditions (diagnosis, commodities, hospitalization status, antipsychotic medications, etc.), and screening tests (lipid panel, hemoglobin, urine and illicit drug use). Logistic regression, analysis of variance, and hypothesis tests were used to analyze the data.

RESULTS

Significant differences were not found in total chlorpromazine equivalent dose equivalencies by race or insurance. However, patients of involuntary admission status, past medication trials, a diagnosis of schizophrenia or bipolar disorder, and who lacked family support had higher total daily doses of antipsychotics upon discharge. Inappropriate therapy was significantly related to differences in increasing age and a diagnosis of insomnia.

CONCLUSION

This single-centered study described patterns of antipsychotic prescribing based on race in an inpatient psychiatry facility. Future studies, using larger and more diverse sample populations, are recommended to elucidate the role that patients' race, admission status, and family support play in the dose and appropriateness of antipsychotics prescribed for mental health care.

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.

Developing a Theory-Informed Smartphone App for Early Psychosis: Learning Points From a Multidisciplinary Collaboration

Background: Actissist is a smartphone app designed to deliver an intervention grounded in cognitive behavior therapy for early psychosis. Actissist was developed by a multidisciplinary team of academics, clinicians, experts by experience and software engineers. Actissist has been tested in two trials, the first a proof-of-concept trial where Actissist was safe, acceptable and feasible, the second, a powered randomized controlled trial. Objective: This article describes how our multidisciplinary team designed and developed Actissist. This article describes: (i) how Actissist was informed by initial qualitative interviews and focus groups and an expert reference group; (ii) refinements made to the app based on ongoing user feedback; (iii) successes and challenges encountered; and (iv) learning points and recommendations for involving stakeholders in digital health interventions. Methods: Expert reference group meetings informed the development of Actissist and design of subsequent trials, which included individuals with lived experience of psychosis, clinicians, academics, computer scientists and software engineers. Person-centered stakeholder involvement was promoted using focus groups and qualitative interviews prior to the development of the app, which informed version one of Actissist. Interviews were carried out with participants who had used Actissist. Two further versions of Actissist were developed following additional rounds of testing. Results: Multidisciplinary working throughout the Actissist project led to the development, inclusion and improvement of the app design and content. These changes and features included non-directive and compassionate content, co-designed recovery videos, relaxation exercises, psychoeducation material, ability to "favorite" areas of the app that users found helpful, and goal-setting. Challenges to collaborative working included discrepancies between what stakeholders want and what is technically possible to deliver, resource pressures, trying to deliver desired features within the boundaries of fundamental trial design considerations, and power imbalances associated with multidisciplinary working. Conclusions: The involvement of stakeholders in the design and development and delivery of Actissist has been fundamental to our development approach. Through this collaborative process, we have identified different perspectives and ideas that would have not been generated by the research team alone. Clinical Trial Registrations: Proof-of-concept trial: http://www.isrctn.com/ISRCTN34966555 Fully-powered randomized controlled trial: https://www.isrctn.com/ISRCTN76986679.

Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection

BACKGROUND

Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing.

METHODS

The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults.

RESULTS

We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic.

CONCLUSIONS

The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.

Apparent Disparities in Hospital Admission and Biologic Use in the Management of Inflammatory Bowel Disease between 2014–2018 in Some Black and Ethnic Minority (BEM) Populations in England

Discrimination in delivery of care to patients with inflammatory bowel disease has been reported in the UK with regards to the South Asian population. This paper explores whether it is also true for Afro-Caribbean and Eastern European migrant workers. Treatment was investigated in NHS trusts, which served substantial migrant and minority communities, through Freedom of Information requests for data on use of biologics or hospital admissions over a five year period. In Bristol, Nottingham, Derby and Burton, Princess Alexandra Hospital Trust in Harlow, Essex and Kings College Hospital NHS Foundation Trust in South London Afro-Caribbean patients were treated significantly less often than White British patients. Eastern European migrant workers, were admitted significantly less often in Croydon, and the Princess Alexandra Hospital NHS Trust in Essex. However, there was no evidence of barriers to access for these communities in Wye Valley Trust, University Hospitals of Bristol NHS Foundation Trust or Queen Elizabeth Hospital Kings Lynn. In North West Anglia both South Asian and Eastern European patients were significantly less likely to be admitted to hospital than members of the White British community. It is incumbent on all gastroenterologists to consider their own clinical practice and encourage their hospital units to adopt effective policies which remove discriminatory barriers to good quality care.

Where next for understanding race/ethnic inequalities in severe mental illness? Structural, interpersonal and institutional racism

In this article we use the example of race/ethnic inequalities in severe mental illness to demonstrate the utility of a novel integrative approach to theorising the role of racism in generating inequality. Ethnic minority people in the UK are at much greater risk than White British people of being diagnosed with a severe - psychosis related - mental illness, and this is particularly the case for those with Black Caribbean or Black African origins. There is entrenched dispute about how we might understand the drivers of this inequality. To address this dispute we build on, and to a certain extent refine, established approaches to theorising structural and institutional racism, and integrate this within a theoretical framework that also incorporates racist/discriminatory interactions (interpersonal racism). We argue that this provides a conceptually robust and thorough analysis of the role of inter-related dimensions of racism in shaping risks of severe mental illness, access to care, and policy and practice responses. This analysis carries implications for a broader, but integrated, understanding of the fundamental drives of race/ethnic inequalities in health and for an anti-racism public health agenda.

Comparison between a morocco and a native-born population, in a sample of first episode psychosis

INTRODUCTION

Ethnic differences have been studied previously in schizophrenia and first episodes of psychosis (FEP). Previous studies in Netherlands have reported a higher incidence of psychosis in male Moroccan immigrants and more clinical severity. However there is lack of studies in Spain with morocco population and FEP.

OBJECTIVES

This study aims to determine the clinical differences in a sample of FEP between Morocco and Spanish population, recruited in a hospitalisation unit.

MATERIAL AND METHODS

Descriptive and cross-sectional study of 83 inpatients (FEP). Functionality and symptomatology were evaluated at entry and discharge, the pattern of use of cannabis was evaluated at entry, the dose of antipsychotic and the pattern of side-effects at discharge. Comparisons between native-born population and Morocco population was made with univariate analysis and logistic regression was made for evaluating the independence of the associations.

RESULTS

The 28.9% of the sample was Morocco group. No significance differences were found in clinical characteristics between groups at entry or at discharge. Compared with native-born, the Morocco group were more male, with less years of education, worse functionality, reported less use of cannabis, a better pattern of side effects and a tendency of more prescription of LAis. After the multivariate analysis, just remains a lower functionality (OR 0.93; IC 95%: 0.88-0.99, P=0.02) and lower years of education (OR 0.75; IC 95%: 0.56-1.01, P=0.05), remain significative with being related with Morocco origin.

CONCLUSIONS

Our study provides evidence for ethnic differences in Morocco population with FEP. Patients with Morocco ethnicity have more probability of being males, less years of educations. Have lower functionality and a better profile of side effects.

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.

Psychological Therapy in Secondary Mental Health Care: Access and Outcomes by Ethnic Group

OBJECTIVE

To explore the differences in access to, and outcomes of, psychological therapy for different ethnic groups across a South London Mental Health Trust.

METHOD

This study used Trust data to explore the proportions of ethnic groups accessing psychological therapy as a proportion of all patients supported by the Trust, as well as their outcomes within broad diagnostic clusters.

RESULTS

Compared to proportions in the local population, there were significantly more White/White British patients and significantly fewer patients from 'other ethnic groups' in the Trust (p < .05). There was also significantly greater proportion of Black/Black British patients with schizophrenia diagnoses compared to the proportion of Black/Black British people in the local population (p < .001). Of those accessing psychological therapy, there were significantly more White/White British and 'other ethnic group' patients and significantly fewer Black/Black British patients (p < .05). For schizophrenia diagnoses, significantly fewer Black/Black British and 'other ethnic group' patients were accessing psychological therapy (p < .05); however for behavioural and emotional disorders, there were significantly higher proportions of 'other ethnic group' and White/White British patients. Outcomes varied by diagnosis; Black/Black British patients experienced significantly higher distress scores at the beginning of therapy for depression and neurotic diagnoses (p < .05), with the latter persisting at the end of treatment.

CONCLUSIONS

Across the Trust, there were significant differences in the proportion of ethnic groups in accessing psychological therapy, as well as in outcomes. More research is needed to understand the factors that may underlie these disparities.