Ethnicity and use of acute psychiatric beds: one-day survey in north and south Thames regions

Patient adherence with infection control measures on a novel 'COVID-19 triage' psychiatric in-patient ward

BACKGROUND

Intra-hospital transmission of coronavirus disease 2019 (COVID-19) is a major concern. Psychiatric in-patient units pose unique challenges for the prevention of transmission. 'COVID-triage' wards with strict infection control procedures have been implemented to prevent the spread of infection, but little is known about the extent to which psychiatric in-patients adhere to these procedures.

AIMS

To examine patient adherence with infection control measures on a novel 'COVID-triage' psychiatric in-patient ward in London, England.

METHOD

This was an observational study of adherence with infection control measures. The proportion of patients who were adherent with infection control measures was calculated. The association of adherence with demographic and clinical factors was examined.

RESULTS

The majority of patients (n = 138/176, 78.4%) were not adherent with infection control measures. However, adherence did improve when patients who were non-adherent were given direct instructions by staff during clinical contact. Patients with diagnoses of psychotic disorders, personality disorders and substance use disorders were less likely to be adherent than those without these diagnoses.

CONCLUSIONS

Psychiatric in-patients show poor adherence with infection control measures. Proactive engagement by staff is key to improving patients' adherence. Urgent efforts are needed to identify and implement other effective methods of improving adherence in acute settings.

Beyond the barriers: South Asian women’s experience of accessing and receiving psychological therapy in primary care

Purpose

A number of initiatives have been developed to ensure easy access to mental health services for Black and Asian Minority Ethnic (BAME) communities. Improving Access to Psychological Therapies (IAPT) is a service that delivers first line interventions for South Asian women; however, little is known about what makes IAPT accessible for this population. This paper aims to explore South Asian women’s experiences of accessing psychological therapy and whether therapy within IAPT helps individuals to re-frame their experiences within their own cultural context.

Design/methodology/approach

A qualitative approach was used. Semi-structured interviews were carried out with South Asian women who accessed an IAPT service. Ten participants took part in the study and interviews were analysed using thematic analysis.

Findings

Six themes were identified; access, experience, cultural framework, therapist characteristics, expectations and “sticking with it”. Having a good therapeutic relationship with the therapist was key. While cognitive behavioural therapy (CBT) enabled clients to manage their symptoms, manualised CBT led to a sense of dissatisfaction for some. Clients spoke of having to make a forced choice to either deny their culture or leave their culture at the door to access therapy. Cultural and religious exclusion had a negative impact on therapy particularly for those whose difficulties were related to their cultural or religious context.

Practical implications

Culture and religion continues to be excluded from psychological therapy for South Asian Women. A cultural shift is required from within IAPT services to maintain engagement for this group. Further clinical implications are discussed.

Originality/value

While the experiences of Black and Asian ethnic minority groups accessing secondary mental health services has been explored, this study explores and highlights the experiences of South Asian Women accessing therapy in primary care, and uniquely identifies the processes that enable women to engage in therapy.

Psychosis, migration and social environment: an age-and-gender controlled study

Purpose

Adverse social experiences are frequently invoked to explain the higher rate of psychosis among migrant groups. The aim of the present study was to establish the socio-environmental factors distinguishing migrant psychotic patients from autochthonous patients.

Subjects and method

We conducted a cross-sectional survey involving 341 migrant psychotic patients matched for age and gender with 341 autochthonous psychotic patients.

Results

Migrant patients lived more often with their parental family, were less often enrolled with a referral psychiatrist, presented a lower rate of employment, a lower percentage of alcohol misuse and of suicide attempts.

Discussion

Our findings add to the growing body of results showing that more attention needs to be focused on socio-environmental variables in psychosis research. However, several limitations have to be taken into account, particularly with regard to selection biases and age of onset of the psychotic illness.

Conclusion

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Migrants’ families are an important keystone in the mental health care process of their sick relatives. Our service models need to be adapted with the aim to make the treatment easier for migrant patients.

Research on mental disorders and their care in immigrant populations: a review of publications from Germany, Italy and the UK

Objective

The review aims to identify the extent and nature of research on mental disorders and their care in immigrant populations in three major European countries with high levels of immigration, i.e. Germany, Italy, United Kingdom (UK).

Methods

Peer-reviewed publications on the subject from the three countries between 1996 and 2004 were analyzed. The research questions addressed, the methods used, and the results obtained were assessed.

Results

Thirteen papers reporting empirical studies were found from Germany, four from Italy and 95 from the UK. Studies addressed a range of research questions and most frequently assessed rates of service utilization in different immigrant groups. The most consistent finding is a higher rate of hospital admissions for Afro-Caribbean patients in the UK. Many studies had serious methodological shortcomings with low sample sizes and unspecified inclusion criteria.

Discussion

Despite large scale immigration in each of the three studied countries, the numbers of relevant research publications vary greatly with a relatively high level of empirical research in the UK. Possible reasons for this are a generally stronger culture of mental health service research and a higher number of researchers who are themselves from immigrant backgrounds in the UK.

Conclusion

Overall the evidence base to guide the development of mental health services for immigrant populations appears limited. Future research requires appropriate funding, should be of sufficient methodological quality and may benefit from collaboration across Europe.

Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: a retrospective cohort study using health administrative data

AIMS

Ethnic minority groups often have more complex and aversive pathways to mental health care. However, large population-based studies are lacking, particularly regarding involuntary hospitalisation. We sought to examine the risk of involuntary admission among first-generation ethnic minority groups with early psychosis in Ontario, Canada.

METHODS

Using health administrative data, we constructed a retrospective cohort (2009-2013) of people with first-onset non-affective psychotic disorder aged 16-35 years. This cohort was linked to immigration data to ascertain migrant status and country of birth. We identified the first involuntary admission within 2 years and compared the risk of involuntary admission for first-generation migrant groups to the general population. To control for the role of migrant status, we restricted the sample to first-generation migrants and examined differences by country of birth, comparing risk of involuntary admission among ethnic minority groups to a European reference. We further explored the role of migrant class by adjusting for immigrant vs refugee status within the migrant cohort. We also explored effect modification of migrant class by ethnic minority group.

RESULTS

We identified 15 844 incident cases of psychotic disorder, of whom 19% (n = 3049) were first-generation migrants. Risk of involuntary admission was higher than the general population in five of seven ethnic minority groups. African and Caribbean migrants had the highest risk of involuntary admission (African: risk ratio (RR) = 1.52, 95% CI = 1.34-1.73; Caribbean: RR = 1.58, 95% CI = 1.37-1.82), and were the only groups where the elevated risk persisted when compared to the European reference group within the migrant cohort (African: RR = 1.24, 95% CI = 1.04-1.48; Caribbean: RR = 1.29, 95% CI = 1.07-1.56). Refugee status was independently associated with involuntary admission (RR = 1.16, 95% CI = 1.02-1.32); however, this risk varied by ethnic minority group, with Caribbean refugees having an elevated risk of involuntary admission compared with Caribbean immigrants (RR = 1.72, 95% CI = 1.15-2.58).

CONCLUSIONS

Our findings are consistent with the international literature showing increased rates of involuntary admission among some ethnic minority groups with early psychosis. Interventions aimed at improving pathways to care could be targeted at these groups to reduce disparities.

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.

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.

Profile of service users attending a voluntary mental health sector service

Aims and Method

Very little research has been undertaken to characterise the service user groups served by the voluntary sector mental health services in Britain. In view of the high reported cases of dissatisfaction with the statutory mental health services in the population of Caribbean origin in Britain, we sought to compare the male service users attending a voluntary sector service in Brixton, South London with those attending a service run by the mental health hospital for that catchment area. The service users and their case workers were interviewed and their case notes reviewed to obtain demographic information such as employment and forensic history and contact with other services. They were also assessed using the Global Assessment of Functioning (GAF) and the Camberwell Assessment of Need (CAN).

Results

The service users attending the voluntary sector were significantly more disadvantaged in the areas of unemployment and contact with other health services particularly general practitioners. They had significantly lower scores on the GAF and had more unmet needs on the CAN, including numeracy and literacy skills. Both patient groups, however, reported problems with intimate relationships.

Clinical Implications

Service users attending voluntary sector services are likely to be more socially and materially deprived than their counterparts attending statutory services and specific strategies are required to assist these organisations in meeting the many needs of the service users.

Mental illness in Black and Asian ethnic minorities: pathways to care and outcomes

A substantial body of research indicates that, for people from Black and Asian ethnic minorities, access to, utilisation of and treatments prescribed by mental health services differ from those for White people (Lloyd & Moodley, 1992; for a review see Bhui, 1997). Pathways to mental health care are important, and the widely varying pathways taken in various societies may reflect many factors: the attractiveness and cultural appropriateness of services; attitudes towards services; previous experiences; and culturally defined lay referral systems (Goldberg, 1999). Contact with mental health care services may be imposed on the individual, but people who choose to engage with services usually do so only if they think that their changed state of functioning is health-related and potentially remediable through these services. In such cases, they will contact whoever they perceive to be the most appropriate carer, and these carers are often not part of a national health care network.

Ethnic isolation and psychosis: re-examining the ethnic density effect

BACKGROUND

Elevated incidence of psychotic illness has been consistently shown among migrant populations. Ethnic density, the proportion of an ethnic group in a defined area, is cited as one factor with a reduced risk of psychosis where ethnicity is shared. However, UK studies have shown mixed results. We set out to re-examine the ethnic density effect at a greater level of geographic detail than previous studies.

METHOD

Using a large sample of patient records from general practitioners in South East London, we were able to assess neighbourhood factors at the detailed lower super output area level. This comprises, on average, 1500 people compared with around 6000 per ward, the measure used in previous studies. We compared black (Afro-Caribbean) and white psychosis incidence by neighbourhood ethnic density over a 10-year period.

RESULTS

We found a clear negative association between ethnic density and psychosis incidence. In neighbourhoods where black people comprised more than 25% of the population, there was no longer a statistically significant ethnic difference in psychosis rates. However, where black people were less well represented, their relative risk increased nearly threefold [odds ratio (OR) 2.88, 95% confidence interval (CI) 1.89-4.39]. Furthermore, incidence rates for black people in the lowest density quintiles were over five times greater than in the most dense quintile (OR 5.24, 95% CI 1.95-14.07). However, at ward level this association was much weaker and no longer statistically significant.

CONCLUSIONS

Ethnic density is inversely related to psychosis incidence at a detailed local neighbourhood level.

The effect of ethnicity on prescribing practice and treatment outcome in inpatients suffering from schizophrenia in Greece

BACKGROUND

No studies have been conducted in Greece with the aim of investigating the influence of ethnicity on the prescribing and treatment outcome of voluntarily admitted inpatients. Most studies conducted in the UK and the US, both on inpatients and outpatients, focus on the dosage of antipsychotics for schizophrenic patients and many suffer from significant methodological limitations. Using a simple design, we aimed to assess negative ethnic bias in psychotropic medication prescribing by comparing discrepancies in use between native and non-native psychiatric inpatients. We also aimed to compare differences in treatment outcome between the two groups.

METHODS

In this retrospective study, the prescribing of medication was compared between 90 Greek and 63 non-Greek inpatients which were consecutively admitted into the emergency department of a hospital covering Athens, the capital of Greece. Participants suferred from schizophrenia and other psychotic disorders. Overall, groups were compared with regard to 12 outcomes, six related to prescribing and six related to treatment outcome as assesed by standardised psychometric tools.

RESULTS

No difference between the two ethnic groups was found in terms of improvement in treatment as measured by GAF and BPRS-E. Polypharmacy, use of first generation antipsychotics, second generation antipsychotics and use of mood stabilizers were not found to be associated with ethnicity. However, non-Greeks were less likely to receive SSRIs-SNRIs and more likely to receive benzodiazepines.

CONCLUSIONS

Our study found limited evidence for ethnic bias. The stronger indication for racial bias was found in benzodiazepine prescribing. We discuss alternative explanations and give arguments calling for future research that will focus on disorders other than schizophrenia and studying non-inpatient populations.

Ethnicity and dangerousness criteria for court ordered admission to a psychiatric hospital

BACKGROUND

Black and minority ethnic (BME) populations are disproportionately detained in psychiatric hospitals.

AIM

To examine the dangerousness criteria for compulsory court ordered admission to a psychiatric hospital in White and BME persons.

METHOD

We examined the psychiatric examinations for court ordered compulsory admissions in 506 White and 299 BME persons from October 2004 until January 2008 in Rotterdam, the Netherlands. The White and BME groups are compared using Chi-square tests and in case of significant differences with logistic regression models adjusted for age, gender, mental disorders and socio-economic background.

RESULTS

In BME persons, violence towards others and neglect of relatives were more often reasons to request court order admission as compared with Whites (39.8 vs. 25.3%, P < 0.001, respectively, 6.4 vs. 2.4%, P = 0.01). This remained true after adjustment for age, gender, mental disorders and socio-economic background [OR 1.56 (95% CI 1.12-2.18), P = 0.01, respectively; OR 3.08 (95% CI 1.31-7.26), P = 0.01]. The other reasons for a request of court order admission had a similar prevalence in both groups (suicide or self-harm, social decline, severe self-neglect, arousal of aggression of others, danger to the mental health of others, and the general safety of persons and goods).

CONCLUSION

Violence towards others and neglect of relatives are more often a reason to request court ordered admission in BME than in White persons. BME patients are more often perceived as potentially dangerous to others.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

A population-based analysis of the health experience of African Nova Scotians

BACKGROUND

People of African descent living in Britain and the United States have higher rates of morbidity from chronic disease than among the general population. We investigated whether the same applied to people of African descent living in a Canadian province.

METHODS

We used administrative data to calculate 10-year cumulative incidence rate ratios for the period 1996-2005 for treated circulatory disease, diabetes mellitus and psychiatric disorders in Preston (population 2425), a community of predominantly African Nova Scotians. We used data for the province of Nova Scotia as a whole as the population reference standard. We also calculated 10-year incidence rate ratios for visits to family physicians and specialists and for admissions to hospital. We compared these findings with those in 7 predominantly white communities in Nova Scotia with otherwise similar socio-economic characteristics.

RESULTS

In the province as a whole, we identified 787,787 incident cases for the 3 disease groups over the 10-year period. Incidence rate ratios for the community of interest relative to the provincial population were significantly elevated for the 3 diseases: circulatory disease (1.19, 95% CI 1.08-1.29), diabetes (1.43, 95% CI 1.21-1.64) and psychiatric disorders (1.13, 95% CI 1.06-1.20). Incidence rate ratios in the community of interest were also higher than those in the comparison communities. Visits to family physicians and specialists for circulatory disease and diabetes were similarly elevated, but the pattern was less clear for visits for psychiatric disorders and hospital admissions.

INTERPRETATION

African Nova Scotians had higher morbidity levels associated with treated disease, which could not be explained by socio-economic characteristics, recent immigration or language. Apart from psychiatric disorders, use of specialist services was consistent with morbidity. Further study is needed to investigate the relative contribution of genetic, biological, behavioural, psychosocial and environmental factors.

"I know he controls cancer": the meanings of religion among Black Caribbean and White British patients with advanced cancer

There is evidence that religion and spirituality affect psychosocial adjustment to cancer. However, little is known about the perceptions and meanings of religion and spirituality among Black and minority ethnic groups living with cancer in the UK. We conducted semi-structured interviews with 26 Black Caribbean and 19 White British patients living in South London boroughs with advanced cancer to explore how religion and spirituality influenced their self-reported cancer experience. Twenty-five Black Caribbean patients and 13/19 White British patients volunteered views on the place of religion or God in their life. Spirituality was rarely mentioned. Christianity was the only religion referred to. Strength of religious belief appeared to be more pronounced among Black Caribbean patients. Three main themes emerged from patients' accounts: the ways in which patients believed religion and belief in God helped them comprehend cancer; how they felt their faith and the emotional and practical support provided by church communities assisted them to live with the physical and psychological effects of their illness and its progression; and Black Caribbean patients identified the ways in which the experience of cancer promoted religious identity. We identified that patients from both ethnic groups appeared to derive benefit from their religious faith and belief in God. However, the manner in which these were understood and expressed in relation to their cancer was culturally shaped. We recommend that when health and social care professionals perform an assessment interview with patients from different cultural backgrounds to their own, opportunities are made for them to express information about their illness that may include religious and spiritual beliefs since these may alter perceptions of their illness and symptoms and thereby influence treatment decisions.

Ethnicity and the Mental Health Act 1983

BACKGROUND

Black and minority ethnic (BME) patients are disproportionately detained under the Mental Health Act 1983. There has been no systematic exploration of differences within and between ethnic groups, nor of the explanations put forward for this excess.

AIMS

To systematically review detention and ethnicity, with meta-analyses of detention rates for BME groups, and to explore the explanations offered for ethnic differences in detention rates.

METHOD

Literature search and meta-analysis. Explanations offered were categorised, supporting literature was accessed and the strength of the evidence evaluated.

RESULTS

In all, 49 studies met inclusion criteria; of these, 19 were included in the meta-analyses. Compared with White patients, Black patients were 3.83 times, BME patients 3.35 times and Asian patients 2.06 times more likely to be detained. The most common explanations related to misdiagnosis and discrimination against BME patients, higher incidence of psychosis and differences in illness expression. Many explanations, including that of racism within mental health services, were not supported by clear evidence.

CONCLUSIONS

Although BME status predicts psychiatric detention in the UK, most explanations offered for the excess detention of BME patients are largely unsupported.

The need for change in UK mental health services: South Asian service users' views

OBJECTIVES

UK literature on mental health services for ethnic minority service users relies heavily on perceptions of professionals, carers and community representatives. This research investigates the views of South Asian service users themselves about experiences of mental health services and how they might be improved.

DESIGN

Thematic analysis of material from focus groups and individual interviews with Asian mental health service users within one local area.

RESULTS

South Asian service users clearly identify the impact of socio-economic exclusion upon their mental health. Cultural and institutional exclusion compound this, leading to continuing insensitivity towards their particular needs within hospital and community-based services. Asian service users feel unsafe to share their particular concerns within many service settings. They see advocacy that recognises their experience of exclusion as a significant resource for mental health improvement. They want sounder financing of culturally appropriate services for recovery; further development of the cultural competence of staff within mainstream services; and educational programmes about mental health directed at minority communities.

CONCLUSION

UK mental health services remain unresponsive to the consistently expressed views of South Asian service users. A major cultural change is required if the UK Government initiative Delivering Race Equality is to impact successfully at the local level. It will have a greater chance of success if the rhetoric of user involvement is matched by systematic consultation with South Asian service users.

Ethnic differences in mental health service use among patients with psychotic disorders

BACKGROUND

There are concerns that ethnic minority patients are over-represented in inpatient mental health settings, but under-utilise community services. This study aims to compare the use of community mental health services between African-Caribbean and White patients with psychosis, before and after the introduction of new community services, and to investigate their impact on inpatient treatment.

METHODS

The sample was drawn from epidemiologically representative patients with psychotic disorders living in two catchment areas in South London, one of which was developing intensive community treatments. Service utilisation was measured at baseline and at 2-year follow-up using the Client Service Receipt Interview (CSRI). The mean number of contacts with specific services was compared between the two groups over time.

RESULTS

A total of 92 White and 48 African-Caribbean patients were compared. The latter were more likely to be younger (P = 0.004), have shorter illness duration (P < 0.001), and had more detentions under the Mental Health Act (P = 0.003). No significant differences were seen in use of community services over time. However, intensive treatment led to a significant reduction in hospital days for African Caribbean patients compared to White patients in the intensive sector and all patients in the standard sector.

CONCLUSIONS

Intensive community treatments reduced inpatient days in African Caribbean patients. Further effort is needed to improve the cultural sensitivity of community mental health services.

Ethnic variation among adolescent psychiatric in-patients with psychotic disorders

BACKGROUND

There is strong evidence that the rates of psychiatric admission for psychosis in the UK are elevated for the Black adult population compared with the White population. Black adults also have a higher rate of involuntary psychiatric admissions. There have been no studies in this country investigating links between ethnic background and psychiatric admission in the adolescent population.

AIMS

To investigate whether Black compared with White adolescents from London are overrepresented in psychiatric in-patient settings and whether they are more likely to be detained under the Mental Health Act 1983.

METHOD

Cross-sectional survey of London adolescents aged 13-17 years, who were in-patients in psychiatric units.

RESULTS

Adolescents from the Black group (Black African, Black Caribbean, Black British) were overrepresented among those admitted with a diagnosis of a psychotic disorder when compared with adolescents from the White group (White British, White Irish, White Other): odds ratio=3.7, 95% CI 2.0-6.7. They were also more likely to be detained on admission and more likely to be born outside the UK and more likely to be born outside the UK and have refugee background.

CONCLUSIONS

The possible impact of various background factors influencing admission is discussed.

Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry

It has been consistently reported that the African-Caribbean population in the UK are more likely than their White counterparts to access psychiatric services via the police and under compulsion. The reasons for these differences are poorly understood. This paper comprises two main parts. The first provides a comprehensive review of research in this area, arguing the current lack of understanding stems from a number of methodological limitations that characterise the research to date. The issue of ethnic variations in pathways to psychiatric care has been studied almost exclusively within a medical epidemiological framework, and the potential insights offered by sociological and anthropological research in the fields of illness behaviour and health service use have been ignored. This has important implications as the failure of research to move beyond enumerating differences in sources of referral to psychiatric services and rates of compulsory admission means no recommendations for policy or service reform have been developed from the research. The second part of the paper sets out the foundations for future research, arguing that the pathway to care has to be studied as a social process subject to a wide range of influences, including the cultural context within which illness is experienced. It is further argued that Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry, University of California Press, Los Angeles, 1980) Health Care System model offers a particularly valuable preliminary framework for organising and interpreting future research. It is only through gaining a more qualitative understanding of the processes at work in shaping different responses to mental illness and interactions with mental health services that the patterns observed in quantitative studies can be fully understood. This further reflects the need for a bridge between the social sciences and psychiatry if services are to be developed to respond to the increasing diversity of modern societies.

Ethnic variations in pathways to and use of specialist mental health services in the UK. Systematic review

BACKGROUND

Inequalities of service use across ethnic groups are important to policy makers, service providers and service users.

AIMS

To identify ethnic variations in pathways to specialist mental health care, continuity of contact, voluntary and compulsory psychiatric in-patient admissions; to assess the methodological strength of the findings.

METHOD

A systematic review of all quantitative studies comparing use of mental health services by more than one ethnic group in the UK. Narrative analysis supplemented by meta-analysis, where appropriate.

RESULTS

Most studies compared Black and White patients, finding higher rates of in-patient admission among Black patients. The pooled odds ratio for compulsory admission, Black patients compared with White patients, was 4.31 (95% CI 3.33-5.58). Black patients had more complex pathways to specialist care, with some evidence of ethnic variations in primary care assessments.

CONCLUSIONS

There is strong evidence of variation between ethnic groups for voluntary and compulsory admissions, and some evidence of variation in pathways to specialist care.

Psychiatric disorders and social characteristics among second-generation Moroccan migrants in Belgium: an age-and gender-controlled study conducted in a psychiatric emergency department

PURPOSE

Clinically, one of the most consistent clinical findings among migrant patients is an increase in the rate of psychosis. The aim of the present study was to confirm this finding in Belgium by comparing second-generation Moroccan migrant patients with Belgian patients, matched for the variables of age and gender.

SUBJECTS AND METHOD

We conducted a cross-sectional survey on 272 patients admitted in a psychiatric emergency unit during the year 1998. We used univariate and multivariate analyses to compare the two subgroups.

RESULTS

Multivariate analyses showed that migrant patients lived more often with their parental family and that they presented a higher rate of admission for psychotic disorders and a lower rate of employment.

DISCUSSION

Our findings add to the growing body of results showing increased incidence of psychosis among immigrants to European countries, but several factors have to be taken into account, particularly with regard to selection biases and differences in help-seeking behaviour and in family perception of the mental illness.

CONCLUSION

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Further studies would be needed to better explain some of our results, particularly the role played by the families of migrant patients.

Users' perceptions of an African and Caribbean mental health resource centre

It has been suggested that well-documented differences in African and African-Caribbean people's contact with mental health services may stem from a spiral of disaffection, reluctance to seek help and re-admission to hospital in times of crisis. In 1997, an African and Caribbean mental health resource centre was established in the London borough of Kensington and Chelsea with the aim of ensuring that the needs of this group were better met. As part of an evaluation of the study, interviews were carried out with 26 clients of the resource centre. This article presents their perceptions of the service provided and its impact on their lives. The clients' accounts indicate that the resource centre was providing a valued service that was successful in reducing their sense of social isolation, enabling them to address issues of identity and self-worth associated with racism and working with other service providers to better meet their needs.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovsky's sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over one's life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.

Ethnicity and outcome of psychosis

BACKGROUND

An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.

AIMS

To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.

METHOD

A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.

RESULTS

Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.

CONCLUSIONS

The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.