Ethnicity and the Mental Health Act 1983

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

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

PROSPERO REGISTRATION NUMBER

CRD42021293255.

Predicting coercion during the course of psychiatric hospitalizations

BACKGROUND

Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail.

METHODS

In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland's largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure.

RESULTS

Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity.

CONCLUSIONS

Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.

Effects of ethnic density on the risk of compulsory psychiatric admission for individuals attending secondary care mental health services: evidence from a large-scale study in England

BACKGROUND

Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density - the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission.

METHODS

Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density.

RESULTS

Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission.

CONCLUSIONS

We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

Compulsory and voluntary admissions in comparison: A 9-year long observational study

BACKGROUND

Few studies, so far, have been specifically designed to highlight the features related to Compulsory Admissions (CA) and Voluntary Admissions (VA) in Italian psychiatric emergency wards.

AIMS

The main purpose of this observational study was to compare the sociodemographic and clinical characteristics of VA and CA and to explore possible predictors of re-admissions.

METHODS

During a 6-month Index Period (February, the 1st-July, the 31st 2008) all psychiatric admissions were documented and then followed-up through all available informatic systems for the next 9 years.

RESULTS

Out of 390 hospitalizations, 101 (25.9%) were compulsory (CA rate was 2.79 per 10,000 inhabitants per year, mean duration of hospitalizations of 7.33 ± 7.84 days). Diagnoses were recorded for the 325 patients who had been hospitalized during index period: schizophrenic psychoses ([p = .042], in particular schizophrenia [p = .027]), manic episode (p = .044), and delusional disorders (p = .009) were associated with CA; conversely, the diagnosis of unipolar major depression (p = .005) and personality disorders (p = .048) were significantly more frequent in VA. The 325 admitted patients were followed up for 1,801 person-years. No significant differences were found in terms of drop-outs, transferring, and discharge rates, and mortality rates due to both natural causes and suicides. Factors associated with at least one compulsory readmission were younger age and having had a previous CA (p = .011); conversely having been engaged with psychiatric services for over 1 year prior to index hospitalization was protective for a subsequent CA (p = .013).

CONCLUSIONS

After a 40-year old political reform, the current study shows that, in a context of integrated outpatient and inpatient services, engagement with outpatient care may be protective for compulsory rehospitalization.

Engagement with services in Black African and Caribbean people with psychosis: The role of social networks, illness perceptions, internalized stigma, and perceived discrimination

OBJECTIVES

Research and policies in the United Kingdom have repeatedly highlighted the need to reduce ethnic disparities and improve engagement with mental health services among Black African and Caribbean people with psychosis. The aim of this study was to examine the role of social network characteristics and psychological factors in engagement with services in Black people with psychosis.

METHODS

A cross-sectional study was conducted with 51 Black African and Caribbean adults with non-affective psychosis and currently receiving care from mental health services in England. Measures were completed to examine relationships between social networks, illness perceptions, perceived racial or ethnic discrimination in services, internalized stigma, and current engagement with services from service user and staff perspectives.

RESULTS

Social network composition (ethnic homogeneity) moderately correlated with better service user and staff reported engagement. Greater perceived personal control over problems was associated with better staff reported engagement. Lower perceived ethnic or racial discrimination in services, and specific illness perceptions (higher perceived treatment control, greater self-identification with psychosis symptoms, more concern and greater emotional response related to problems) were associated with better service user reported engagement. Internalized stigma was not associated with service engagement. Multivariate regression analyses suggested that a more ethnically homogenous social network was the strongest predictor of better service user and staff reported engagement.

CONCLUSIONS

Psychosocial interventions that target social networks, perceived ethnic and racial discrimination in services, and illness perceptions may facilitate better engagement and improve outcomes. Further longitudinal studies are required to examine causal mechanisms.

The contagiousness of memes: containing the spread of COVID-19 conspiracy theories in a forensic psychiatric hospital

COVID-19 has transformed healthcare service provision. In addition to the spread of a virus, there has been an equally concerning emergence and spread of conspiracy theories. Such theories can threaten societal cohesion and adherence to the necessary public health guidance. In a forensic in-patient setting, such difficulties can be amplified. In this paper, we outline the key theory in relation to the development and spread of conspiracy theory memes. We propose primary, secondary and tertiary level responses to tackle the possible generation and spread of harmful conspiracies in the forensic in-patient setting. We consider this to be important, as there is a risk that such beliefs could affect patients' mental health and, in extremis, undermine physical health efforts to reduce the spread of COVID-19.

Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales

BACKGROUND

Recent evidence on suicide rates among psychiatric patients from minority ethnic backgrounds is scarce. We aimed to examine suicide rates among minority ethnic psychiatric patients and describe their social and clinical characteristics.

METHODS

We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018. Data were collected as part of the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates and standardised mortality ratios (SMRs) were estimated for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients.

FINDINGS

A total of 698 patients in the four minority ethnic groups of South Asian, Black Caribbean, Black African, and Chinese were included (482 [69%] men; 216 [31%] women; mean age 41 years [SD 14·9, range 12-91] and compared with 13 567 White patients (9030 [66·6%] men; 4537 [33·4%] women; mean age 48 years [SD 15·8, range 10-100]). Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2·73 deaths, 95% CI 2·68-2·78) per 100 000 population. Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1·89 deaths [95% CI 1·55-2·23] per 100 000 population) and lower rates in South Asian patients (1·49 deaths [1·33-1·64] per 100 000 population). There was an increase in rates among White patients in 2007-12 followed by a fall but no change among other ethnic groups. Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%). Minority ethnic patients overall showed markers of social adversity and received higher intensity care yet were viewed by clinicians as at lower risk than White patients.

INTERPRETATION

Effective approaches to prevention might differ between minority ethnic groups. Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness.

FUNDING

The Healthcare Quality Improvement Partnership.

Inpatient Institutional Care: The Forced Social Environment

The landscape of mental health recovery is changing; there have been calls for a shift from the clinical expertise being the dominant voice within mental healthcare towards a more personalised and collaborative service that supports those in need of mental healthcare to define what recovery is for the individual. Within this new recovery movement, there has been a recognition of the importance of the social environment in which individuals are situated and the relationship of this to mental health and wellbeing. Included in this is the importance of an individual’s role within society and the ways in which knowledge, such as experts by experience, can hold an important value. The argument then, is that social connectedness forms part of the recovery journey and that relationships can help us develop or re-connect with who we are in powerful ways. Such a view has only been strengthened by the recent and ongoing global COVID-19 pandemic. Within the UK, discussions of the importance of our wellbeing have become commonplace within the context of restricted social contact. With this heightened awareness of how the social contributes to wellbeing, it is important to consider the environments in which those in receipt of mental healthcare are situated. One of which is institutionalised care, where it is commonplace to restrict social contact. For example, by virtue of being within a locked environment, individuals’ freedom of movement is often non-existent and thus contacts with those not residing or working within the institution is restricted. While such restrictions may be deemed necessary to protect the individual’s mental health, such environments can be unintentionally toxic. Data are presented from an ethnography that was conducted within an inpatient forensic mental health hospital in the UK to highlight the problematic social environment which some individuals experience. Key interpersonal issues are presented, such as, trust, racism, the threat of physical violence and bullying that was experienced by staff and residents at the hospital. Consideration is given to the coping strategies enacted by residents and the pathologising of such behaviour. The consequences on interpersonal wellbeing are explored.

A systematic review of care pathways for psychosis in low-and middle-income countries

Pathways to care for psychosis in high-income countries have been well studied, with the finding of an association between longer duration of untreated psychosis (DUP) and poorer outcomes focusing interest on care pathways to minimise treatment delay. Little is known about how people with psychosis in low-to middle-income countries (LMIC) present for help and specific care pathways that might be associated with treatment delays in those contexts. We conducted a systematic review using electronic databases (MEDLINE, PsychINFO, Embase, Ovid) to explore what proportion of patients with psychosis in LMIC are accessing care through traditional healers and whether this is associated with treatment delay. Studies were included if they assessed the pathway to care for participants with a psychotic illness in a LMIC. From 3929 results, 15 studies met our inclusion criteria. In 7 out of 15 studies first contact for the majority of patients were traditional health practitioners (THPs). In 5 out of 15 studies, mental health practitioners (MHPs) were most often the initial care pathway and in 3 studies first contact was with primary care. DUP ranged from a mean of 30 weeks to 225 weeks. Accessing THPs as initial contact was associated with a longer DUP. In LMICs, a large proportion of patients use THP as their first point of contact for accessing care. This is associated with longer DUP. Services in these countries need to focus both on raising public awareness and collaborative working with THPs to facilitate access to biomedical care.

Effectiveness of treatment for 6813 patients with mental health conditions in Cambridgeshire: a cross-sectional study

BACKGROUND

The Health of the Nation Outcomes Scales (HoNOS) has been widely used as an outcome measure in UK mental health settings for the past decade. The data-set gathered provides a unique opportunity to evaluate the effectiveness of the totality of mental healthcare in 'real-world' conditions; much of our clinical evidence currently comes from highly parameterised clinical trials investigating single interventions in highly selected patients.

AIMS

To examine all outcomes measured by HoNOS for a range of diagnostic groups, evaluate the influence of patient demographics on those outcomes, and observe changes in patient groups over time.

METHOD

Here we show the data from 6813 adult patients treated in Cambridgeshire between 2012 and 2017. Patients were split into three diagnostic groups: psychosis, non-psychosis and organic. Changes in HoNOS scores from initial assessment to discharge were tested and regressions were used to evaluate the influence of age, gender and ethnicity on the changes, as well as to model changes in the severity of initial presenting symptoms with time.

RESULTS

HoNOS scores significantly improve after treatment for psychotic, non-psychotic and organic conditions in adults and older adults. Age, but not gender or ethnicity, influenced change in HoNOS scores. Patients entering secondary mental health services had increased initial HoNOS scores over time.

CONCLUSIONS

The UK repository of HoNOS scores provides a significant and relatively underutilised resource that can be exploited to gain insights into mental illness and treatment effectiveness. This is likely to have many applications, including influencing the commissioning of services.

Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis

AIMS

Voluntary admission rates of schizophrenia vary widely across studies. In order to make the topic be informed by evidence, it is important to have accurate estimates. This meta-analysis examined the worldwide prevalence of voluntary admissions for patients with schizophrenia.

METHOD

PubMed, EMBASE, PsycINFO, the Cochrane Library, Web of Science and Medline databases were systematically searched, from their commencement date until 19th November 2018. Meta-analysis of included studies was performed using the random-effects model.

RESULTS

Thirty-five studies with 134,100 schizophrenia patients were included. The overall voluntary admission rate of schizophrenia was 61.9 % (95 %CI: 52.3 %-70.7 %), while the involuntary rate was 43.0 % (95 %CI: 34.8 %-51.7 %). Subgroup analyses revealed that patients in Europe had significantly higher voluntary admission rates, while their North American counterparts were more likely admitted involuntarily. Papers published prior to 2008 reported higher involuntary admission rates. Meta-regression analyses showed that higher male percentage and higher study quality were significantly associated with higher voluntary admission rate.

CONCLUSION

Although the worldwide prevalence of voluntary admissions was higher than that of involuntary admissions, the latter was common for schizophrenia. With the continuing liberalization of mental health laws broadening community-based psychiatric services, the rate of voluntary psychiatric admissions is expected to further increase over time.

Patterns of psychiatric hospitalizations among migrant workers and asylum-seekers in Israel: a single hospital archive study, 2005-2011

Aim: Migrants have increased risk for psychiatric hospitalizations. Over the last decades Israel has become a destination for migration of migrant workers and asylum-seekers.Methods: The current retrospective study retrieved socio-demographic, clinical and migration-related chart data for 117 migrants admitted to a major Israeli psychiatric hospital between 2005-2011, to delineate characteristics and risk-factors for psychiatric hospitalizations. Multivariate logistic regression analyses were performed to predict re-hospitalization.Results: Of the study sample, 61% were single men, 20% had been exposed to trauma, 15% had prior psychiatric hospitalizations and 24% had attempted suicide. Approximately, 76% were involuntarily hospitalized and diagnosed with psychosis. None were diagnosed with PTSD. Approximately, 20% were re-hospitalized. Factors significantly associated with re-hospitalization were male gender (OR = 15.2, 95%, CI 1.8-126.9, p = 0.012), prior psychiatric hospitalization (OR = 15.4, 95% CI 2.1-111.9, p < 0.01), being single (OR = 5.96, 95% CI1.14-31.07, p = 0.03) and traumatic exposure (OR = 4.75, 95% CI: 1.17-19.36, p= 0.03). Shorter duration in Israel, unemployment, asylum-seekers, no temporary-visa and use of restraints were more prevalent among those re-hospitalized.Conclusion: Identification of migrants at risk and trauma-informed, culturally relevant services can reduce hospitalizations.

Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences

BACKGROUND

Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members.

METHODS

Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis.

RESULTS

Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies.

CONCLUSION

The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses

PURPOSE

Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England.

METHODS

Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously.

RESULTS

We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4).

CONCLUSIONS

The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

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.

Reported immigration and medical coercion among immigrants referred to a cultural consultation service

Members of visible minorities are commonly targets of social coercion related to immigration and medical measures. Social coercion is associated with poor mental health outcomes and mistrust of medical services. This study will determine if Afro-Canadian immigrants referred to a Cultural Consultation Service (CCS) in Montreal report more or less medical and immigration coercion compared with other ethnic minorities. We reviewed the charts of 729 referrals to the CCS and gathered data on the 401 patients included in the study. Chi-square statistics examined the relation between minority group and self-reported coercion. Binary logistic regression models controlled for standard sociodemographic variables in addition to ethnicity, language barrier, length of stay in Canada since immigration, refugee claimant status, referral source, presence of psychosis in the main diagnosis, and presence of legal history. Patients were diverse and included 105 Afro-Canadians, 40 Latin Americans, 73 Arab and West Asians, 149 South Asians, and 34 East and Southeast Asians. Being Afro-Canadian was significantly and positively associated with medical coercion (p = .02, 95% CI = 1.15-4.57), while being South Asian was negatively and significantly associated with immigration coercion (p = .03, 95% CI = .29-.93). Members of visible minority communities are not equal in their reported experience of social coercion after arriving to Canada. Future research clarifying pathways to mental health care for immigrants and the experience of new Canadians in immigration and health care settings would give needed context to the findings of this study.

How Do Early Psychosis Services Define and Operationalize the Duration of Untreated Psychosis?

Reducing the duration of untreated psychosis (DUP) is a key aim of early psychosis (EP) care. However, substantial variability in how the start and end points of DUP are defined impact its utility in clinical decision-making, and as an outcome measure. In this study, qualitative interviews were conducted with providers to assess how EP services and providers define, operationalize, and measure DUP. Twenty-five providers across 14 clinics were interviewed. Participants emphasized symptom frequency, conviction, distress caused, and impact when determining psychosis onset. DUP endpoint was typically identified as the first assessment in an episode of care that included an accurate diagnosis, leading to specialty EP treatment. Participants proposed a more structured operationalization of DUP, relative to those historically adopted in the literature. Integrating front-line provider perspectives could improve the accuracy of DUP measurement and address the heterogeneity in how the construct is operationalized across research and practice.

Compulsory admission at first presentation to services for psychosis: does ethnicity still matter? Findings from two population-based studies of first episode psychosis

OBJECTIVES

Compared with the majority population, those from minority ethnic groups in the UK are more likely to be admitted compulsorily during a first episode of psychosis (FEP). We investigated whether these disparities in pathways in to care continue.

METHODS

We analysed data from two first episode psychosis studies, conducted in the same geographical area in south London 15 years apart: the Aetiology and Ethnicity in Schizophrenia and Other Psychosis (AESOP) and the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) studies. The inclusion/exclusion criteria for case ascertainment for first episode psychosis were identical across the two studies. We performed multivariable logistic regression to estimate odds of compulsory admission by ethnic group, controlling for confounders.

PARTICIPANTS

Two hundred sixty-six patients with first episode psychosis, aged 18-64 years, who presented to mental health services in south London in 1997-1999 and 446 with FEP who presented in 2010-2012.

RESULTS

When the two samples  were compared, ethnic differences in compulsory admission appear to have remained the same for black African patients, i.e. three times higher than white British in both samples: AESOP (adj. OR = 3.96; 95% CI = 1.80-8.71) vs. CRIS-FEP (adj. OR = 3.12; 95% CI = 1.52-6.35). Black Caribbean patients were three times more likely to be compulsorily admitted in AESOP (adj. OR = 3.20; 95% CI = 1.56-6.54). This was lower in the CRIS-FEP sample (adj. OR = 1.68; 95% CI = 0.71-3.98) and did not meet conventional levels for statistical significance.

CONCLUSION

Ethnicity is strongly associated with compulsory admissions at first presentation for psychosis with evidence of heterogeneity across groups, which deserves further research.

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 Differences in Referral Routes to Youth Mental Health Services

OBJECTIVE

To examine whether there are ethnic differences in referral route to youth mental health services.

METHOD

This was an analysis of national, routinely collected data from 14,588 young people (mean [SD] age = 12.28 [3.75] years, 54% female; 64% white British) accessing mental health services in the United Kingdom. Ethnicity was self-reported by young people and carers, and referral route was recorded by services.

RESULTS

After accounting for service-level variation and controlling for age, sex, problem type, and contextual factors, ethnicity was significantly associated with referral route. Compared to white British young people, black young people (odds ratio [OR] = 2.90, 95% CI = 2.07-4.06) and mixed-race young people (OR = 2.66, 95% CI = 1.91-3.72) were more than twice as likely to be referred through social care/youth justice than through primary care. Compared to white British young people, Asian young people (OR = 1.85, 95% CI = 1.34-2.54) were almost twice as likely to be referred through social care/youth justice than through primary care. We conducted a sensitivity analysis to examine whether ethnic differences in referral route were attenuated when also accounting for service area deprivation, and the above effects were only partially attenuated.

CONCLUSION

There are ethnic differences in referral route to youth mental health services in the United Kingdom, and young people from minority ethnic backgrounds are more likely to be referred through routes that are less likely to be voluntary. Understanding the reasons for these differences is critical for reducing inequalities and improving pathways to mental health care access.

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.

Psychological interventions on a specialist Early Intervention Inpatient Unit: An opportunity to engage?

BACKGROUND

This study explored engagement with psychology on a specialist early intervention psychosis inpatient unit, with a focus on whether demographics or admission factors impacted on engagement.

METHOD

This was a retrospective cohort study using data extracted from patient notes for all service users who were admitted to an Early Intervention ward during a specified 6-month period. One hundred and one records were identified.

RESULTS

Sixty-eight (67.3%) of the service users engaged in psychological therapy, 45.6% (n = 47) attended psychology groups and 58.4% (n = 59) engaged in individual psychology sessions. Service users admitted to the ward voluntarily were more likely to engage in individual psychology sessions in comparison to those admitted under section of the mental health act (β = -0.270, P < .005). Length of admission predicted engagement with groups (β = 0.38, P < .001) and individual psychology sessions (β = 0.408, P < .001). Ethnicity, gender and number of admissions did not predict engagement in psychology.

CONCLUSIONS

Psychological interventions are acceptable on a specialist early intervention psychosis inpatient ward and offer an opportunity to engage service users. Engagement was not predicted by demographic factors typically seen in community settings. Implications arising from these differences are discussed.

Making a difference: ethnic inequality and severe mental illness

In this paper, we explore ethnic inequalities in severe mental illness and care experiences. We consider the barriers to progressive and cohesive action and propose ways of overcoming these. Clinical and policy leadership must bring together hidden patient voices, divergent professional narratives and quality research.Declaration of interestK.B. is Editor of the British Journal of Psychiatry, but has not played any role in the decision-making for this paper. K.B. leads and J.N. is a partner and K.H. a researcher in the Synergi Collaborative Centre.

Size and clustering of ethnic groups and rates of psychiatric admission in England

Aims and methodTo compare rates of admission for different types of severe mental illness between ethnic groups, and to test the hypothesis that larger and more clustered ethnic groups will have lower admission rates. This was a descriptive study of routinely collected data from the National Health Service in England.

RESULTS

There was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates.Clinical implicationsOur findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression.Declaration of interestNone.

Development, validation and cultural-adaptation of the knowledge about psychosis questionnaire for African-Caribbean people in the UK

The absence of assessment tools incorporating different cultural models of mental illness is a major barrier to recruiting ethnic minorities into clinical trials, reducing generalisability of findings and potentially increasing disparities in access to evidence-based care. This study aimed to develop and validate a new Knowledge about Psychosis (KAP) self-report measure and a culturally-adapted version for African-Caribbean people (CaKAP). Content and face validity were achieved through consultations with experts in psychosis and a focus group with service users, carers, and community members. Eighty-seven predominantly White British participants and 79 African-Caribbean participants completed the knowledge questionnaires (KAP and CaKAP) and measures of help-seeking and stigma. Overall, the measures showed good internal consistency and test re-test reliability. Construct validity was evidenced via significant positive associations between knowledge about psychosis and help-seeking and significant negative associations between knowledge and stigma. These measures could improve the delivery of psychosocial interventions and outcome measurement in research trials.

Ethnicity and outcome of appeal after detention under the Mental Health Act 1983

Aims and Method

There is insufficient research into the relationship between ethnicity and appeals against detention under mental health legislation. We sought to identify rates and success of appeals in different ethnic groups through a retrospective analysis of all detentions under the Mental Health Act 1983 over 1 year.

Results

We found high rates of appeals overall, with substantial differences between ethnic groups (36 (39%) White British compared with 71 (63%) Black Caribbean (P = 0.0001) and 21 (68%) White Irish (P = 0.01) individuals (Yates corrected chi-squared)). Success rates on appeal were very low in all groups.

Clinical Implications

There are significant ethnic differences in appeals against detention under the Mental Health Act.

Race and prescribing

Treatment of mental illness in Black and minority ethnic groups differs from that in the White majority. Large differences in admission, detention and seclusion rates have been recorded. These disparities extend into the physical healthcare setting, particularly in the USA but also within the UK National Health Service. There are many influences on prescribing of psychotropic medication, not least the metabolising capacity of the individual. Ethnic differences do occur, particularly for East Asian peoples. However, these differences are broadly similar across ethnic groups, particularly for the cytochrome P450 enzymes responsible for metabolising psychotropic medicines. Psychotropic medication prescribing also differs by ethnicity. Specifically, antipsychotic dose, type and route of administration may differ. However, most data originate in the USA and UK studies have not replicated these findings, even after controlling for multiple confounding factors. Similarly, antidepressant prescribing and access to treatment may differ by ethnicity. These differences may have complex causes that are not well understood. Overall, prescribing of antipsychotics appears to be broadly equitable in Black and minority ethnic groups.

Psychopathological Assessment of Risk of Restraint in Acute Psychiatric Patients

The study aims to identify independent predictors of physical restraint in acute psychiatric patients and to determine the predictive power of a risk assessment model centered on psychopathological dimensions. We included 1552 patients admitted to a psychiatric intensive care unit over a 5-year period. Patients were rated on the Brief Psychiatric Rating Scale (BPRS-E) at admission. Principal axis factoring (PAF) with varimax rotation was performed on BPRS-E items to identify psychopathological factors. Multiple logistic regression analysis was performed. PAF pointed six factors: positive symptoms, negative symptoms, resistance, activation, negative affect, and disorganization. Male sex, younger age, proposal for compulsory admission, severity of symptoms, resistance, activation, and disorganization were identified as independent predictors. Negative symptoms and negative affect were instead protective factors. The BPRS-E factors, when added to other sociodemographic and clinical variables, significantly increased the predictive power of the model. Our findings suggest that a systematic evaluation of the psychopathological dimensions can be usefully included in the early risk assessment of restraint.

The role of ethnicity in pathways to emergency psychiatric services for clients with psychosis

BACKGROUND

This study investigates the role of ethnicity in pathways to emergency mental health care in Toronto for clients with psychosis, while taking into account neighborhood factors. Previous literature has focused on Afro-Caribbean clients, reporting an increased risk of accessing mental health care through negative pathways.

METHODS

A retrospective chart review for clients from 6 different ethnic origin groups presenting with psychosis - East Asian, South Asian, Black African, Black Caribbean, White European, and White North American - was undertaken in a psychiatric emergency department (ED). Logistic regression models were constructed to examine the relationship between pathways to care (involuntary detention under the Mental Health Act (MHA), police or ambulance referral, accompaniment by family or friends) with individual and neighbourhood factors.

RESULTS

A total of 765 clients were included in the study. East Asian (OR =2.36, p < 0.01) and South Asian (OR 2.99, p < 0.01) origin clients have increased odds of presenting to the ED while involuntarily detained under the MHA. Involuntary status under the MHA increased the odds of presenting via police or ambulance (OR 8.27, p < 0.001). East Asian origin clients have increased odds of presenting to the ED by police or ambulance (OR =2.10, p < 0.05). Clients from neighbourhoods with higher levels of residential instability have increased odds of presenting by police or ambulance (OR =1.35, p < 0.01), while clients from neighbourhoods with higher levels of ethnic concentration have increased odds of being accompanied to the ED by family or friends (OR =1.33, p < 0.01).

CONCLUSION

In contrast to previous studies, East Asian and South Asian origin clients with psychosis have increased odds of a coercive pathway to emergency psychiatric services in Toronto. Black African and Black Caribbean origin clients do not have increased odds of a coercive pathway. Clients living in areas with high levels of residential instability are more likely to encounter a negative pathway. Ethnic concentration may be a supportive factor in family and friend accompaniment.

Assessing the risk for suicide in schizophrenia according to migration, ethnicity and geographical ancestry

BACKGROUND

Suicide is a leading cause of mortality among those afflicted by schizophrenia. Previous studies demonstrated that the stressors associated with immigration may lead to an onset of schizophrenia and suicide separately in susceptible individuals. However, no studies have shown whether immigration may lead to suicidal behaviour for individuals with schizophrenia. Our study proposes that an individual's geographical ancestry, ethnicity or migration status may be predictive of suicide risk in schizophrenia.

METHODS

In a sample of 276 participants with schizophrenia spectrum disorders, we conducted cross-sectional assessments to collect clinical information. Self-identified ethnicity and suicide history were collected through self-report questionnaires and interview-based scales. Ancestry was identified using 292 genetic markers from HapMap. Migrants were classified as those who immigrated to Canada during their lifetime. Using a regression analysis, we tested whether a history of migration, ethnicity or geographical ancestry were predictive of a history of suicide attempts.

RESULTS

Our analysis failed to demonstrate a significant relationship between suicide history and migration, ethnicity or ancestry. However, ethnicity appears to be significantly associated with the number of psychiatric hospitalizations in our sample.

CONCLUSION

Ethnicity and migration history are not predictive of previous suicide attempts. Ethnicity may be an important demographic factor affecting access to mental health resources and frequency of hospitalizations.

Predictors of engagement in first-episode psychosis

Engagement with psychiatric services is critical for ensuring successful outcomes in patients experiencing a first episode of psychosis (FEP). However, it is not known how sociodemographic factors and patient beliefs about the causes of mental illness affect engagement. This study explored predictors of engagement in a cohort of 103 FEP patients presenting to an early-intervention service. Beliefs that mental illness is caused by social stress or thinking odd thoughts predicted higher engagement scores. Patients with no qualifications were found to have higher engagement scores than those educated to a higher level. Ethnicity, gender, age and socioeconomic factors were not significantly correlated with engagement scores. Duration of untreated illness (DUI) significantly predicted higher engagement scores, but only for values >1220days. Duration of untreated psychosis (DUP) was not a significant predictor of patient engagement scores. Patient beliefs about the causes of mental illness are an important factor to be taken into consideration and may represent a target of interventions to increase engagement in FEP.

Rates of voluntary and compulsory psychiatric in-patient treatment in England: an ecological study investigating associations with deprivation and demographics

BACKGROUND

Individual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment.

AIMS

To describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation.

METHOD

Secondary analysis of 2010/11 data from the Mental Health Minimum Dataset.

RESULTS

Areas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20-39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant.

CONCLUSIONS

Age structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas.

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

PURPOSE

There is substantial evidence to suggest that Black and minority ethnic (BME) patients are disproportionately detained under the Mental Health Act (MHA). We examined ethnic differences in patients assessed for detention and explored the effect of ethnicity after controlling for confounders.

METHODS

A prospective study of all MHA assessments conducted in 1 year (April 2009-March 2010) within Birmingham and Solihull Mental Health Foundation Trust, UK. Proportion of assessments and detentions within denominator population of service users and regional populations were calculated. Multiple regression analysis was conducted to determine which variables were associated with the outcome of MHA assessment and the role of ethnicity.

RESULTS

Of the 1115 assessments, 709 led to detentions (63.58 %). BME ethnic groups were statistically more likely to be assessed and detained under the MHA as compared to Whites, both in the service user and the ethnic population estimates in Birmingham, UK. MHA detention was predicted by having a serious mental illness, the presence of risk, older age and living alone. Ethnicity was not associated with detention under the MHA with age, diagnosis, risk and level of social support accounted for.

CONCLUSION

The BME 'disproportionality' in detention rates seems to be due to higher rates of mental illness, greater risk and poorer levels of social support rather than ethnicity per se.

Ethnicity and pathways to care during first episode psychosis: the role of cultural illness attributions

BACKGROUND

Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations.

METHODS

We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions ("individual;" "natural;" "social;" "supernatural;" "no attribution") were assessed.

RESULTS

Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85).

CONCLUSION

Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

Mistrust of mental health services: ethnicity, hospital admission and unfair treatment

AIMS

To explore the role of psychiatric admission, diagnosis and reported unfair treatment in the relationship between ethnicity and mistrust of mental health services.

METHODS

The Mental Illness-Related Investigations on Discrimination (MIRIAD) study was a cross-sectional study of 202 individuals using secondary mental health services in South London. Two structural equation models were estimated, one using Admission (whether admitted to hospital for psychiatric treatment in the past 5 years) and one using involuntary admission to hospital in the past 5 years.

RESULTS

Increased mistrust was directly associated with the latent variable 'unfair treatment by mental health services and staff' and with Black or mixed ethnicity in both models. Those with a diagnosis of schizophrenia spectrum (as compared to depression and bipolar disorder) had a lower average score on the latent variable, suggesting that on average they reported less unfair treatment. We found evidence of increased reporting of unfair treatment by those who had an admission in the past 5 years, had experienced involuntary admission, and for people of Black of mixed Black and White ethnicity.

CONCLUSIONS

Neither prevalence of schizophrenia spectrum nor rates of hospital admission explained the greater mistrust of mental health services found among people of Black and mixed Black and White ethnicity compared with White ethnicity. Rather, people of Black and mixed Black and white ethnicity may be more likely to experience unfair treatment, generating mistrust; furthermore, this group is more likely to express mistrust even after accounting for reporting of unfair treatment by mental health services and staff.

Black and Minority Ethnic Groups’ Perception and Experience of Early Intervention in Psychosis Services in the United Kingdom

In the United Kingdom, Black and minority ethnic (BME) service users experience adverse pathways into mental health care. Ethnic differences are evident even at first-episode psychosis; therefore, contributory factors must operate prior to first presentation to psychiatric services. This study examines the cultural appropriateness, accessibility, and acceptability of the Early Intervention (EI) for Psychosis Services in Birmingham (the United Kingdom) in improving the experience of care and outcomes for BME patients. Thirteen focus groups were conducted with EI service users ( n = 22), carers ( n = 11), community and voluntary sector organizations ( n = 6), service commissioners ( n = 10), EI professionals ( n = 9), and spiritual care representatives ( n = 8). Data were analyzed using a thematic approach and framework analysis. Findings suggest that service users and carers have multiple, competing, and contrasting explanatory models of illness. For many BME service users, help-seeking involves support from faith/spiritual healers, before seeking medical intervention. EI clinicians perceive that help-seeking from faith institutions in Asian service users might lead to treatment delays. The value of proactively including service user’s religious and spiritual perspectives and experiences in the initial assessment and therapy is recognized. However, clinicians acknowledge that they have limited spiritual/religious or cultural awareness training. There is little collaborative working between mental health services and voluntary and community organizations to meet cultural, spiritual, and individual needs. Mental health services need to develop innovative collaborative models to deliver holistic and person-centered care.

Custody, care and country of origin: demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Involuntary detention is a feature of psychiatric care in many countries. We previously reported an involuntary admission rate of 67.7 per 100,000 population per year in inner-city Dublin (January 2008-December 2010), which was higher than Ireland's national rate (38.5). We also found that the proportion of admissions that was involuntary was higher among individuals born outside Ireland (33.9%) compared to those from Ireland (12.0%), apparently owing to increased diagnoses of schizophrenia in the former group. In the present study (January 2011-June 2013) we again found that the proportion of admissions that was involuntary was higher among individuals from outside Ireland (32.5%) compared to individuals from Ireland (9.9%) (p<0.001), but this is primarily attributable to a lower rate of voluntary admission among individuals born outside Ireland (206.1 voluntary admissions per 100,000 population per year; deprivation-adjusted rate: 158.5) compared to individuals from Ireland (775.1; deprivation-adjusted rate: 596.2). Overall, admission rates in our deprived, inner-city catchment area remain higher than national rates and this may be attributable to differential effects of Ireland's recent economic problems on different areas within Ireland. The relatively low rate of voluntary admission among individuals born outside Ireland may be attributable to different patterns of help-seeking which mental health services in Ireland need to take into account in future service-planning. Other jurisdictions could also usefully focus attention not just on rates on involuntary admission among individuals born elsewhere, but also rates of voluntary admission which may provide useful insights for service-planning and delivery.

Ethnic variations in compulsory detention and hospital admission for psychosis across four UK Early Intervention Services

BackgroundSubstantial ethnic variations have been found in incidence, pathways to care and outcomes in psychosis. It is unknown whether these remain as marked in the presence of specialist Early Intervention Services (EIS) for psychosis. We present the first UK study exploring ethnic differences in compulsory detention and hospitalization rates for EIS patients. We investigated whether the excess rates of compulsory admission for people from Black groups have persisted following nationwide introduction of EIS. We also explored variations in compulsory admission for other ethnic groups, and differences by gender and diagnosis.MethodsFour inner-city London EIS teams gathered data from first-presentation psychosis patients between 2004¿2009 using the MiData audit tool. Clinical, sociodemographic and pathways to care data were recorded regarding adult patients from eight different ethnic groups at entry to EIS and one year later.ResultsBlack African EIS service users had odds of being detained and of being hospitalised three times greater than White British patients, even after adjustment for confounders. This was most marked in Black African women (seven to eight times greater odds than White British women). A post-hoc analysis showed that pathways to care and help-seeking behaviour partially explained these differences.ConclusionThese findings suggest EIS input in its current form has little impact on higher admission and detention rates in certain Black and minority groups. There is a need to tackle these differences and engage patients earlier, focusing on the needs of men and women from the most persistently affected groups.

A systematic review of ethnic variations in hospital admission and compulsory detention in first-episode psychosis

BACKGROUND

Marked ethnic variations in incidence, pathways to care and outcomes have been demonstrated in psychosis. Less research has focused specifically on first-episode psychosis (FEP), particularly adverse contacts such as compulsory detention and hospitalization. This is despite international initiatives to promote equity of care and active early intervention.

AIM

Systematically review current evidence for ethnic variations in rates of compulsory admission and hospitalization in FEP.

METHODS

Relevant articles published before December 2012 were identified from PubMed, PSYCInfo, and CINAHL together with manual searching of reference lists. Studies providing quantitative data on compulsory detention rates and/or hospitalization, comparing ethnic groups in FEP, were included and quality rated by independent raters.

RESULTS

All included studies (n = 7) provided data on compulsory detention while fewer (n = 3) focused on admission rates. Three studies reported increased detention in Black and minority ethnic groups, while one reported more hospitalization in White patients. Only two studies covered early intervention services (EIS).

CONCLUSIONS

There is a paucity of high quality, well powered studies addressing this important issue, especially in EIS settings. In order to best inform and evaluate fast-developing services, it will be essential to combine large methodologically robust studies with qualitative analysis of patient, carer, and staff experiences.

Ethnicity as a predictor of detention under the Mental Health Act

BACKGROUND

There has been major concern about the 'over-representation' of Black and ethnic minority groups amongst people detained under the Mental Health Act (MHA). We explored the effect of patient ethnicity on detention following an MHA assessment, once confounding variables were controlled for.

METHOD

Prospective data were collected for all MHA assessments over 4-month periods in the years 2008, 2009, 2010 and 2011 each in three regions in England: Birmingham, West London and Oxfordshire. Logistic regression modelling was conducted to predict the outcome of MHA assessments - either resulting in 'detention' or 'no detention'.

RESULTS

Of the 4423 MHA assessments, 2841 (66%) resulted in a detention. A diagnosis of psychosis, the presence of risk, female gender, level of social support and London as the site of assessment predicted detention under the MHA. Ethnicity was not an independent predictor of detention.

CONCLUSIONS

There is no evidence for that amongst those assessed under the MHA, ethnicity has an independent effect on the odds of being detained.

Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Background

Black and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.

Aims and objectives

Study 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.

Methods

Study 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’

Results

There were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.

Conclusions

Statutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Are long-term psychiatric patients causing more crisis consultations outside office hours in mental health care?

BACKGROUND

As well as an improvement in community services, the de-institutionalization of patients receiving long-term psychiatric care can lead to marginally staffed mental health services, more homelessness, rising admission rates and more people in prison cells. It is assumed that an imbalance between community and hospital care for chronic patients puts pressure on crisis services.

AIMS

In this study, the central question is whether patients receiving long-term psychiatric care in Amsterdam do indeed put pressure on the city's emergency mental health services. We compare the pressure exerted by this group with the pressure resulting from the use of these services by all registered patients.

METHODS

Data were taken from the client registration systems of three mental health organizations in Amsterdam in the period from 2000 to 2004. Inclusion criteria for long-term psychiatric patients were age above 19 years and uninterrupted receipt of mental health care for a minimum of two successive years.

RESULTS

Annually, 6%-8% of all non-long-term patients experienced a crisis outside office hours in the period under investigation; this was 4%-6% for long-term patients. The non-long-term patients accounted for 83% of crisis contacts outside office hours over the entire study period, with long-term patients accounting for 17%.

CONCLUSIONS

The assumption that crises are more prevalent in long-term patients in the community seems to be an example of stigmatization rather than an observation based on fact.

Acute psychiatric treatment and the use of physical restraint in first-generation immigrants in Italy: a prospective concurrent study

BACKGROUND

and

AIMS

Immigrants in Europe appear at higher risk of psychiatric coercive interventions. No studies have investigated this issue in Italy. The aim of this study is to investigate whether the use of physical restraint, compulsory admission and other treatment characteristics differ in immigrated and Italian-born patients admitted to a psychiatric intensive care unit.

METHODS

One hundred first-generation immigrant patients were compared to 100 age-, gender- and diagnosis-matched Italian-born patients. Subjects were diagnosed according to DSM-IV-TR and rated on the Clinical Global Impression - Severity Scale and the Global Assessment of Functioning. Clinical data and treatment characteristics were collected.

RESULTS

Immigrant patients were more likely to be physically restrained as compared to Italian-born patients (11% vs 3%; χ (2) = 4.92; p = 0.027; RR = 3.67; 95% CI = 1.05-12.7). No differences in the proportion of involuntary treatment were found. Immigrant patients did not receive higher doses of antipsychotics or benzodiazepines, but they had a longer stay in the hospital.

CONCLUSIONS

The higher rate of physical restraint among migrants may reflect cultural, ethnic and language differences leading to communication problems between immigrant patients and mental health professionals. Since coercive interventions can be harmful, specific strategies to prevent this phenomenon in immigrants are needed.