Psychotropic medication and ethnicity: an inpatient survey

Differences in clinical presentation at first hospitalization and the impact on involuntary admissions among first-generation migrant groups with non-affective psychotic disorders

BACKGROUND

Some migrant and ethnic minority groups have a higher risk of coercive pathways to care; however, it is unclear whether differences in clinical presentation contribute to this risk. We sought to assess: (i) whether there were differences in clinician-rated symptoms and behaviours across first-generation immigrant and refugee groups at the first psychiatric hospitalization after psychosis diagnosis, and (ii) whether these differences accounted for disparities in involuntary admission.

METHODS

Using population-based health administrative data from Ontario, Canada, we constructed a sample (2009-2013) of incident cases of non-affective psychotic disorder followed for two years to identify first psychiatric hospitalization. We compared clinician-rated symptoms and behaviours at admission between first-generation immigrants and refugees and the general population, and adjusted for these variables to ascertain whether the elevated prevalence of involuntary admission persisted.

RESULTS

Immigrants and refugee groups tended to have lower ratings for affective symptoms, self-harm behaviours, and substance use, as well as higher levels of medication nonadherence and poor insight. Immigrant groups were more likely to be perceived as aggressive and a risk of harm to others, and both groups were perceived as having self-care issues. Adjustment for perceived differences in clinical presentation at admission did not attenuate the higher prevalence of involuntary admission for immigrant and refugee groups.

CONCLUSIONS

First-generation migrant groups may differ in clinical presentation during the early course of psychotic illness, although these perceived differences did not explain the elevated rates of involuntary admission. Further research using outpatient samples and tools with established cross-cultural validity are warranted.

Impact of language proficiency on mental health service use, treatment and outcomes: "Lost in Translation"

BACKGROUND

Mastery of a language is bound to place of origin; low language proficiency is thus related to migration and cultural differences, all of which influence access to mental health care, treatment and outcomes. Switzerland, being multilingual, allows the disentangling of language proficiency from migration and, to some extent, culture. This study uses propensity score matching to explore how language proficiency relates to help-seeking behaviour, service use, treatment and outcomes in patients with mental health disorders.

METHODS

We used the first admission of patients admitted to and discharged from an academic psychiatric hospital in Switzerland between January 1st, 2013 and December 31st, 2019, with an observation period of one-year post-discharge (until December 31st, 2020). We paired 2101 patients with low language proficiency to 2101 language proficient patients, balancing baseline sociodemographic and clinical characteristics using propensity score matching.

RESULTS

Patients with low language proficiency had a higher probability of compulsory admission (OR: 1.79, 99%CI: 1.60-2.02); which remained after adjustment for confounders (OR: 1.51; 99%CI: 1.21-1.89). Whilst in treatment, they had higher rates of compulsory medication (OR: 1.73, 99%CI: 1.16-2.59) and seclusion/restraint (OR: 1.87, 99%CI: 1.25-2.79). Furthermore, patients initially admitted voluntarily had a higher probability of being compulsorily retained (OR: 1.74, 99%CI: 1.24-2.46). Both groups showed similar clinical improvement rates and service use parameters.

CONCLUSIONS

Our results demonstrate that low language proficiency constitutes a risk factor for coercive measures throughout hospitalisation. The results demonstrate the need for an increase in language sensitivity in psychiatric care.

Psychiatric disorders among migrants in Germany: prevalence in a psychiatric clinic and implications for services and research

Past studies examining the prevalence of psychiatric disorders among migrants have described a higher rate of schizophrenia, whereas the only major German study found a lower rate. Considering the changed composition of migrants today, a new assessment has become necessary. All admission records of migrants to a psychiatric clinic in 1993 and 1994 were assessed for diagnosis, symptomatology and treatment. Two hundred sixty-three migrant admissions, 8.4% of total admissions, were assessed. Of these 41.4% received a diagnosis of a schizophrenic disorder, significantly more than other clinic patients. The mean age at admission was 33.8 years, at onset of illness 28.6 years and at time of migration 20.3 years. Only 7.9% were mentally ill at the time of migration. Of those with psychotic and depressive symptoms at admission, 70% received a diagnosis of a schizophrenic disorder and 78% were treated with antipsychotics. Antidepressants were prescribed only to 47% of those with a diagnosis of a depressive disorder and only 33% of those with depressive and no psychotic symptoms. An underrepresentation of migrants shows differences in the use of psychiatric services. The higher rate of schizophrenia may be due to misdiagnosis, an artifactual effect of underrepresentation of other disorders or an actual higher rate among migrants. The reluctance to use antidepressants underlines the necessity of training, so as not to withhold treatment options due to cultural barriers.

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.

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.

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.

Antipsychotic prescribing of consultant forensic psychiatrists working in different levels of secure care with patients with schizophrenia

Aims and method To detect any differences in the antipsychotic prescribing practices of consultant forensic psychiatrists working in different levels of secure care with patients diagnosed with schizophrenia, and to identify potential reasons for any differences. Prescribing data were collected from four secure hospitals within one National Health Service trust. A questionnaire was sent to consultant forensic psychiatrists working at those hospitals as well as those working in the trust's community forensic services. Results Consultants working in high security prescribed more oral antipsychotics than consultants working in medium and low security, who prescribed more depot antipsychotics, as established via the prescribing data. The questionnaire provided insight regarding the reasons for these preferences. Clinical implications There were differences in the antipsychotic prescribing practices of consultant forensic psychiatrists working in different levels of secure care, and, overall, the rate of depot antipsychotic prescribing was lower than might be expected. Although it was positive that the rate of polypharmacy was low when compared with earlier studies, the lower-than-expected rate of depot antipsychotic prescribing has clinical implications.

Ideology, Camouflage or Contingency? Racism in British Psychiatry

"...Are we so sure that the racist form of intolerance results chiefly from the wrong ideas of this or that group of people about the dependence of cultural evolution on organic evolution? Might not these ideas be simply ideological camouflage for more concrete oppositions based on a desire to subjugate other groups and maintain a posi tion of power?"

Theory and Research on Stereotypes and Perceptual Bias

This article presents theory and selected research on stereotyping and cognitive automaticity as a didactic resource base for multicultural counselor educators. Multicultural trainers can use this information in the classroom to establish the existing scientific evidence indicating that perceptual processes taking place outside of conscious awareness give rise to biased perceptions involving racial or ethnic categories. The objective of this didactic resource is to impress upon counseling trainees the importance of coming to terms with racial prejudice and biases often hidden from conscious scrutiny. In addition to the didactic material, several experiential exercises designed to elicit awareness of biases in personal attitudes and beliefs toward culturally diverse groups are presented. Suggestions for future research are also included.

Identification of Adverse Drug Events from Free Text Electronic Patient Records and Information in a Large Mental Health Case Register

OBJECTIVES

Electronic healthcare records (EHRs) are a rich source of information, with huge potential for secondary research use. The aim of this study was to develop an application to identify instances of Adverse Drug Events (ADEs) from free text psychiatric EHRs.

METHODS

We used the GATE Natural Language Processing (NLP) software to mine instances of ADEs from free text content within the Clinical Record Interactive Search (CRIS) system, a de-identified psychiatric case register developed at the South London and Maudsley NHS Foundation Trust, UK. The tool was built around a set of four movement disorders (extrapyramidal side effects [EPSEs]) related to antipsychotic therapy and rules were then generalised such that the tool could be applied to additional ADEs. We report the frequencies of recorded EPSEs in patients diagnosed with a Severe Mental Illness (SMI) and then report performance in identifying eight other unrelated ADEs.

RESULTS

The tool identified EPSEs with >0.85 precision and >0.86 recall during testing. Akathisia was found to be the most prevalent EPSE overall and occurred in the Asian ethnic group with a frequency of 8.13%. The tool performed well when applied to most of the non-EPSEs but least well when applied to rare conditions such as myocarditis, a condition that appears frequently in the text as a side effect warning to patients.

CONCLUSIONS

The developed tool allows us to accurately identify instances of a potential ADE from psychiatric EHRs. As such, we were able to study the prevalence of ADEs within subgroups of patients stratified by SMI diagnosis, gender, age and ethnicity. In addition we demonstrated the generalisability of the application to other ADE types by producing a high precision rate on a non-EPSE related set of ADE containing documents.

AVAILABILITY

The application can be found at http://git.brc.iop.kcl.ac.uk/rmallah/dystoniaml.

Factors associated with non evidence-based prescribing of antipsychotics

OBJECTIVES

Non evidence-based prescribing of antipsychotics is common in the UK and internationally with high doses and polypharmacy the norm. These practices often remain even after systematic attempts are made to change. We aimed to establish which factors are linked to antipsychotic prescribing quality so we can identify and target patients for interventions to improve quality and allow us to understand further the drivers of non evidence-based prescribing.

OBJECTIVES

A cross-sectional survey with a collection of factors potentially affecting antipsychotic prescribing quality outcomes was carried out in eight secondary care units in England. Participants were inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose, polypharmacy, type and route were the main outcome measures.

OBJECTIVES

Data were collected for 1198 patients. Higher total dose was associated with greater weight, higher number of previous admissions, longer length of admission, noncompliance with medication and use of an atypical antipsychotic. A lower total dose was associated with clozapine use. Polypharmacy was associated with not being a patient at the South London and Maudsley NHS Trust centre, the subject having a forensic history, a greater number of previous admissions and higher total dose. Younger age, not being detained under a Mental Health Act section, atypical antipsychotic use and oral route were predictors of antipsychotic monotherapy. Atypical antipsychotic use was associated with oral route, higher total dose, being administered only one antipsychotic, having had fewer previous antipsychotics and no anticholinergic use. Use of the oral route was associated with not being sectioned under the Mental Health Act, atypical antipsychotic use, younger age, non-schizophrenia diagnosis, fewer previous admissions and a lower total dose.

OBJECTIVES

In patients with chronic illness who are detained, heavier, noncompliant, not taking clozapine and on a depot antipsychotic, prescribers use larger doses and antipsychotic polypharmacy. We found that use of percentage of licensed maximum doses favours typical antipsychotics arbitrarily, and that high doses and polypharmacy are inextricably linked.

Cultural and age differences in beliefs about depression: British Bangladeshis vs. British Whites

This study examines beliefs about depression as a function of ethnic background (British Bangladeshis vs. British Whites) and age. A total of 364 participants completed a 65-item questionnaire, containing general questions regarding depression and anti-depressive behaviour; the causes of depression, and treatments for depression. The hypotheses were broadly supported; there were significant interactions between ethnicity and age, which generally revealed an increasingly negative attitude towards depression with increasing age amongst British Bangladeshis. Older British Bangladeshis believed depression was an illness that brought a sense of shame and loss of dignity to the individual and his or her family, and they also favoured a lay referral system for sufferers. They also had more superstitious beliefs about depression than both younger British Bangladeshis and British Whites. A pattern of increasing negativity with increasing age was not evident amongst the British Whites, but older individuals in both groups tended to believe that depression was not helped by psychological intervention. The attitudes towards depression in the young was similar (and generally positive) in both ethnic groups. These findings highlight the necessity to provide more culturally sensitive and accessible services for migrant communities – particularly amongst older individuals.

Carers' representations of affective mental disorders in British Chinese communities

Infrequent use of and delayed presentation to professional services have increased the burden of mental illness in minority ethnic communities. Within the growing literature on informal carers, the Chinese remain relatively unstudied. This article reports a qualitative study of 14 carers to explore illness representations of affective disorders in British Chinese communities. Firstly, it places the study within a theoretical framework that permits an understanding of mental health and illness in different sociocultural belief systems. Next, it presents carers' narrative accounts in conceptualising mental illness, including its causes, manifestations and impact on patients and carers, and contextualises the findings within the existing literature. Finally, the article examines how the caring role may be constructed from the broader social experience of carers and their relationships within a community structure that values the group over the individual. Coping mechanisms are discussed in the context of the practice of caring as a moral obligation and of policy implications for more culturally appropriate support services for both Chinese carers and mental health patients.

Exploring perceptions of "wellness" in black ethnic minority individuals at risk of developing psychosis

BACKGROUND

The NICE Schizophrenia guidelines (NICE, 2009, Update) recommend that services should address cultural differences in treatment, expectations and adherence, and clients' explanatory models of illness should be better understood. Service users from Black African and Black Caribbean communities are overrepresented in psychosis services in the UK, yet there is no literature on how wellness is understood by this group.

AIMS

This study explored perceptions of wellness in Black African and Black Caribbean individuals with an At Risk Mental State (ARMS) for psychosis.

METHOD

A Q set of potential meanings of wellness was identified from a literature search and interviews with people at risk of developing psychosis. From this, 50 potential definitions were identified; twenty Black African and Black Caribbean ARMS clients ranked these definitions.

RESULTS

Following factor analysis of completed Q sorts, six factors emerged that offered insight into perceptions of wellness in this population. These factors included: sense of social purpose explanation, the surviving God's test explanation, the internalization of spirituality explanation, understanding and attribution of symptoms to witchcraft explanation, avoidance and adversity explanation, and seeking help to cope explanation.

CONCLUSIONS

Although preliminary, differences between the factors suggests that there may be perceptions of wellness specific to these groups that are distinct from the medical view of wellness promoted within early detection services. These differences may potentially impact upon engagement, particularly factors that clients feel may facilitate or aide their recovery. It is suggested that these differences need to be considered as part of the assessment and formulation process.

Migrant pathways to community mental health centres in Italy

BACKGROUND

Many studies indicate that migrants in western countries have limited access to and low utilization of community mental health centres (CMHCs) despite the high prevalence of mental disorders.

AIMS

We aimed to compare migrant pathways to care across four CMHCs located in different Italian provinces and to identify pathway to care predictors.

METHODS

Migrants attending the four CMHCs between 1 July 1999 and 31 December 2007 were included in the study. Data were gathered retrospectively from clinical data sets and chart review.

RESULTS

Five hundred and eleven (511) migrants attended the four CMHCs, 61% were referred by GPs or other health services and 39% followed non-medical pathways to care (self-referral or through social and voluntary organizations), with important site variations. Younger age and being married were predictors of medical pathways to care; lacking a residence permit and having a diagnosis of substance abuse were related to non-medical pathways.

CONCLUSIONS

Pathways to CMHCs are complex and influenced by many factors. Non-medical pathways to care seem to be frequent among migrants in Italy. More attention should be paid to developing psychiatric consultation liaison models that also encompass the social services and voluntary organizations.

Antipsychotic prescribing in Black and White hospitalised patients

Ethnicity may affect the prescribing of antipsychotic treatment. Previous UK studies conducted in south London have found few differences in antipsychotic prescribing quality for Black and White patients. This larger multicentre study examined the effect of ethnicity on antipsychotic prescribing quality in areas serving the largest proportions of Black patients in the UK. A cross-sectional survey with collection of multiple confounding factors potentially affecting outcomes in eight secondary care units in England over a three month period. Participants were Black or White inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose (expressed as a percentage of licensed maximum), high dose (being prescribed antipsychotic medication above maximum dose), polypharmacy (more than one antipsychotic prescribed), type (typical or atypical antipsychotic) and costs were the main outcome measures. Data were collected for 938 patients. There were no significant differences in any outcome by ethnicity: dose (adjusted percentage difference 0.97 [95% confidence interval (CI) -4.28, 6.22], p = 0.72); high dose (adjusted odds ratio (AOR) 0.98 [CI 0.63, 1.51], p = 0.92); polypharmacy prescribed (AOR 1.15 [CI 0.87, 1.51], p = 0.33); polypharmacy administered (AOR 1.08 [CI 0.78, 1.49], p = 0.66); use of typical antipsychotics (AOR 1.25 [CI 0.87, 1.79], p = 0.22); and cost (adjusted effect size 1.75 [CI -9.81, 13.31], p = 0.77). Antipsychotic prescribing practice did not differ between Black and White patients.

Ethnicity and access to an inner city home treatment service: a case-control study

There is strong evidence suggesting ethnic variations in mental health service use and disproportionate numbers of people of black ethnic origin being admitted to hospital. The objective of this study was to establish whether people of black ethnic origin had equal access to home treatment in a mental health crisis. Using a case-control design, we selected a random sample of 240 inpatient episodes and compared them with a sample of 77 home treatment episodes over a 12-month period (1 April 2008-31 March 2009). We found no difference in the proportion of people of black ethnic origin being home treated in comparison to receiving an inpatient admission, although they experienced longer hospital admissions than people of other ethnic origin. Diagnosis, housing status and source of referral were found to be significant in influencing the choice of intervention in our multivariate analysis. People of black ethnic origin were found to use home treatment to the same extent as other ethnic groups in a mental health crisis, but further research is required for the early discharge function of home treatment teams to evaluate whether this aspect of care is experienced differently by different ethnic groups.

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.

Increased use of antipsychotic long-acting injections with community treatment orders

BACKGROUND

Community treatment orders (CTOs) are increasingly being used, despite a weak evidence base, and problems continue regarding Second Opinion Appointed Doctor (SOAD) certification of medication.

AIMS

The aim of the current study was to describe current CTO usage regarding patient characteristics, prescribed medication and CTO conditions.

METHOD

A 1-year prospective cohort study with consecutive sampling was conducted for all patients whose CTO was registered in a large mental health trust. Only the first CTO for each patient was included. Measures included sociodemographic variables, psychiatric diagnosis, CTO date of initiation and conditions, psychotropic medication and date of SOAD certification for medication. This study was conducted in the first year of CTO legislation in England and Wales.

RESULTS

A total of195 patients were sampled (mean age 40.6 years, 65% male, 52% black ethnic origin). There was significant geographical variability in rates of CTO use (χ(2) = 11.3, p = 0.012). A total of 53% had their place of residence specified as a condition and 29% were required to allow access into their homes. Of those with schizophrenia, 64% were prescribed an antipsychotic long-acting injection (LAI). Of the total group, 7% received high-dose antipsychotics, 10% were prescribed two antipsychotics and only 15% received SOAD certification in time.

CONCLUSIONS

There was geographical and ethnic variation in CTO use but higher rates of hospital detention in minority ethnic groups may be contributory. Most patients were prescribed antipsychotic LAIs and CTO conditions may not follow the least restrictive principle.

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.

Ethnic comparisons of antipsychotic use in schizophrenia

OBJECTIVE

The aim of the present study was to compare ethnic groups for antipsychotic prescribing in schizophrenia over 4.5 years.

METHODS

All clinical files in three mental health services caring for outpatients in Auckland, New Zealand were reviewed at two time points (T1 =31 March 2000, T2 =31 October 2004). Data were collected (patient characteristics, diagnosis, antipsychotic treatment) and analysed at each time point. Adjustments were made for age and sex in the comparisons. After the first audit, feedback was provided to all three services.

RESULTS

Differences in baseline prescribing were found between ethnic groups; rates of antipsychotic polypharmacy, second-generation antipsychotic (SGA) use, depot antipsychotic use, clozapine use and total antipsychotic dose. Overall five of the six prescribing outcome variables changed over the 4.5 years; only mean antipsychotic daily dose remained the same. Monotherapy rates increased in all ethnic groups with no difference found between them at T2 (85-86%). Similarly the prescribing variables of oral SGA use increased (83-87%), depots decreased (T2 =14-19%) and oral first-generation antipsychotics (FGAs) decreased (T2 =5-8%), all with no difference found between ethnic groups at T2. While clozapine use increased in all ethnic groups, a significant difference remained at T2; European, NZ Maori and Pacific all increased to 33-39%, but rates for Asian subjects increased only to 20%. The difference in mean daily antipsychotic dose between ethnic groups (122 mg day(-1) chlorpromazine equivalent (CPZe) at T1; 86 mg day(-1) CPZe at T2) reached statistical significance at both time points but overall the average dose (total mg day(-1)) for each group was within the usual clinical range. Adjustment for age and sex did not change the significance of any of the comparisons between ethnic groups.

CONCLUSIONS

Most baseline differences in antipsychotic prescribing between ethnic groups resolved over time, with equal access for patients to recommended best practice with antipsychotic treatment in schizophrenia. Further work is required to look at differences in access to clozapine for Asian people.

Ethnicity and quality of antipsychotic prescribing among in-patients in south London

Ethnicity may influence treatment decisions in mental disorders. We undertook a survey of the prescribing of antipsychotics for in-patients in three south London mental health trusts. A total of 255 patients (152 White, 103 Black) were included. Median dose of antipsychotic (% of licensed dose) was 58.3% for White and 50.0% for Black patients (adjusted effect size=0.14, 95% CI -0.34 to 0.63). High-dose antipsychotics were prescribed to 15.1% of White and 11.7% of Black patients (adjusted odds ratio (OR)=0.5, 95% CI 0.19-1.33), and antipsychotic polypharmacy was recorded for 25.7% and 31.1% respectively (adjusted OR=3.05, 95% CI 1.44-6.46). Prescribing quality was similar for Black and White patients.

No evidence for restrictive care practices in Măori admitted to a New Zealand psychiatric inpatient unit: do specialist cultural teams have a role?

OBJECTIVE

To ascertain the presence, and describe the pattern and extent, of restrictive care practices in the treatment of mental health inpatients in a rural New Zealand unit.

METHODS

Retrospective data was anonymously extracted from patient records at Rotorua Hospital (Rotorua, New Zealand). Data sets were compiled from 300 consecutive patient admissions between January 2000 and December 2001. The demographic and diagnostic characteristics extracted were gender, age, ethnicity (Măori or non-Măori classification only), primary diagnosis, length of hospital stay, seclusion, medication on discharge, dosage of antipsychotic medication if given, referral to psychotherapy, voluntary/involuntary status on admission, and readmission rates.

RESULTS

After controlling for other clinical variables, ethnicity was not associated with specific diagnoses, increased use of seclusion, and involuntary status on admission or higher readmission rates. Măori patients were more likely to receive antipsychotic medication and at higher doses than non-Măori. Măori were less likely to be referred to psychotherapy services and had shorter lengths of stay.

CONCLUSION

There was no evidence of widespread restrictive care practices against Măori, although the disparities in antipsychotic prescription and psychotherapy referral suggest some restrictive care practices do exist. The use of specialist cultural teams in general mental health services may prevent restrictive care practices.

Assessment of need for psychosocial interventions in an Asian population of carers of patients with schizophrenia

AIM

This paper reports on a study to establish the profile of need for psychosocial family interventions and to examine the concurrent validity of the Relatives' Cardinal Needs Schedule with an Asian population of carers in England, UK.

BACKGROUND

Although psychosocial interventions for schizophrenia have a strong evidence base, little is known of the needs of Asian families. A cardinal need is indicative of the existence of a problem causing the carer a strain for which the carer is willing to co-operate if help is offered and for which systematic help has not been provided in the last 12 months.

METHODS

The Relatives' Cardinal Needs Schedule was used to assess needs in a small randomly selected sample of Asian carers in one English locality and to compare the results with independent measures of patient symptoms and carer distress.

RESULTS

Feedback from carers indicated that the Relatives' Cardinal Needs Schedule was culturally acceptable and appropriate to their needs. There was evidence for the validity of the assessment in that there were large and statistically significant associations between the number of needs detected by the Relatives' Cardinal Needs Schedule and independent measures of both carer distress (as measured by the 28 item General Health Questionnaire) and patient symptom severity (as reliably assessed from case notes).

CONCLUSION

The Relatives' Cardinal Needs Schedule may prove useful for nurses and service managers in establishing the need for psychosocial family interventions amongst Asian families in the United Kingdom.

Multicultural mental health services: projects for minority ethnic communities in England

Black and minority ethnic (BME) communities form 7.8% of the total population of the U.K. Many of these communities face a variety of disadvantages when they access, or are forced to access, statutory mental health services under the National Health Service. Efforts have been made to address these problems by developing projects both within statutory mental health services and in the non-governmental ('voluntary') sector. This article describes some of these projects located in England, drawing out the themes and models that underlie their approaches, and discusses the lessons that can be learned from the U.K. experience.

Fear, black people and mental illness: a vicious circle?

The relationships between black communities and the mental health (MH) services are fraught. Paradoxically, black communities receive the MH services they don't want, but not the ones they do or might want. Black people mistrust and often fear services, and staff are often wary of the black community, fearing criticism, and not knowing how to respond, are fearful of black people, in particular, young black men. The situation is fueled by prejudice, misunderstanding, misconceptions and sometimes racism. The present paper describes the findings of a study to explore the issues in greater depth. The study was premised on a belief that there are 'circles of fear' which lead to poorer treatment of black communities. A purposive sampling approach was used to seek out groups and individuals in whom the 'circles of fear' were likely to be evident. The findings suggest that there are fears which impact negatively on the interaction between black communities and MH services. Two major themes emerged in this study, i.e. the sources of fear and the consequences of fear. Sources of fear included perceptions of MH services, attitudes to mental illness and diagnosis, and experiences of hospital care. The impact of fear included limited trust, limited engagement and delayed help-seeking behaviour. The study concludes that these fears mar the interactions between these communities and MH services, affect help-seeking behaviour adversely, and lead to restrictive and punitive interventions. Progress will only be made in breaking the 'circles of fear' if there is a systematic change in the experience of black services users at each point in the care pathway.

Comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across Europe

OBJECTIVE

To compare prescribed daily doses (PDDs) of psychotropic drugs in several European centres.

METHOD

A one-day census of psychotropic drug prescriptions to 613 patients in 39 acute psychiatric wards in ten countries.

RESULTS

Patients in Spain were on most drugs; patients in Germany were on the fewest. Chlorpromazine equivalents in Denmark, England, Germany and Spain were at high levels as were diazepam equivalents in Belgium, Finland, The Netherlands and Norway. Newer anti-psychotics were used in the majority of centres, although older anti-psychotics were used commonly in three centres.

CONCLUSION

The high doses of psychotropic drugs patients receive in some centres may be having little additional therapeutic effect and could increase their risk of side effects. The use of older anti-psychotics in some centres may be causing side effects that could be reduced by using newer anti-psychotics.

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.

High use of sedatives and hypnotics in ethnic minorities in Sweden

OBJECTIVE

To study use of analgesics, and psychotropic drugs in relation to health indicators in four ethnic minorities in Sweden in comparison with Swedish-born.

DESIGN

Cross-sectional study based on data from the Survey of Living Conditions and Immigrant Survey of Living Conditions in Sweden in 1996.

STUDY POPULATION

Random samples of 1890 Swedish residents, in the age range 27-60 years, born in Chile, Poland, Turkey and Iran and 2452 age-matched Swedish-born residents.

RESULTS

A two fold higher use of prescribed analgesics and antidepressants and a five to sixfold higher use of hypnotic and sedative drugs was demonstrated in members of ethnic minorities in Sweden in comparison with Swedish-born. In a multivariate analysis the higher use of prescribed analgesics and antidepressants was explained almost entirely by a higher morbidity in the minority study groups. A twofold higher use of sedatives and hypnotics was demonstrated in the minority study populations compared to the Swedish-born sample even after adjustment for extensive indicators of psychiatric and physical health in the multivariate analysis.

CONCLUSIONS

The higher use of sedatives and hypnotics in relation to health in the minority samples in the present study indicates a differential treatment of minor psychiatric disorders of members of ethnic minorities in Swedish health services. Further studies that yield more qualitative data regarding the interaction of Swedish physicians with migrant patients are needed to explain these differences and to create a basis for intervention.

Tardive dyskinesia in psychosis: are women really more at risk? UK700 Group

It is commonly held that women are more at risk of developing tardive dyskinesia (TD). However, recent evidence suggests that this may only be the case in samples of older patients, men being more at risk in the younger age groups. Abnormal movements were measured with the Abnormal Involuntary Movement Scale (AIMS) in a sample of 706 chronic psychotic patients aged not older than 65 years (median age 36 years). Female gender was associated with a lower risk of TD (OR, 0.5; 95% CI, 0.3-0.7). The effect of gender was independent of other risk factors such as older age, severity of negative symptoms and exposure to antipsychotic medication in the previous 2 years. There was no evidence that the effect of these risk factors differed between the sexes. In samples of relatively young patients with chronic psychotic illness, who typically represent the majority of patients in community programmes for the severely mentally ill, men are more at risk of TD than women.

The prescribing of psychotropic drugs by primary care physicians: an international collaborative study

Psychotropic drugs play a major role in primary care management of mental disorders. This study expands the existing data on prescribing practices using data from a 15-center, primary care epidemiologic survey. Questions to be addressed include the following: Which clinical and nonclinical factors are related to the prescribing of psychotropic drugs by primary care physicians? How do prescribing patterns vary across primary care centers? At each center, primary care patients were screened using the General Health Questionnaire, and a stratified random sample completed a standardized diagnostic assessment. For each patient completing the diagnostic assessment, the treating primary care physician provided data on clinical diagnosis and medications prescribed. Study results indicated that 11.5% of all practice attenders, 51.7% of cases who received a diagnosis of mental disorders by a physician, and 27.6% of cases who received a diagnosis using the Composite International Diagnostic Interview were treated with psychotropic medication because of their psychologic problems. Anxiolytics, hypnotics, and antidepressants each accounted for approximately 20% of all prescriptions. Prescription rates increased with the prominence of psychologic complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation. Rates and type of drugs also varied among specific mental disorders; 19.3% of patients with brief recurrent depression but 55.0% with agoraphobia got any psychotropic drug. Antidepressant drugs were prescribed in 7.7% of anxiety disorders compared with 31.9% of depressive disorders. There were large differences between international centers. When comparing client-type centers with clinic-type centers, overall prescription rates were similar (51.2 vs. 52.9%), but significant differences were observed with respect to psychotropic polypharmacy (12.6% client, 6.3% clinic), tranquilizer medication (24.2 client, 32.9% clinic), and antidepressant medication (17.3 client, 8.9% clinic). Psychotropic drugs have an important role in the treatment of mental disorders by general practitioners. Prescription is associated with a number of clinical but also nonclinical factors that must be recognized when guidelines for international use are to be published. Recognition of mental disorders and selection of specific drug classes are important areas in which medical practice needs improvement.

Nithsdale, Nunhead and Norwood: similarities and differences in prevalence of schizophrenia and utilisation of services in rural and urban areas

BACKGROUND

The prevalence of schizophrenia is known to be greater in urban than in rural areas. Less studied are differences between the patients themselves and, more specifically, their use of psychiatric services.

METHOD

The prevalence of schizophrenia was determined in rural Nithsdale in Scotland and urban Nunhead and Norwood in South London. Information about patients' psychiatric history, use of services during the study year and global assessment of functioning were obtained from case records and staff.

RESULTS

There were no significant differences in prevalence rates between Nithsdale patients, all White (2.78 per 1000 general population), Nunhead (3.46 per 1000) and Norwood (2.24 per 1000) Whites; rates were significantly higher among the non-Whites in Nunhead (7.36 per 1000) and Norwood (5.53 per 1000), who were mainly Black Caribbeans. Nithsdale patients were at a higher level of functioning and made substantially more use of psychiatric services. During the study year, 42% of Nithsdale patients used more than one of three principal community services, namely day, out-patient and community psychiatric nursing care.

CONCLUSIONS

The prevalence of schizophrenia is no different in rural Nithsdale and inner-city Nunhead and Norwood, when only White patients are considered. Nithsdale patients were at a higher level of functioning and made more use of available psychiatric services.

The essential elements of culturally sensitive psychiatric services

The recent re-structuring of the British National Health Service (NHS) involving a greater emphasis on community treatment has not specifically taken account of the unequal access to mental health services experienced by black people. The greater use amongst black people of compulsory orders, police involvement and reliance on psychotropic medication, although well established, has not influenced policy or led to a strategy to ensure that services appropriately meet the needs of the culturally diverse population in this country. We present the literature on service utilisation by black people and emphasise potential solutions in areas with which black people are dissatisfied. The service structures, ideology and mechanisms presented form the foundations of good practice.

Demographic factors associated with extreme non-compliance in schizophrenia

Having identified total non-compliance with neuroleptic medication as a major problem in a significant proportion of schizophrenic patients, an analysis of potentially important demographic factors associated with this problem was carried out. The in-patient records of 256 schizophrenic patients were examined with reference to ethnicity, gender, age, number of admissions and amount of time spent in hospital over a 3-year period. Non-compliant patients differed from those who were at least partially compliant in that they were more likely to be Afro-Caribbean and male, have shorter stays in hospital and have more admissions. There was no difference between these groups in terms of age, although certain subgroups exhibited some age differences. Logistic regression analyses revealed that gender and ethnicity were significant predictors of extreme non-compliance, to the extent that in male Afro-Caribbeans there was a 31% chance that prophylactic medication would be completely refused. The implications of these results and methodological issues are discussed.

Long-term follow-up of young Afro-Caribbean Britons and white Britons with a first admission diagnosis of schizophrenia

In this follow-up study, a group of black and white patients were followed up between 4 years 9 months and 10 years after a first admission with a clinical diagnosis of schizophrenia. It was possible to trace 98% of the sample, and historical, clinical and social data were obtained from case notes and interviews with patients and informants. There was no evidence of greater misdiagnosis in black patients, but their outcome was poorer in terms of readmissions and allocation to schizophrenic catego classes on follow-up (almost significant at 5% level). On follow-up, no differences were found in physical treatments and after-care arrangements or contacts with services. However, more black patients were readmitted on forensic sections and from prison, and more were treated in secure units. Explanations for the increased contact with penal and forensic services are discussed. The poorer clinical outcome found in black patients was associated with four factors apparent before first admission; living alone, unemployment, conviction and imprisonment.

A follow-up of second generation Afro-Caribbeans and white British with a first admission diagnosis of schizophrenia: attitudes to mental illness and psychiatric services of patients and relatives

A sample of second generation Afro-Caribbeans and white British with a diagnosis of schizophrenia, and their relatives, were interviewed 5-10 years after first admission. There was no difference between Afro-Caribbeans and whites on measures of satisfaction, conceptualization about illness and attitudes to different types of treatment and management. However black relatives were more likely to attribute causation of illness to substance use and to view services as racist. Most black patients and relatives thought that black day centres would be beneficial.

Depression and anxiety among Afro-Caribbean general practice attenders in Britain

Schizophrenia is diagnosed more frequently among Afro-Caribbeans in Britain than among white British controls. Studies among the general population indicate that non-psychotic disorders such as anxiety, depression and functional somatic symptoms are the commonest expression of psychiatric morbidity. Yet, among Afro-Caribbean primary care attenders, rates of anxiety and depression appear lower than in the general population. This finding is at odds with the reportedly higher rates of schizophrenia among this group. The majority of authors favour socio-cultural explanations to account for the higher rates of schizophrenia. Yet many of the factors that are evoked to account for the greater incidence of schizophrenia would be expected to lead to higher rates of non-psychotic disorders in primary care settings. Possible explanations for these apparently contradictory findings are discussed.