Inner London collaborative audit of admissions in two health districts. II: Ethnicity and the use of the Mental Health Act

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.

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.

A comparison of hospital and community stay in patients who underwent compulsory admission before and after the 2007 Amendment to the Mental Health Act in Taiwan

OBJECTIVE

The main purpose of this study was to assess the empirical findings of compulsory admission for psychiatric disorders before and after the 2007 amendment to the Mental Health Act in Taiwan.

METHODS

A matched case-control study design was applied. Participants were selected using the National Health Insurance Research Database (NHIRD) in Taiwan. The control and case data were collected in 2006 and 2011, and the number of compulsory admission cases was recorded with a case-control ratio of 1:4, along with information on age (±3 years) and gender. In 2006, the number of patients recruited was 9265, including 1853 compulsorily admitted patients and 7412 voluntarily admitted patients. In 2011, the number of patients recruited was 4505, including 901 compulsorily admitted patients and 3604 voluntarily admitted patients.

RESULTS

The data collected for the patients who underwent compulsory admission before and after the amended Mental Health Act included gender, diagnosis, Charlson Comorbidity Index Score (CCIS), length of stay in an acute hospital ward (days), hospital accreditation level, ownership, teaching hospital status, psychiatrist gender and age, and hospital location. Although the number of compulsory admission cases (1853 vs. 901) markedly decreased and the length of stay in an acute hospital ward (30.7 ± 25.0 days vs. 39.0 ± 22.6 days) increased from 2006 to 2011, the readmission rate was reduced from 52.6% in 2006 to 42.5% in 2011.

CONCLUSIONS

The average lengths of hospital stay and community survival time were greater for compulsorily admitted patients than those for voluntarily admitted patients. This result might be attributed to a number of changes implemented since the 2007 amendment of the Mental Health Act, including a strict review process for compulsory admissions and a new discharge planning process, which require further research for approval.

Schizophrenia in Afro-Caribbean Immigrants

Hospital admission rates for schizophrenia are higher in Afro-Caribbean immigrants to Britain than in the white British-born population. However, the reported differences in incidence and prevalence could be due to confounding variables: the diagnosis of schizophrenia might not carry the same prognostic implications in the two groups; and the differences in formal admission rates might not persist when demographic and diagnostic differences are allowed for. The case-notes of 50 Afro-Caribbean immigrants and 41 British-born white patients with a hospital diagnosis of schizophrenia were examined retrospectively, the average period covered being 12 years. There were no differences in the number of readmissions, but in the Afro-Caribbean group readmissions were shorter. Involuntary admissions were twice as common in Afro-Caribbeans and this excess was not explained by differences in age, sex, or type of illness. The reported excess of schizophrenia in Afro-Caribbean immigrants to Britain is real, but the illness seems to run a milder course than in the white British-born population.

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.

Risk factors for readmission in schizophrenia patients following involuntary admission

Background

Individuals with schizophrenia who are involuntarily admitted may have poorer prognosis, including higher readmission rates, than those voluntarily admitted. However, little is known about the risk factors for readmission in those schizophrenia patients who are involuntarily admitted.

Aims

We aim to explore the risk factors for readmission in this population.

Method

We enrolled 138 schizophrenia patients with involuntary admission from July 2008 to June 2013 and followed those patients for readmission outcomes at 3 months and at 1 year.

Results

The one-year and 3-months readmission rates were 33.3% and 15.2%, respectively. Unmarried status (adjusted odds ratio (aOR) = 6.28, 95% CI: 1.48–26.62), previous history of involuntary admission (aOR = 4.08, 95% CI: 1.19–14.02), longer involuntary admission days (aOR = 1.04, 95% CI: 1.01–1.07) and shorter total admission days (aOR = 1.03, 95% CI: 1.01–1.05) were associated with increased risk for 1-year readmission. Younger age (aOR = 1.10, 95% CI 1.02–1.18) was associated with increased risk for 3-months readmission.

Conclusions

Unmarried status, prior history of involuntary admission, longer involuntary admission days and shorter total admission days were associated with increased risk for 1-year readmission. Healthcare providers may need to focus on patients with these risk factors to reduce subsequent readmissions.

On addressing ‘Whiteness’ during clinical psychology training

In discussing ‘Whiteness’, a context is provided as to current issues facing British clinical psychology, with an overview of the history of clinical psychology in the United Kingdom, and a particular focus on how issues of immigration, diversity, and racism have been addressed. Following this, the constantly changing training context of clinical psychologists within Britain is explored, with lacunae evident around confronting institutional racism and Black trainee experiences. The history of addressing this issue within the University of East London’s clinical psychology training programme is outlined, as well as the recent introduction of workshops to focus on ‘Whiteness’ and ‘decolonising’ the profession, in response to consistent trainee concerns. This is integrated with respect to focusing on the sorts of psychologists that might be needed to advance and transform the profession positively in the current global political climate.

The Low Proportion and Associated Factors of Involuntary Admission in the Psychiatric Emergency Service in Taiwan

Background

The involuntary admission regulated under the Mental Health Act has become an increasingly important issue in the developed countries in recent years. Most studies about the distribution and associated factors of involuntary admission were carried out in the western countries; however, the results may vary in different areas with different legal and socio-cultural backgrounds.

Aims

The aim of this study was to investigate the proportion and associated factors of involuntary admission in a psychiatric emergency service in Taiwan.

Methods

The study cohort included patients admitted from a psychiatric emergency service over a two-year period. Demographic, psychiatric emergency service utilization, and clinical variables were compared between those who were voluntarily and involuntarily admitted to explore the associated factors of involuntary admission.

Results

Among 2,777 admitted patients, 110 (4.0%) were involuntarily admitted. Police referrals and presenting problems as violence assessed by psychiatric nurses were found to be associated with involuntary admission. These patients were more likely to be involuntarily admitted during the night shift and stayed longer in the psychiatric emergency service.

Conclusions

The proportion of involuntary admissions in Taiwan was in the lower range when compared to Western countries. Dangerous conditions evaluated by the psychiatric nurses and police rather than diagnosis made by the psychiatrists were related factors of involuntary admission. As it spent more time to admit involuntary patients, it was suggested that multidisciplinary professionals should be included in and educated for during the process of involuntary admission.

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.

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.

At the crossroads of anthropology and epidemiology: current research in cultural psychiatry in the UK

Cultural psychiatry research in the UK comprises a broad range of diverse methodologies, academic disciplines, and subject areas. Methodologies range from epidemiological to anthropological/ethnographic to health services research; mixed methods research is becoming increasingly popular, as are public health and health promotional topics. After briefly outlining the history of cultural psychiatry in the UK we will discuss contemporary research. Prominent themes include: the epidemiology of schizophrenia among Africans/Afro-Caribbeans, migration and mental health, racism and mental health, cultural identity, pathways to care, explanatory models of mental illness, cultural competence, and the subjective experiences of healthcare provision among specific ethnic groups such as Bangladeshis and Pakistanis. Another strand of research that is attracting increasing academic attention focuses upon the relationship between religion, spirituality, and mental health, in particular, the phenomenology of religious experience and its mental health ramifications, as well as recent work examining the complex links between theology and psychiatry. The paper ends by appraising the contributions of British cultural psychiatrists to the discipline of cultural psychiatry and suggesting promising areas for future research.

Compulsory admissions of emergency psychiatric inpatients in Turin: the role of diagnosis

Many studies have found high levels of compulsory admission (CA) among non-affective psychoses. Aims of the present study were to investigate whether there was a mere association between diagnosis and CA in a cohort of 848 patients referring to a Psychiatric Emergency Service in a catchment area in Turin during a 2-year period, independent of socio-demographic features, psychiatric history, and clinical status. Diagnosis as a risk factor for CA was assessed constructing a logistic regression model, using the following steps: first, assessing the association between diagnoses and CA, without controlling for confounding factors; second, entering socio-demographic factors; third, entering socio-demographic factors and psychiatric history; and fourth, entering socio-demographic, psychiatric history, and aspects of clinical presentation into the model. At step 1 patients with Non Affective Psychoses, Mania and Personality Disorders had a significantly higher CA risk, compared to patients with Depressive Disorders. At step 4 diagnosis was no longer associated with CA. History of CAs within past 5years and Brief Psychiatric Rating Scale (BPRS) hostile-suspiciousness were positively associated with CA. Length of illness, history of previous suicidal attempts and BPRS anxiety-depression were negatively associated with CA. Overall, the percentage of correctly predicted cases was 39.8%. The remaining 60% can be explained by inherent variability or unknown, lurking variables. Finally, the study was carried out at a single facility. Much of the increased CA likelihood in diagnostic categories might be attributable to specific symptom patterns, not to patients' severity of illness or diagnosis per se.

Ethnicity, violent offending, and vulnerability to schizophrenia: a pilot study

Previous research has highlighted increased risk for schizophrenia in Afro-Caribbeans as well as over-representation in the prison population. This small-scale study examined the relationship between criminality, ethnicity, and psychosis-proneness in a male prison sample. Twenty British Caucasian and 20 Afro-Caribbean prisoners were divided into equal sub-groups of violent and non-violent offenders. Participants completed measures of schizotypy, delusional ideation, and hostility. Afro-Caribbean offenders scored more highly on negative schizotypy and delusional ideation than their Caucasian counterparts. Violent offenders scored more highly on the positive symptoms of schizotypy than non-violent prisoners. Both ethnicity and violent offending may be relevant factors when considering vulnerability to psychosis in the offending population.

Ethnic variations in pathways to acute care and compulsory detention for women experiencing a mental health crisis

BACKGROUND

Much recent debate on excess rates of compulsory detention and coercive routes to care has focused on young black men; evidence is less clear regarding ethnic variations among women and factors that may mediate these.

AIM

To explore ethnic variations in compulsory detentions of women, and to explore the potential role of immediate pathways to admission and clinician-rated reasons for admission as mediators of these differences.

METHOD

All women admitted to an acute psychiatric inpatient ward or a women's crisis house in four London boroughs during a 12-week period were included. Data were collected regarding their pathways to care, clinician-rated reasons for admission, hospital stays, and social and clinical characteristics.

RESULTS

Two hundred and eighty seven (287) women from white British, white other, black Caribbean, black African and black other groups were included. Adjusting for social and clinical characteristics, all groups of black patients and white other patients were significantly more likely to have been compulsorily admitted than white British patients; white British patients were more likely than other groups to be admitted to a crisis house and more likely than all the black groups to be admitted because of perceived suicide risk. Immediate pathways to care differed: white other, black African and black other groups were less likely to have referred themselves in a crisis and more likely to have been in contact with the police. When adjustment was made for differences in pathways to care, the ethnic differences in compulsory admission were considerably reduced.

DISCUSSION

There are marked ethnic inequities not only between white British and black women, but also between white British and white other women in experiences of acute admission. Differences between groups in help-seeking behaviours in a crisis may contribute to explaining differences in rates of compulsory admission.

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.

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.

Admission to women's crisis houses or to psychiatric wards: women's pathways to admission

OBJECTIVE

This study compared the sociodemographic and clinical characteristics and pathways to admission for women admitted to women's crisis houses and to psychiatric hospitals. A women's crisis house is a residential mental health crisis facility for women who would otherwise be considered for voluntary hospital admission.

METHODS

A survey of all 388 female admissions to women's crisis houses and psychiatric hospitals in four boroughs of London during a 12-week period in 2006 was conducted with questionnaires administered to key workers involved in the admissions.

RESULTS

Pathways to admission were significantly less complex for women admitted to the crisis houses (fewer preadmission contacts with police, emergency departments, and other services). Women admitted to psychiatric wards were more likely to require supervision or observation. A multivariate analysis of data for the 245 voluntary admissions indicated that women admitted to women's crisis houses were significantly less likely to have a care coordinator (odds ratio [OR]=.528) or to have gone to an accident and emergency department (OR=.214) before admission. No other differences were found between the two groups.

CONCLUSIONS

Pathways to admission were somewhat different for women admitted to women's crisis houses, but few clinical or sociodemographic differences were found between the two groups. Women's crisis houses may be a viable alternative to traditional wards for voluntary patients not needing intensive supervision and observation. Research should examine whether women's crisis houses are as effective as traditional inpatient services in treating women with acute psychiatric problems.

Ethnicity and the Mental Health Act 1983

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Trends in involuntary psychiatric hospitalization in Israel 1991-2000

BACKGROUND

Though information about involuntary psychiatric hospitalizations (IPH) is crucial for the planning of Israel's National Mental Health Care Policy, very few studies have been carried out to date on this subject.

AIMS

To identify trends in first IPH to all inpatient psychiatric settings in Israel.

METHOD

The sample included all admissions of adults (18 years and older) over the ten-year period, 1991-2000, according to the registration of such admissions in the National Psychiatric Case Registry.

RESULTS

A 2.4-fold increase was found in first IPH over the decade studied. The typical profile of the involuntarily admitted patient was that of a native-born Jewish male, aged 18-24 or 65 and older, single, with less than 8 years of education, and with a diagnosis of schizophrenia or delusional psychosis.

CONCLUSIONS

These findings suggest the need for improving the interfaces between hospital and community services, and for preparing specific guidelines to extend the use of involuntary ambulatory treatment orders. Further study is needed to explore the respective roles of involuntary inpatient and outpatient treatment.

Ethnic differences among patients in high-security psychiatric hospitals in England

BACKGROUND

Black (Black Caribbean and Black African) patients are over-represented in admissions to general adult and medium-security psychiatric services in England.

AIMS

To describe the sociodemographic, clinical and offence characteristics of patients in high-security psychiatric hospitals (HSPHs) in England, and to compare admission rates and unmet needs by ethnic group.

METHOD

A total of 1255 in-patients were interviewed, and their legal status, socio-demographic characteristics and individual treatment needs were assessed.

RESULTS

Black patients in HSPHs are over-represented by 8.2 times (range 3.2-24.4,95% CI 7.1-9.3), are more often male (P=0.037), and are more often diagnosed with a mental illness and less often diagnosed with a personality disorder or learning disability (P<0.001) than White patients. Unmet needs were significantly less common among White than among Black patients (mean values of 2.22 v. 2.62, difference=0.40,95% CI 0.06-0.73).

CONCLUSIONS

Compared with the proportion of Black patients in the general population in their region of origin, a much higher proportion of Black patients were admitted to HSPHs, and fewer of their needs were met.

Race, culture and psychiatry: a history of transcultural psychiatry

The term 'transcultural psychiatry' has encompassed changing notions of race, culture and psychiatry and, as a result, it is a difficult concept to define. For a long time psychiatrists and social scientists have been commenting on how the psyches and psychiatric illnesses differ in non-White populations. However, transcultural psychiatry was not created as a distinct discipline until after World War II. This article will attempt to tell the story of transcultural psychiatry, charting its genesis in the aftermath of World War II, and then go on to describe how it has taken different forms in response to developments within psychiatry and wider sociocultural changes.

Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study

BACKGROUND

Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African-Caribbean and Black African patients with a psychotic illness.

AIMS

To establish whether African-Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres.

METHOD

All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (AESOP) study. For this analysis we included all White British, other White, African-Caribbean and Black African patients from the AESOP sampling frame. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes.

RESULTS

African-Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African-Caribbean men were the most likely to be compulsorily admitted.

CONCLUSIONS

These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African-Caribbean and Black African patients.

Ethnicity and its relevance in a seven-year admission cohort to an English national adolescent medium secure health service unit

BACKGROUND

There is some research which variously suggests that adults from some ethnic minority groups in the UK may be disproportionately likely to attract certain psychiatric diagnoses, and, in turn, to be admitted to inpatient facilities and compulsorily detained there; there are concerns too about over-representation in the criminal justice system. Little such work has been done with adolescents.

AIMS

To determine the proportion of young people from ethnic minorities admitted to one UK specialist medium secure hospital unit for adolescents and describe their diagnoses.

METHODS

Data were extracted from the case records of all 61 young people admitted to this unit at any time between 1 April 1995 and 31 March 2002.

RESULTS

Inpatients from ethnic minority backgrounds were significantly over-represented when compared with National Census data. This was mainly accounted for by inpatients from Black African (11%) and Black Caribbean backgrounds (8%). There were, however, no within unit differences in final diagnoses between the ethnic groups.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our findings confirm both a high overall proportion of young people from ethnic minorities using a national medium secure hospital service and considerable ethnic diversity within that. They are discussed in the context of one relevant national government initiative for improving responses to minority groups.

Social exclusion and risk of emergency compulsory admission. A case-control study

BACKGROUND

Emergency detentions under section 4 of the Mental Health Act 1983 are more frequent in socially deprived areas of England and Wales. However, it is not clear whether individual socio-economic disadvantage increases likelihood of emergency detention. Therefore, this study tests the hypothesis that a higher proportion of people who are socially excluded will be admitted to hospital under section 4 than those who are not.

METHODS

A total of 300 mental health act assessments in two London boroughs with different rates of section 4 admissions were studied by retrospective case note review in a case-control design. An index of social exclusion was created and piloted for this study.

RESULTS

The logistic regression analysis discovered four risk factors for section 4 admissions: presenting with a risk to self or others at the mental health act assessment, bi-polar affective disorder, non-White British ethnicity and low social support. There were no significant differences between the two boroughs on these variables. Risk factors for any compulsory admission were: presenting with a risk, psychosis and non-White British ethnicity.

CONCLUSION

This study found low social support to be the only social exclusion indicator that increases likelihood of admission under section 4. While individual-level variables explain some of the variation in section 4 rates, it is likely that, as indicated by other studies, different configurations of mental health services affect rates to a greater degree.

Factors influencing compulsory admission in first-admitted subjects with psychosis

BACKGROUND

There is a growing body of evidence that patients with early psychosis have undesirable pathways to care, yet few studies have explored the factors related to compulsory admission in patients with psychosis. The aim of the present study was to examine the demographic and clinical factors and pathways to care influencing compulsory admission in first-admitted subjects with psychosis.

METHODS

Pathways to care, clinical and demographic characteristics, were assessed using multiple sources of information in 86 subjects with psychosis first admitted in two hospitals of South-Western France. Characteristics independently associated with compulsory admission were explored using logistic regressions.

RESULTS

Nearly two-thirds of the subjects (61.6%) were compulsorily admitted. Compulsory admission was independently predicted by being a male (adjusted OR = 3.2, 95 % CI 1.2-8.6, p = 0.02), having a diagnosis of schizophrenia broadly defined (adjusted OR = 2.8, 95 % CI 1.02-7.4, p = 0.04) and absence of depressive or anxiety symptoms (adjusted OR = 0.05, 95% CI 0.005-0.5, p=0.01).

CONCLUSION

These results suggest that factors related to the disease itself play an important role in decisions concerning compulsory admission. The high frequency of compulsory admission as the first mode of contact with psychiatric hospital in subjects with psychosis constitutes a major public health issue. Further research on the strategies aimed at avoiding compulsory admission in subjects with incipient psychosis is necessary.

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

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

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

African and African Caribbean users' perceptions of inpatient services

It has been suggested that well-documented differences in African and African Caribbean people's contact with mental health services may stem from the organization, processes and practices of services themselves. This article presents the findings of a qualitative study which explored the inpatient experiences of a sample of African and African Caribbean people. Although some positive experiences were described, in the main, participants' accounts revolved around a sense of loss of control and around experiences of overt and implicit racism. Underpinning these experiences were relationships with staff that were perceived to be unhelpful. On the basis of both the positive and negative experiences described, we draw conclusions about the changes required to ensure that inpatient services more effectively meet the needs of this group.

Formal justifications for compulsory psychiatric detention

The formal justifications for all detentions under s.2 of the Mental Health Act 1983 within an inner-city mental health trust were examined over a 12-month period. The study explored: the nature of the justifications for detention; the extent to which these were associated with patient characteristics; and the extent to which the two medical practitioners involved in each case agreed on the justifications. The justifications reflected a greater emphasis on the protection of the individual concerned rather than the protection of others. A content analysis of the textual justifications revealed five broad themes: the nature of the risk posed by the patient; the patient's capacity to provide informed consent; their need for hospitalization; their lack of consent to informal admission; and their reliability or likely compliance. There was a significant association between patients' sex, ethnic group, diagnosis and the nature of risk indicated in the documentation, but further research is needed to clarify the nature of this association. The study found that in nearly a quarter of cases, the two professionals did not agree about whether or not the patient presented a danger to others. This lack of agreement was not associated with any patient or professional characteristics, and may reflect the complexity of this area of risk assessment. The authors suggest that the issue of 'risk' needs to be addressed in a more sophisticated manner within the Mental Health Act. Specifically, further guidance is needed as to the nature and levels of risk that constitute grounds for detention. Further guidance is also needed regarding the issues that need to be recorded on the legal documentation for detention.

Use of the Mental Health Act criteria in the decision-making process for compulsory admissions: a study of psychiatrists in South London

This study investigates the decision-making process for admitting patients compulsorily under the Mental Health Act 1983 of England and Wales. We used three case-vignettes describing different clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. The vignettes were administered to a group of psychiatrists working at the Bethlem Royal and Maudsley Hospitals in South London. The psychiatrists were asked to rate 11 factors from the most to the least important in their decision to admit the individual compulsorily. Three factors resembled the criteria considered in the Mental Health Act 1983 for compulsory admission: current mental state; severity of the disease; and dangerousness to self or others. Three were other clinical features of the patient: diagnosis; psychiatric history; and likely response of the mental state to the medical treatment. The remaining five were sociodemographic features of the patient: age and gender; owning a home; occupational status; and social support available. The psychiatrists were not given the option that the patient would accept a voluntary admission to hospital. We obtained responses from 42 psychiatrists (25 males and 17 females). The most important factor for deciding to detain a patient compulsorily was perceived dangerousness to self and others. The current mental state of the patient and the severity of the illness were the next two important factors. Our results confirm that the criteria recommended by the Mental Health Act 1983 of England and Wales were applied consistently in three different hypothetical situations. The need for protection of the patient or others may take precedence over the current mental state of the patient or the severity of the illness, a finding that warrants further investigation in view of the current debate on the responsibility of psychiatrists in deciding to detain subjects affected by personality disorder.

Schizophrenia: a review of current research and thinking

Schizophrenia is the major mental illness of our time and causes serious disturbances for those with the condition as well as using up significant proportions of scarce health resources. This paper reviews the recent literature on advances in classification, aetiology, epidemiology and treatments. Methodological problems encountered in researching this condition are discussed. Advances in treatments offered for this condition have improved outcomes but whether the patient receives these treatments may depend on what local services are prepared to offer.

Immigration, moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991-1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.

The philosophical and sociological context of mental health care legislation

This paper explores mental health legislation from a philosophical and sociological perspective. It is argued that mental health law exists primarily as a coercive social control instrument and that the maintenance of a separate legislative framework for the mentally ill is based upon dubious legal and philosophical grounds. The need for changes in mental health law has been accelerated by the move in Britain toward care in the community. One of the most important issues at the centre of the debate revolves around the concept of 'dangerousness' and mental disorder. The research into the extent to which the risk of violence can be predicted appears problematic from a reform perspective. Prediction is considered to be the overriding problem that leads to a violation of patients' civil rights, especially in relation to black and ethnic minority groups. Equity in law is necessary for the protection of patient's rights and particularly for the protection of those people who enter mental health care systems concerned with issues of control at the expense of care.

Community care services for the mentally ill: consumers' views

In this study a broadly representative sample of clients in the City of Westminster, receiving Care in the Community for reasons of mental ill-health, were interviewed regarding their experiences of, and levels of satisfaction with, services provided. The results reveal the vulnerability of services users, the benefits of community care, the high regard the majority have for their helpers, the limitations imposed by scarce resources, and the negative effects of only loose co-ordination between health and social services. Respondents also provide a rich source of data on how services might be improved.

Ethnic differences in risk of compulsory psychiatric admission among representative cases of psychosis in London

OBJECTIVE

To compare the risk of detention under the Mental Health Act 1983 in a representative group of people with psychotic disorders from different ethnic groups.

SETTING

Two defined geographical areas in south London.

DESIGN

Annual period prevalent cases of psychosis were identified in 1993 in the study areas from hospital and community data. Standardised criteria were applied to case notes to establish diagnosis and detention under the act.

SUBJECTS

535 patients were identified, of whom 439 fulfilled ICD-10 criteria for psychosis.

MAIN OUTCOME MEASURES

Risk of ever having been detained under the Mental Health Act 1983, risk of detention under specific sections of the act during the study year, and risk of contact with forensic services for the different ethnic groups.

RESULTS

439 patients with a psychotic illness were identified. Nearly half of the white patients had been detained under the act compared with 70% and 69% of black Caribbean and black African patients, respectively. Black Caribbean and black African patients were more likely than white patients to have been involuntarily detained (adjusted odds ratio 3.67; 95% confidence interval 2.07 to 6.50 and 2.88; 1.04 to 7.95, respectively). Rates of use of sections 2, 3 and 136 in the study year were higher for black than for white patients, and black patients were more likely than white patients to have been admitted to a psychiatric intensive care facility or prison.

CONCLUSION

Independent of psychiatric diagnosis and sociodemographic differences, black African and black Caribbean patients with psychosis in south London were more likely than white patients to have ever been detained under the Mental Health Act 1983.

Schizophrenia: a review of the contemporary literature and implications for mental health nursing theory, practice and education

Contemporary research in the aetiology, neuropsychology and epidemiology of schizophrenia is reviewed. The picture coming from this work is a group of brain diseases of neurodevelopmental origin which manifest themselves in a variety of ways. In turn, there are a range of cognitive deficits associated with the schizophrenias which may, in the extreme, produce major functional handicap. This new knowledge has obvious implications for nurse education and a priority is to place this in undergraduate programmes. However, more importantly, it is argued that we need to alter conceptual frameworks. for example, in some cases we should care for people with schizophrenia in the same way as one would care for an individual suffering the after-effects of a head injury. In the more severe forms of the illness we should take into account the probability that our patients may have significant problems of memory and attention, and thus modify interventions accordingly. It seems clear that our current nursing theories are not underpinned by relevant knowledge of the nature of schizophrenia and this problem warrants urgent attention.