Access to mental health care in an inner-city health district. II: Association with demographic factors

Investigating geographical variation in the use of mental health services by area of England: a cross-sectional ecological study

BACKGROUND

There is evidence of geographical variation in the use of mental health services in the UK and in international settings. It is important to understand whether this variation reflects differences in the prevalence of mental disorders, or if there is evidence of variation related to other factors, such as population socioeconomic status and access to primary care services.

METHODS

This is a cross-sectional ecological study using Public Health England data. The unit of analysis was the population served by clinical commissioning groups (CCGs), National Health Service (NHS) catchment areas. The analysis explored associations between area characteristics and the number of people in contact with mental health services using regression modelling. Explanatory variables included age, gender, prevalence of severe mental illness (SMI), prevalence of common mental disorder (CMD), index of multiple deprivation (IMD), unemployment, proportion of the population who are Black and Minority Ethnic (BAME), population density, access to and recovery in primary care psychological therapies. Unadjusted results are reported, as well as estimates adjusted for age, prevalence of CMD and prevalence of SMI.

RESULTS

The populations of 194 CCGs were included, clustered within 62 trusts (NHS providers of mental health services). The number of people in contact with mental health services showed wide variation by area (range from 1131 to 5205 per 100,000 population). Unemployment (adjusted IRR 1.11; 95% CI 1.05 to 1.17; p < 0.001) and deprivation (adjusted IRR 1.02 95% CI 1.01 to 1.04; p < 0.001) were associated with more people being in contact with mental health services. Areas with a higher proportion of the population who are BAME (IRR 0.95 95% CI 0.92 to 0.99 p = 0.007) had lower service use per 100,000 population. There was no evidence for association with access to primary care psychological therapies.

CONCLUSIONS

There is substantial variation in the use of mental health services by area of England. Social factors including deprivation, unemployment and population ethnicity continued to be associated with the outcome after controlling for the prevalence of mental illness. This suggests that there are factors that influence the local population use of mental health services in addition to the prevalence of mental disorder.

Prenatal Psychological Distress and Access to Mental Health Care in the ELFE Cohort

Background:

Pregnant women are vulnerable to the deleterious impact of environmental stressors. The aims were to identify the environmental and pregnancy characteristics independently associated with prenatal psychological distress and access to mental health care.

Methods:

We used data from the French cohort Étude Longitudinale Française depuis l’Enfance (ELFE), a nationally representative cohort of children followed-up from birth to adulthood. Information about prenatal psychological status and access to mental health care was collected during the maternity stay. Maternal/pregnancy characteristics independently associated with psychological distress and access to mental health care were explored using multivariate analyses.

Results:

Of the 15,143 mothers included, 12.6% reported prenatal psychological distress. Prenatal distress was more frequent in women with very low economical status, alcohol/tobacco use, unplanned/unwanted pregnancy, late pregnancy declaration, multiparity and complicated pregnancy (high number of prenatal visits, prenatal diagnosis examination, obstetrical complications). Of the women reporting prenatal distress, 25% had a prenatal consultation with a mental health specialist and 11% used psychotropic drugs during pregnancy. Decreased likelihood to consult a mental health specialist was found in young women, with intermediate educational level and born abroad.

Limitations:

Causal inferences should be made cautiously as the questionnaire did not collect information on the temporal sequence between psychological distress and associated characteristics.

Conclusions:

Women with social and obstetrical vulnerabilities are at increased risk of poor mental health during pregnancy. Improving mental health care access during pregnancy is a public health priority.

A retrospective observational analysis to identify patient and treatment-related predictors of outcomes in a community mental health programme

OBJECTIVES

This study aims to identify patient and treatment factors that affect clinical outcomes of community psychological therapy through the development of a predictive model using historic data from 2 services in London. In addition, the study aims to assess the completeness of data collection, explore how treatment outcomes are discriminated using current criteria for classifying recovery, and assess the feasibility and need for undertaking a future larger population analysis.

DESIGN

Observational, retrospective discriminant analysis.

SETTING

2 London community mental health services that provide psychological therapies for common mental disorders including anxiety and depression.

PARTICIPANTS

A total of 7388 patients attended the services between February 2009 and May 2012, of which 4393 (59%) completed therapy, or there was an agreement to end therapy, and were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Different combinations of the clinical outcome scores for anxiety Generalised Anxiety Disorder-7 and depression Patient Health Questionnaire-9 were used to construct different treatment outcomes.

RESULTS

The predictive models were able to assign a positive or negative clinical outcome to each patient based on 5 independent pre-treatment variables, with an accuracy of 69.4% and 79.3%, respectively: initial severity of anxiety and depression, ethnicity, deprivation and gender. The number of sessions attended/missed were also important factors identified in recovery.

CONCLUSIONS

Predicting whether patients are likely to have a positive outcome following treatment at entry might allow suitable modification of scheduled treatment, possibly resulting in improvements in outcomes. The model also highlights factors not only associated with poorer outcomes but inextricably linked to prevalence of common mental disorders, emphasising the importance of social determinants not only in poor health but also poor recovery.

Variation in compulsory psychiatric inpatient admission in England: a cross-sectional, multilevel analysis

Background

Rates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes.

Objectives

To quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places.

Design

Cross-sectional analysis using multilevel statistical modelling.

Setting

England, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services.

Participants

1,287,730 patients.

Main outcome measure

The study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period.

Data sources

The Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers.

Results

A total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models.

Conclusions

This was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Improving mental health outcomes: achieving equity through quality improvement

OBJECTIVE

To investigate equity of patient outcomes in a psychological therapy service, following increased access achieved by a quality improvement (QI) initiative.

DESIGN

Retrospective service evaluation of health outcomes; data analysed by ANOVA, chi-squared and Statistical Process Control.

SETTING

A psychological therapy service in Westminster, London, UK.

PARTICIPANTS

People living in the Borough of Westminster, London, attending the service (from either healthcare professional or self-referral) between February 2009 and May 2012.

INTERVENTION

s) Social marketing interventions were used to increase referrals, including the promotion of the service through local media and through existing social networks.

MAIN OUTCOME MEASURE

s) (i) Severity of depression on entry using Patient Health Questionnaire-9 (PHQ9). (ii) Changes to severity of depression following treatment (ΔPHQ9). (iii) Changes in attainment of a meaningful improvement in condition assessed by a key performance indicator.

RESULTS

Patients from areas of high deprivation entered the service with more severe depression (M = 15.47, SD = 6.75), compared with patients from areas of low (M = 13.20, SD = 6.75) and medium (M = 14.44, SD = 6.64) deprivation. Patients in low, medium and high deprivation areas attained similar changes in depression score (ΔPHQ9: M = -6.60, SD = 6.41). Similar proportions of patients achieved the key performance indicator across initiative phase and deprivation categories.

CONCLUSIONS

QI methods improved access to mental health services; this paper finds no evidence for differences in clinical outcomes in patients, regardless of level of deprivation, interpreted as no evidence of inequity in the service with respect to this outcome.

Ethnic variation in the prevalence of depression and anxiety in primary care: a systematic review and meta-analysis

Primary care plays a key role in the detection and management of depression and anxiety. At present it is not clear if the prevalence of depression and anxiety in primary care differs between migrants and ethnic minorities (MI) and natives and ethnic majorities (MA). A systematic review and a meta-analysis of studies comparing the prevalence of depression and anxiety in MI and MA in primary care were performed. Studies were identified by searching MEDLINE, PsychINFO, EMBASE and through hand-search. We included 25 studies, most of which had a relatively small sample size. Significant variations were found in the prevalence of anxiety and depression across studies. Pooled analyses were carried out for 23 studies, based on random-effects models. Pooled RR of depression and anxiety in MI were 1.21 (95% CI 1.04-1.40, p=0.012) and 1.01 (95% CI 0.76-1.32, p=0.971), with high heterogeneity (I²=87.2% and I²=73%). Differences in prevalence rates among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. Further research on larger samples and with culturally adapted instruments is needed to estimate the prevalence of depression and anxiety in MI seeking help for these disorders.

Experiences of acute mental health care in an ethnically diverse inner city: qualitative interview study

PURPOSE

Ethnic inequalities in experiences of mental health care persist in the UK, although most evidence derives from in-patient settings. We aimed to explore service users' and carers' accounts of recent episodes of severe mental illness and of the care received in a multi-cultural inner city. We sought to examine factors impacting on these experiences, including whether and how users and carers felt that their experiences were mediated by ethnicity.

METHODS

Forty service users and thirteen carers were recruited following an acute psychotic episode using typical case sampling. In-depth interviews explored illness and treatment experiences. Ethnicity was allowed to emerge in participants' narratives and was prompted if necessary.

RESULTS

Ethnicity was not perceived to impact significantly on therapeutic relationships, and nor were there ethnic differences in care pathways, or in the roles of families and friends. Ethnic diversity was commonplace among both service users and mental health professionals. This was tolerated in community settings if efforts were made to ensure high-quality care. Home Treatment was rated highly, irrespective of service users' ethnicity. In-patient care was equally unpopular and was the one setting where ethnicity appeared to mediate unsatisfactory care experiences. These findings highlight the risks of generalising from reports of (dis)satisfaction with care based predominantly on in-patient experiences.

CONCLUSIONS

Home treatment was popular but hard to deliver in deprived surroundings and placed a strain on carers. Interventions to enhance community treatments in deprived areas are needed, along with remedial interventions to improve therapeutic relationships in hospital settings.

Use of translated versions of the MMSE with South Asian elderly patients in the UK

The elderly population is increasing all over the world, a trend expected to continue well into the next century, particularly in low-income countries (Levkoff et al, 1995). There is an established association between increasing age and cognitive decline (Fillenbaum, 1984) and dementias are common in this age group.

Variations in anxiolytic and hypnotic prescribing by GPs: a cross-sectional analysis using data from the UK Quality and Outcomes Framework

BACKGROUND

Wide variations in anxiolytic and hypnotic prescribing by GPs in England have been described, but are largely unexplained.

AIM

To examine the relationships between the volume of anxiolytics and hypnotics prescribed by GPs and their practice characteristics, population demography, and performance indicators.

DESIGN OF STUDY

Cross-sectional study.

SETTING

All general practices in England.

METHODS

A dataset was constructed for 8469 (98.8%) general practices including: standardised prescribing volume data for anxiolytics and hypnotics (average daily quantities per 1000 STAR-PUs [Specific Therapeutic group Age-sex weightings Related Prescribing Units]), practice descriptors, Index of Multiple Deprivation 2004, ethnicity data (2001 UK Census), and Quality and Outcomes Framework (QOF) data.

RESULTS

The standardised volume of anxiolytics and hypnotics prescribed varied eightfold between practices on the 5th and 95th centiles. A regression model was constructed which explained 20.5% of the variation. Higher prescribing practices were located in more deprived areas (standardised beta 0.31), but also in areas with a lower proportion of ethnic minorities (black or black British = -0.22; Asian or Asian British = -0.12). Higher volumes were also prescribed by practices with lower QOF scores ('Clinical Care' domain = -0.12; 'Organisational' domain = -0.08). Other significant but weaker predictors were: lower proportions of female GPs, higher recorded prevalence of serious mental illness and non-training status. The proportion of GPs trained outside UK was not a predictor.

CONCLUSION

Demographic factors were more powerful determinants of prescribing than characteristics of the practice itself. Nevertheless, the findings provide some support for the notion that high prescribing practices were less well developed, in that their QOF scores were lower and they were less likely to be training practices.

Disengagement from mental health services. A literature review

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

Patient-physician communication in the primary care visits of African Americans and whites with depression

BACKGROUND

Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment.

OBJECTIVE

The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices.

MAIN OUTCOMES

Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys.

RESULTS

African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07).

CONCLUSIONS

This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.

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

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Conceptual models of treatment in depressed Hispanic patients

PURPOSE

Though patient variables are likely to play an important role in the undertreatment of depression, little is known of patients' perceptions of standard depression treatments. In an effort to understand their perspective, we investigated depressed Hispanic patients' perceptions of primary care treatments and the specific benefits associated with them.

METHODS

We undertook semistructured interviews with 121 depressed Hispanic medical patients waiting for their appointments. We developed and implemented a coding scheme using standard iterative procedures.

RESULTS

More than one half of the patients viewed physician consultation and medication as helpful. Almost all patients considered psychotherapy to be helpful. Supportive talk was the most commonly mentioned specific benefit of physician consultation. The most common benefit of medication was its anxiolytic, sedative effect; energizing effects were less common. The most common benefits associated with psychotherapy included support, advice, and catharsis. Patients currently taking medication for depression had a more favorable view of pharmacological treatment; differences by language of interview were noted.

CONCLUSIONS

Patients' perceptions of the specific efficacies of depression treatment did not match priorities implicit in current treatment guidelines. Such perceptions may play a key role in shaping patients' decisions to initiate and maintain treatment.

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.

Who treats whom? An application of the Pathways to Care model in Australia

OBJECTIVE

The present paper applies Goldberg and Huxley's Pathways to Care (PTC) model to the Australian health-care system to ask: who is treated in each sector and what does this tell us about the performance of the health-care system? It examines the factors associated with reaching primary care, outpatient and inpatient sectors, as well as private and public mental health services.

METHOD

Data from the Australian National Survey of Mental Health and Wellbeing were used to determine the proportion of the population treated in each sector. Sociodemographic and clinical characteristics were examined and logistic regression was used to determine which factors were associated with use of different sectors of care.

RESULTS

Of the total population, 80.5% reached primary care, 8.2% primary care for mental health problems, 6.5% outpatient care and 0.4% reached the mental health inpatient sector. Clinical severity increased across these sectors and was an important determinant of access to care. Those consulting private practitioners were clinically similar to those consulting in the public sector. Sociodemographic characteristics were important determinants of access to primary, specialist and private mental health care. Being aged over 55 years or living in a rural area was associated with lower access to several sectors.

CONCLUSIONS

Although at a broad level the health-care system is performing as expected, limited access among some groups is cause for concern. Applying the PTC model to a population sample offered useful insights into the performance of the Australian health-care system.

North Birmingham assertive outreach evaluation. Patient characteristics and clinical outcomes

BACKGROUND

Given the adoption of assertive outreach teams into UK mental health policy, it is important to assess whether gains identified in efficacy studies can be replicated in ordinary clinical settings.

AIM

The aim of the study was to assess patient characteristics and clinical outcomes in routine assertive outreach services in the UK.

METHODS

Patients (N=250), newly taken onto five assertive outreach teams, were followed up over 2 years. Baseline characteristics and outcome measures were compared.

RESULTS

Most patients had an International Statistical Classification of Diseases and Related Health Problems, 10th Revision, diagnosis of schizophrenia, schizotypal or delusional disorder and long-standing involvement with psychiatric services. Around a half had a history of substance abuse and violence. At follow-up, the majority had ongoing input from the teams and there was a significant decrease in the use of in-patient care. There was no improvement in symptoms, risk behaviours or social functioning.

CONCLUSION

Patients on assertive outreach teams remain in contact with services and spend less time in hospital yet show little change with respect to clinical outcomes.

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.

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.

Globalisation and mental disorders. Overview with relation to depression

BACKGROUND

Globalisation is the process by which traditional boundaries of cultures are changing. Industrialisation, urbanisation and influence of the media are influencing idioms of distress across cultures.

AIMS

To discuss the role of globalisation, using the epidemiology, diagnosis, clinical presentation and treatment of depression across various cultures as an example.

METHOD

Recent studies focusing on transcultural aspects of depression were reviewed and summarised.

RESULTS

Cultural, social and religious mores account for variations in the presentation of depression across cultures. Somatic symptoms are common presenting features throughout the world and may serve as cultural idioms of distress, but psychological symptoms can usually be found when probed. Feelings of guilt and suicide rates vary across cultures and depression may be underdiagnosed.

CONCLUSIONS

Training packages could enhance clinicians'cultural competency in multicultural settings. However, globalisation is likely to influence idioms of distress and pathways to care in ways that are difficult to predict.

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.

Organizational context and provider perception as determinants of mental health service use

This study refines and tests an individual client model of service use and contrasts it with a model of service provision based on gateway provider perspectives. Structural equation models demonstrate that provider variables account for more service use variation than client variables. The client model accounts for 24% of the variance in service use, while the provider model accounts for 55% of the variance. Youth self-reported mental health was not positively associated with increased services or with provider perception of youth mental health. The provider model demonstrates the critical role played by provider perceptions, which are influenced more by work environment than by client problems.

Psychopathology, adversity, and service utilization of young refugees

OBJECTIVE

To investigate the psychopathology, social impairment, adversities, and service utilization of refugee families and their children seeking help at a child and adolescent psychiatry clinic in London.

METHOD

A retrospective case-control study of 30 refugee children and families individually matched with nonrefugee immigrant families and white British families. Case note review was carried out to obtain data on diagnosis, social adjustment, past adversity, exposure to violence, current socioeconomic circumstances, and use of the child and adolescent psychiatric service.

RESULTS

Refugee children tended to have disorders with a psychosocial etiology rather than neurobiological disorders. Refugees had similar levels of social impairment compared with the other groups. Refugees were much more isolated and disadvantaged and had different referral pathways but were not more likely to drop out of treatment prematurely.

CONCLUSIONS

Refugee children and families had been exposed to high levels of adversity. The ability of community agencies to refer families who could use treatment has significant resource implications.

Validating screening instruments for cognitive impairment in older South Asians in the United Kingdom

BACKGROUND

The numbers of older South Asians in the United Kingdom are rising. Investigation of their mental health has been neglected compared to their physical health.

OBJECTIVES

This study aimed to determine the sensitivity and specificity of modified versions of two screening instruments for cognitive impairment (Mini-Mental State Examination and Abbreviated Mental Test) in a community-based population.

DESIGN

Two-stage study comparing screening instruments against diagnostic interview.

SETTING

South, central and north Manchester.

SUBJECTS

Community-resident South Asians aged 60 years and over.

METHODS

Subjects were approached via their general practitioners and interviewed at home. Sensitivity and specificity for the screening instruments were calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

For the Gujarati population, the MMSE cutoff was >/=24 (sensitivity 100%, specificity 95%) and AMT>/=6 (sensitivity 100%, specificity 95%). For the Pakistani population, the MMSE cutoff was >/=27 (sensitivity 100%, specificity 77%) and AMT>/=7 (sensitivity 100%, specificity 87%).

CONCLUSIONS

Culturally modified versions of the Mini-Mental State Examination and Abbreviated Mental Test are acceptable and may have a high degree of sensitivity. They may assist with the recognition of cognitive impairment, if an appropriate cutoff is used.

Outcomes focused service delivery: developing an academic-management partnership

OBJECTIVE

Current mental health policies emphasise the need for services to be integrated and to develop outcomes-based evaluation systems. An overview of the challenges faced by service managers and clinical academics who develop the appropriate financial, personnel and academic infrastructure for these tasks is presented.

METHOD

By drawing on experiences within the St George Service and references to other services, we propose a model for a successful partnership between the academic and management components of a district service.

RESULTS

Major logistic impediments to the development of a partnership are identified, although the long-term scientific and service delivery benefits are highlighted. Key areas within both academic practice and managerial approaches requiring transformation are discussed.

CONCLUSIONS

A successful long-term partnership between management and an academic department within a district service may provide the opportunity for rapid progress in population-based service evaluation and health outcomes research.