Department of Psychiatry, Barts and the London, Queen Mary's School of Medicine and Dentistry, London, UK
Department of General Practice and Primary Care, Barts and the London, Queen Mary's School of Medicine and Dentistry, London, UK
Department of Psychiatry, Barts and the London, Queen Mary's School of Medicine and Dentistry, London, UK
Department of General Practice and Primary Care, Barts and the London, Queen Mary's School of Medicine and Dentistry, London, UK
Correspondence: Kamaldeep Bhui, Department of Psychiatry, Barts and the London, Queen Mary's School of Medicine and Dentistry, Mile End Road, London E1 4NS, UK. E-mail: k.s.bhui{at}mds.qmw.ac.uk
Funding from London National Health Service Research and Development.
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ABSTRACT |
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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.
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INTRODUCTION |
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METHOD |
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The following bibliographic databases were searched: ASSIA, CINAHL, the Cochrane Trials Register, EMBASE, HealthStar, Medline, PsycLIT, Science Citation Index and SIGLE. The search was restricted to studies published in English between January 1983 and October 2000 inclusive. We identified titles and abstracts of papers that potentially fulfilled our inclusion criteria. The grouped search terms included: (a) GREAT BRITAIN, HEALTH SERVICES, INDIGENOUS ETHNIC GROUP; (b) HOSPITALS, PSYCHIATRIC, MENTAL HEALTH SERVICES, PSYCHIATRY, MENTAL DISORDERS, PSYCHOTROPIC DRUGS; (c) ETHNIC or MULTI-ETHNIC, UK or BRITAIN or LONDON, MENTAL or PSYCHIATRY or PSYCHOTROPIC. In databases where MESH terms were available they were exploded and combined. Searches were adapted for the different databases and performed independently by two reviewers. These searches were supplemented by personal bibliographies of the investigators, forward citation tracking using the Science Citation Index and Social Science Citation Index databases and by references in retrieved articles. We sent a list of all included studies to three external experts, asking them to identify any other relevant studies.
Abstracts, if available, or full papers were assessed independently by two reviewers. All potentially relevant papers were then assessed against inclusion and exclusion criteria. Disagreement was resolved by a third reviewer. Data were extracted independently by two reviewers. Discrepancies were resolved by discussion or by a third reviewer. For studies reporting pathways to specialist mental health care, continuing contact with mental health services and use of in-patient services, we conducted a narrative review because differences in the measurement and reporting of outcomes made combination of point estimates inappropriate. The narrative analysis involved comparison of tabulated data and appraisal of methodological quality (see below). For the review of variation in compulsory admissions to in-patient facilities, in addition to a narrative review, we performed a meta-analysis to quantify variation between ethnic groups in compulsory admission to in-patient facilities. We have expressed the main results as combined odds ratios with the random effects method after performing tests for heterogeneity. We combined data on the proportions of White and Black patients who were compulsorily admitted in the primary studies. We examined publication bias and related biases in a funnel plot and carried out a test of funnel plot asymmetry. All analyses were performed with StatsDirect (http://www.statsdirect.com/).
Two reviewers independently assessed the methodological quality of each published study, with criteria adapted from Raine's review of gender differences in health service use (Table 1; Raine, 2000). We assessed the quality of published studies in four domains: sample source and size; method of ethnic group classification; adjustment for disease and confounding variables, including socio-economic status; and whether ethnic groups were combined appropriately in the analysis. Each of these was equally important in the allocation of quality score. Papers varied in their classification of ethnic groups and these were often aggregated into broad categories. In our analysis we have used the most commonly reported aggregated categories, comparing Black and South Asian groups with White participants. We summarised the results of the papers and examined whether quality scores, geographical location of the research, the composition of the ethnic groups and study design could explain any heterogeneity of findings.
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RESULTS |
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Methodological findings
Most papers reported observational studies in health service settings using
a cross-sectional design, without making a distinction between incident and
prevalent cases (see Table 2).
A total of 34 studies included information from medical records, 15 from
direct interview and 10 used questionnaires. Clearly the majority of studies
are therefore subject to recall bias and information bias, and where samples
were recruited from in-patient and out-patient services, selection bias is
likely to be important. Only three studies were of a prospective cohort design
in which biased assessment of risk factors is minimised. As far as could be
judged, potential biases due to study design did not explain heterogeneity.
Thirty-five papers included Black participants; eight did not distinguish
between people of AfricanCaribbean and African origin. Eight papers
included South Asians as a separate category but did not distinguish between
people of Pakistani, Indian or Bangladeshi origin. Six papers identified White
subgroups but none analysed them separately. Ten papers used country of birth
alongside ethnicity information. Nineteen studies did not use ethnic group
census categories; studies collecting data before 1991 used proxy measures for
ethnic group, such as place of birth. Thirteen papers did not give any
explanation for their classification of ethnic groups. Most papers included
small numbers of participants from each ethnic group. Twenty-eight papers
adjusted for age, 28 for gender and 16 for some measure of socio-economic
status, with 24 taking measures to address potential confounding due to
variation in diagnoses or illness severity. Although socio-economic status is
known to be a confounder in studies of ethnic variations in health, papers
adjusting for it did not always score highly on the total quality scores. None
of the papers reported sample size calculations. The majority of studies (26)
investigated services in London; other locations were Birmingham (McGovern
& Cope, 1987,
1991;
Birchwood et al, 1992;
Commander et al,
1997a,b,
1999), Manchester
(Thomas et al, 1993),
Nottingham (Harrison et al,
1989; Owens et al,
1991; Singh et al,
1998) and Bristol (Ineichen
et al, 1984).
Do pathways to specialist care vary with ethnic group?
Black patients had more-complex pathways to specialist services, seeing at
least three carers before contact with specialist services
(Commander et al,
1999). Compared with White patients, a greater proportion of Black
patients had some contact with a helping agency the week before psychiatric
service contact (Harrison et al,
1989) and admission was more likely to follow a domiciliary visit
(Commander et al,
1997a). Compared with White and South Asian patients who
visited their general practitioner (GP), Black people were less likely to be
referred to specialist services (Thomas
et al, 1993; Cole
et al, 1995; Burnett
et al, 1999). An explanation might be the GPs' lower
likelihood of recognising a psychiatric problem in Black people
(Odell et al, 1997; Bhugra et al, 1999;
Burnett et al, 1999).
However, among patients presenting to general practice who are recognised to
have a mental health problem, Black patients were more likely to be found in
specialist services (Commander et al,
1997b,c).
The police were more likely to be involved in admissions or readmissions of
Black people (Thomas et al,
1993; Burnett et al,
1999; Commander et
al, 1999). These three papers had medium-quality scores, as
did one showing that police involvement before admission was explained by a
lack of GP involvement rather than ethnic origin of the patients
(Cole et al, 1995).
Two medium-quality papers found that Black people were most likely to present
in crisis, often seeing the duty psychiatrist in an accident and emergency
department as a first point of contact with services
(Turner et al, 1992;
Cole et al, 1995). In
contrast, a low-quality paper showed no variation between ethnic groups in the
pathways to specialist care (Moodley &
Perkins, 1991). Variation in the diagnostic categories and
differences in ethnic group composition do not explain the heterogeneous
outcomes of these studies.
In west London, specialist referral following primary care assessments appeared to be equally common among White and South Asian patients, but hospital admission was more likely among South Asians following a domiciliary visit (Bhugra et al, 1999; Burnett et al, 1999). In Birmingham, South Asians had the highest community rates of mental disorder, were the most frequent consulters in primary care and were less likely than White people to have their mental disorder recognised (Commander et al, 1997b,c). Of all ethnic groups with a mental disorder, South Asians were the least likely to be referred to specialist care (Commander et al, 1997b; Odell et al, 1997). Quality ratings were similar for papers from Birmingham and London and do not explain the different findings. However, the two papers reporting no variation in detection between South Asians and Whites contained smaller samples (total South Asians=24) than studies detecting significant differences (total South Asians=1516).
Is contact between specialist services and Black and South Asian
people maintained?
Compared with White patients, services were less likely to maintain contact
with non-Whites in one part of south London (Norwood) but not in another
neighbouring area (Nunhead; McCreadie
et al, 1997). Another paper from London found no
variation between ethnic groups in continuity of community care
(Bindman et al, 2000),
whereas AfricanCaribbean people in Birmingham had more broken
contact with aftercare services
(McGovern & Cope, 1991).
All three of these papers were of medium quality with a cross-sectional design
and specifically recruited AfricanCaribbean people. The study with the
largest sample size found differences between geographical areas, suggesting
that variation in local service configuration and practice are influential and
that ethnicity alone does not account for variations in patient contact
(McCreadie et al,
1997).
In two papers from London, compared with White people, Black people were more likely to be in contact with services at 5- and 18-year follow-up, respectively (Takei et al, 1998; Goater et al, 1999). These papers were of medium quality and both recruited Black people of Caribbean origin. There were no papers that looked specifically at the pattern of South Asian peoples' contact with specialist services.
Use of in-patient services
Of 20 papers on in-patients, 17 reported measures of in-patient service use
(representation on in-patient units (13) consistently showed greater use of
in-patient services by Black people
(McGovern & Cope, 1987;
Owens et al, 1991;
Birchwood et al, 1992;
Thomas et al, 1993;
Flannigan et al,
1994; Callan,
1996; van Os et al,
1996; Commander et al,
1997b,c;
Koffman et al, 1997; McCreadie et al,
1997; Parkman et al,
1997; Takei et al,
1998). One of these positive studies was of high quality and nine
were of medium quality. Two papers (of low quality) found no variation in
in-patient service use (Ineichen et
al, 1984; Castle et
al, 1994). One paper, a first-incidence study, found an
excess of in-patient use by White patients
(Goater et al, 1999).
A study of admissions found an excess of admissions among Black women in one
London borough but a 40% lower admission rate compared with White women in
another borough (Bebbington et al,
1994). Quality scores and differences in the ethnic composition of
the samples, as far as this could be judged, do not account for this
heterogeneity. The evidence most consistently suggests an excess use of
in-patient facilities by Black patients. Two papers on first-contact
(incident) admissions indicate no excess among Black people
(Castle et al, 1994;
Goater et al, 1999),
despite adjustment for age, gender and socio-economic status in one paper
(Goater et al, 1999).
Among patients of Caribbean origin, Jamaicans had the highest annual admission
rates to British hospitals (Glover,
1989).
Despite variation in study quality, geographical region and South Asian group composition and different degrees of adjustment for confounders and diagnosis, results for in-patient use were more consistent for South Asians than for Black patients. Compared with Black patients, South Asians were less likely to be admitted for in-patient care, had the lowest admission rates to secure wards (Commander et al, 1997c; Koffman et al, 1997), had shorter admissions than other ethnic groups (Gupta, 1991) and were least likely to be readmitted (Birchwood et al, 1992). Compared with White patients, South Asians were more likely to be admitted to in-patient care (Commander et al, 1997b; Koffman et al, 1997).
Compulsory admissions
Of 23 papers measuring compulsory admissions, the majority (18) showed a
higher rate for Black compared with White patients
(Ineichen et al,
1984; Moodley &
Thornicroft, 1988; Harrison
et al, 1989; Dunn
& Fahy, 1990; Moodley
& Perkins, 1991; Owens
et al, 1991; Birchwood
et al, 1992; Crowley
& Simmons, 1992; Lloyd
& Moodley, 1992; Perkins
& Moodley, 1993; Thomas
et al, 1993; Davies
et al, 1996; Koffman
et al, 1997;
McCreadie et al,
1997; Parkman et al,
1997; Singh et al,
1998; Takei et al,
1998; Commander et
al, 1999). Eight of these adjusted for age, gender and
socio-economic status. Two adjusted for other potential confounders: class;
past admissions; Mental Health Act status (compulsory admission for assessment
or detention); police involvement; and general population representation
(Perkins & Moodley, 1993;
McKenzie et al,
1995). Other papers adjusted for age at first contact
(Takei et al, 1998),
psychosis, risk of violence and diagnosis
(Singh et al, 1998).
One paper that adjusted for first-contact admissions, past admissions and
marital status showed excess admissions among Black people
(Owens et al, 1991),
challenging reports that the absence of a relative or intimate relationship
accounts for compulsory admission (Cole
et al, 1995). Davies et al
(1996) recruited people with
psychosis from a broad range of services. After adjustment for living alone as
well as for age and total number of previous admissions, this paper still
found excess compulsory admissions among Black people. Although papers
reporting on in-patients suggest that a higher rate of readmissions and
absconding explained the excess of compulsory admissions among Black people
(Falkowski et al,
1990; Thomas et al,
1993), Davies et al
(1996) adjusted for previous
admissions and still found higher rates of compulsory admissions among Black
people.
Some papers reported contradictory findings. For example, a medium-quality paper showed that, compared with White women, Black women were less likely to be voluntarily admitted in one London borough (South Southwark), but were more likely to be voluntarily admitted in another London borough (Hammersmith & Fulham; Bebbington et al, 1994). Such differences probably reflect variations in local practice and services. The majority of papers, using a variety of ethnic group measures and study designs and adjusting for a number of potential confounders, provide strong evidence for a relative excess of compulsory admissions of Black people.
Of three papers investigating compulsory admissions among South Asian patients, two low-quality papers found that these were less common among South Asian patients (Birchwood et al, 1992; Crowley & Simmons, 1992). One medium-quality paper found no difference between South Asian and White patients (Thomas et al, 1993). These findings are inconclusive as all three studies relied on routinely collected data from medical records and included small numbers of South Asian people.
We calculated a summary odds ratio from the 12 papers (Fig. 1) that reported the exact proportions of compulsorily admitted Black and White in-patients and sample sizes. The meta-analysis gave a pooled odds ratio (Blacks compared with Whites) of 4.31 (95% CI 3.33-5.58). Analysis of the funnel plot did not show evidence of publication bias (P=0.69).
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DISCUSSION |
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Explaining the findings
No papers reported investigations of discrimination as a risk factor.
Perceived discrimination could have a detrimental effect on mental health,
placing Black people at higher risk of mental illness and perhaps of mental
health service use (Karlsen & Nazroo,
2002). Perceived discrimination within health care services may
further compound this, whereas excessive use of compulsory admission could
account for less satisfaction with services and fear of contact with services.
Although social isolation (Cole et
al, 1995) can also mediate higher contact with emergency
services among Black patients, local variations in clinical practice and
service provision are well recognised as sources of inequalities. Most studies
did not compare regional variations of clinical practice or service
configuration. Most studies were based in London. Even though the majority of
the UK's minority ethnic communities live in the largest cities, mental health
policy should reflect the needs of regions with smaller proportions of
minority ethnic groups. Indeed, recent evidence suggests that contextual
effects, such as a lower ethnic density, can actually lead to higher rates of
schizophrenia requiring greater service use
(Boydell et al,
2002).
Methodological considerations
The composition of any one ethnic group varied across the papers. This
raises uncertainty about the generalisability of the findings from any single
paper to populations that fall within the same ethnic group but have different
ethnic subgroup profiles (for example, South Asians with different places of
birth, country or region of origin within the Indian subcontinent).
Improvement in the quality of the more recent publications is encouraging but
the majority did not justify their classification of ethnic groups
(Senior & Bhopal, 1994)
and did not take account of possible variations in service use between
subgroups within the larger ethnic categories. Adjustment for
socio-economic status did not always relate to study quality, but adjustment
for confounders generally and ethnic group definitions did relate to
quality.
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FUTURE PRIORITIES |
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX |
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Intervention studies
International studies, including quantitative studies of interventions
aiming to improve access and uptake of mental health services by different
ethnic groups. The types of interventions could include educational (for users
and/or health care professionals), organisational, financial, regulatory.
Study designs could include controlled trial, parallel group or
before-and-after studies.
Grey/unpublished literature
UK-based data sought from health authorities and by asking three
experts to identify any major omissions from the identified
publications.
Service use
Studies that investigate the rates of use by ethnic groups of facilities
provided for mental health care, whether service provision is targeted or
non-targeted.
Service provision
Studies were included that investigate provision of services for different
ethnic populations and the uptake of these services by their targeted
population.
Management of disorders
Drug treatment of any affective or psychotic condition in primary or
secondary care.
Participants
Adults identified by ethnic group with an affective or psychotic
disorder.
Date of publication
January 1983 to end October 2000.
Language
English, French or German.
Exclusion criteria
Studies of services for children, adolescents, psycho-sexual disorders,
substance misuse, alcohol misuse and forensic mental health were excluded.
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ACKNOWLEDGMENTS |
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Received for publication March 18, 2002. Revision received July 25, 2002. Accepted for publication July 31, 2002.
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