Academic Unit of Child and Adolescent Psychiatry, Imperial College London
Correspondence: Dr Matthew Hodes, Academic Unit of Child and Adolescent Psychiatry, Imperial College London, St Marys Campus, Norfolk Place, London W2 1PG. Tel: +44 (0)20 7886 1145; Fax: +44 (0)20 7886 6299; e-mail: m.hodes{at}imperial.ac.uk
Declaration of interest The study was funded by a grant from The Health Foundation.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To investigate whether Black compared with White adolescents from London are overrepresented in psychiatric in-patient settings and whether they are more likely to be detained under the Mental Health Act 1983.
Method Cross-sectional survey of London adolescents aged 1317 years, who were in-patients in psychiatric units.
Results Adolescents from the Black group (Black African, Black Caribbean, Black British) were overrepresented among those admitted with a diagnosis of a psychotic disorder when compared with adolescents from the White group (White British, White Irish, White Other): odds ratio=3.7, 95% CI 2.06.7. They were also more likely to be detained on admission and more likely to be born outside the UK and more likely to be born outside the UK and have refugee background.
Conclusions The possible impact of various background factors influencing admission is discussed.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Measures
We collected information from the case notes or from the anonymised case
summaries using the data sheet designed for this study. Data were fully
completed on 102 (90%) young people but baseline demographic details were
available for all adolescents. Psychiatric diagnoses according to DSMIV
diagnostic criteria (American Psychiatric
Association, 1994) were assigned using the OPCRIT checklist and
program (McGuffin et al,
1991). The OPCRIT system has been shown to have good reliability
(Williams et al,
1996) and validity (Craddock
et al, 1996) and has been used previously for adolescents
with psychosis (Hollis, 2000).
A sample of ten case summaries, assigned with the diagnosis of a psychotic
disorder by the first rater (J.T.), was rated by the second rater (M.H.), who
was blind to the results of the initial ratings. There was complete agreement
between two ratings for diagnostic categories of psychotic disorders. In two
cases there was agreement that the diagnosis was non-affective psychosis, but
an assignment of different diagnostic subcategories was given by the raters.
Eight adolescents who agreed to psychiatric interview (15% of the 55
adolescents with psychosis) were interviewed using the Schedule for Affective
Disorders and Schizophrenia for School Age Children (KSADS;
Chambers et al, 1985).
There was complete agreement between OPCRIT and the KSADS interview
diagnoses on specific diagnostic categories.
We used UK Census 1991 ethnic categories for self-ascribed ethnicity recorded in the medical files. Because the numbers in each ethnic category were relatively small they had to be grouped into broader ethnic categories:
White: White British, White Irish, White Other
Black: Black British, Black Caribbean, Black African, Black Other
Asian: Indian, Pakistani, Bangladeshi, Asian Other
Other: other ethnic groups and mixed ethnic origins.
We used the Census 1991 data (projections for the year 2001) for the total number of youngsters aged 1317 years in different ethnic groups in Greater London. The Census 2001 data were not available at the time of writing this paper.
Ethics
We obtained approval from the London Multi-Centre Research Ethics
Committee, as well as from the 40 relevant local research ethics
committees.
Data analysis
The point prevalence of adolescents with psychosis who were psychiatric
in-patients was calculated according to ethnic group. Odds ratios were
estimated using logistic regression and calculated using the White adolescent
group as the reference group. Confidence intervals were estimated at the 95%
level. MantelHaenszel analysis was used for estimates of the odds ratio
and the relative risk. Differences in proportions were tested with
Fishers exact test and the 2 test. Differences in the
duration of hospital stay (regarded as a continuous variable) between
different ethnic groups were established by analysis of variance (ANOVA).
Results were analysed with SPSS for Windows (version 10) and STATA (version 5,
for windows).
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
A total of 95 patients (84%) were in adolescent psychiatric units and 18 young people (16%) were in-patients on adult psychiatric wards. The mean age was 16.2 years. Of all the in-patients, 55 (49%) were admitted for assessment and treatment of either definite or suspected psychotic disorder. They were predominantly male and older adolescents: 38 males (70%) v. 17 females (30%); 40 (73%) in-patients aged 16 or 17 years. Their demographic details are summarised in Table 2.
|
In this group of young people with clinical features of psychotic disorders, complete information was available on 51 young people and therefore OPCRIT could be used to ascertain DSMIV diagnoses: 23 (45%) had diagnoses of schizophrenia spectrum disorders, 9 (18%) had diagnoses of affective psychotic disorders (including schizoaffective disorders) and 20 (37%) were diagnosed with a psychotic disorder not otherwise specified. All the cases diagnosed with psychotic disorders by the clinicians have also received an OPCRIT DSMIV diagnosis of a psychotic disorder.
Ethnic representation in in-patient units is different from the expectations based on the representation in the population of Greater London in this age group (Table 3). Young people in the Black group (Black Caribbean, Black African and Black British) were overrepresented in the in-patient adolescent psychotic population compared with the White group (odds ratio=3.7 after adjusting for gender). The relative risk for being in an in-patient unit is greater for the older Black adolescents (4.7; 95% CI 2.59.0) than for younger adolescents and is greater for males (4.8; 95% CI 2.49.6) than females. There was no difference in the duration of stay in hospital between the Black and White adolescent groups, with a mean of 17 weeks (s.d.=19.8; 95% CI 9.026.6) for White and 18 weeks (s.d.=15.2; 95% CI 9.326.9) for Black adolescents. The data on the duration of stay were available for 46 of 55 young people with psychotic disorders.
|
The overrepresentation of Black adolescents in the psychotic group was mainly due to the high numbers of adolescents of African origin, who made up 20% (11/55) of all adolescents with psychosis. However, only one of the eleven African youngsters had a diagnosis of schizophrenia, with the rest having a psychosis not otherwise specified or an affective psychotic disorder. On the other hand, six of the eight adolescents in the other Black groups (Black British, Black Caribbean) had schizophrenia, with only two having a psychosis not otherwise specified or an affective psychotic disorder. This diagnostic difference in the two groups was statistically significant (Fishers exact test: P=0.0063).
Young refugees were highly represented in our sample of youngsters admitted for psychotic illnesses. There were 10 refugees in the sample of 55 young people. It is striking that eight of those ten were Black African adolescents. Among the Black group, largely those from an African background, there were high levels of social and family adversity, with many experiencing recent migration, poverty and not living with family.
On admission, 4 (16%) of 25 White, 12 (63%) of 19 Black, 1 (14%) of 7 Asian
and 1 (25%) of 4 young people of other ethnic background were detained under
the Mental Health Act 1983. Black adolescents were significantly more likely
to be detained on admission compared with their White counterparts
(2 test: P < 0.03), but they did not seem to have
a greater history of offending or more history of threatening or violent
behaviour. However, there is no significant difference between the ethnic
groups when detention at any point during the admission is taken into account:
13 (52%) of 25 White, 15 (79%) of 19 Black, 5 (71%) of 7 Asian and 1 (25%) of
4 adolescents of other ethnic background were detained at some point during
the admission.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
More adolescents from the Black group than the White group were detained under the Mental Health Act 1983 on admission, but that difference diminished during admission. One recent study of adult patients showed that detentions in England are over six times more likely to be of Black than of White people (Davies et al, 1996). Earlier studies showed that Black adult patients were more likely to experience a less desirable pattern of access to psychiatric services, particularly through police contacts (Dunn & Fahy, 1990). However, a more recent study in South London concluded that adverse pathways to psychiatric care in AfricanCaribbean patients are not present at their first admissions but are likely to develop over time (Burnett et al, 1999).
Reliability of findings
This is the first study in the UK investigating links between psychiatric
admission for psychosis and ethnic background in the adolescent population.
Complete data were obtained for more than 90% of young people, but baseline
demographic details were available for all the adolescents.
There was a high level of agreement on the diagnostic measures, including high interrater reliability for assigning the diagnosis, between clinical diagnoses and those assigned using OPCRIT and between diagnoses assigned by two raters of OPCRIT, one of whom was blind to ethnicity and clinical diagnosis. There was complete agreement between OPCRIT diagnoses and diagnoses established with psychosis using KSADS.
Explanation of findings
Possible explanations for the findings are that the poorer social support
and high level of adversities for the African adolescents with psychosis
resulted in a greater need for admission. Another plausible explanation is
that there is a higher incidence of psychosis in ethnic minority adolescents.
Both of these may occur in association with a high level of exposure to
stressors, including war and organised violence. It is relevant that
post-traumatic stress disorder may occur comorbidly with non-schizophrenic
psychoses (David et al,
1999). There may also be cultural variation in the experience of
hallucinatory experiences among adolescents
(Johns et al, 2002).
A further possible explanation is that there has been diagnostic bias, but
this is not likely in view of the care taken regarding diagnosis, the level of
impairment of the psychotic group and similar duration of in-patient treatment
prior to the survey date for the Black and White groups.
Limitations
There are limitations to the sample methods that we used in the study.
Because this was a cross-sectional survey of in-patients on one particular
day, there is a possibility that those patients who had a longer duration of
stay up until the study day would be overrepresented in the results and those
with a shorter duration underrepresented. However, against this was the
finding that the length of admission prior to the study day was not
significantly different between the Black and White adolescent psychotic
groups. Other limitations of the study include the small sample size. There
was reliance on case-note data rather than the use of standardised interviews
with the adolescents and informants to assess psychiatric state and ethnic and
cultural background.
Implications
The current findings have implications for service planning with regard to
the need for adolescent psychiatric beds and associated out-patient services.
Areas with high numbers of ethnic minority populations, especially refugees,
will need a higher level of psychiatric bed provision than areas with a more
settled, White British population. Further research should investigate further
the reasons for the ethnic variation in admission for adolescents, and whether
there are variations in the incidence of adolescent psychosis and the pathways
to care for this group.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Audini, B. & Lelliott, P. (2002) Age,
gender and ethnicity of those detained under Part II of the Mental Health Act
1983. British Journal of Psychiatry,
180, 222
-226.
Burnett, R., Mallett, R., Bhugra, D., et al (1999) The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multi-ethnic population. Psychological Medicine, 29, 475 -483.[CrossRef][Medline]
Chambers, W. J., Puig-Antich, J., Hirsch, M., et al (1985) The assessment of affective disorders in children and adolescents by semi structured interview. Testretest reliability of the schedule for affective disorders and schizophrenia for school-age children, present episode version. Archives of General Psychiatry, 42, 696 -702.[Abstract]
Commander, M. J., Dharan, S. P., Odell, S. M., et al (1997) Access to mental health care in an inner-city health district. I: Pathways into and within specialist psychiatric services. British Journal of Psychiatry, 170, 312 -316.[Abstract]
Craddock, M., Asherson, P., Owen, M. J., et al (1996) Concurrent validity of the OPCRIT diagnostic system. Comparison of OPCRIT diagnoses with consensus best-estimate lifetime diagnoses. British Journal of Psychiatry, 169, 58-63.[Abstract]
David, D., Kutcher, G. S., Jackson, E. I., et al (1999) Psychotic symptoms in combat-related posttraumatic stress disorder. Journal of Clinical Psychiatry, 60, 29-32.
Davies, S., Thornicroft, G., Leese, M., et al
(1996) Ethnic differences in risk for compulsory psychiatric
admission among representative cases of psychosis in London.
BMJ, 312, 533
-537.
Dunn, J. & Fahy, T. A. (1990) Police admissions to a psychiatric hospital. Demographic and clinical differences between ethnic groups. British Journal of Psychiatry, 156, 373 -378.[Abstract]
Goodman, R. & Richards, H. (1995) Child and adolescent psychiatric presentations of second-generation Afro-Caribbeans in Britain. British Journal of Psychiatry, 167, 362 -369.[Abstract]
Harrison, G., Owen, D., Holton, A., et al (1988) A prospective study of severe mental disorder in Afro-Caribbean patients. Psychological Medicine, 18, 643 -657.[Medline]
Hollis, C. (2000) Adult outcomes of child and
adolescent-onset schizophrenia: diagnostic stability and predictive validity.
American Journal of Psychiatry,
157, 1652
-1659.
Johns, L. C., Nazroo, J.Y., Bebbington, P., et al
(2002) Occurrence of hallucinatory experiences in a community
sample and ethnic variations. British Journal of
Psychiatry, 180, 174
-178.
Koffman, J., Fulop, N. J., Pashley, D., et al (1997) Ethnicity and use of acute psychiatric beds: one-day survey in North and South Thames regions. British Journal of Psychiatry, 171, 238 -241.[Abstract]
Lelliott, P., Audini, B. & Duffett, R.
(2001) Survey of patients from an inner-London health
authority in medium secure psychiatric care. British Journal of
Psychiatry, 178, 62
-66.
Maden, A., Friendship, C., McClintock, T., et al (1999) Outcome of admission to a medium secure psychiatric unit. 2. Role of ethnic origin. British Journal of Psychiatry, 175, 317 -321.[Abstract]
McGovern, D. & Cope, R. (1987) First psychiatric admission rates of first and second generation Afro-Caribbeans. Social Psychiatry, 22, 139 -149.[Medline]
McGuffin, P., Farmer, S. & Harvey, I. (1991) A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT system. Archives of General Psychiatry, 48, 764 -770.[CrossRef][Medline]
Pipe, R., Bhat, A., Matthews, B., et al (1991) Section 136 and the African/Afro-Caribbean minorities. International Journal of Social Psychiatry, 37, 14-23.[Medline]
Williams, J., Farmer, A. E., Ackenheil, M., et al (1996) A multicentre inter-rater reliability study using the OPCRIT computerized diagnostic system. Psychological Medicine, 26, 775 -783.[Medline]
Received for publication July 25, 2003. Revision received January 12, 2004. Accepted for publication January 15, 2004.
Related articles in BJP: