Division of Psychological Medicine, Institute of Psychiatry, London, UK
Psychiatry Unit, Department of Clinical Medical Sciences, University of the West Indies, Trinidad
Department of Psychiatry, University of Nottingham, Nottingham
Division of Psychological Medicine, Institute of Psychiatry, London
Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Division of Psychiatry, University of Bristol, Bristol
Division of Psychological Medicine, Institute of Psychiatry, London
Department of Psychiatry, University of Cambridge, Cambridge
Division of Psychological Medicine, Institute of Psychiatry, London, UK
on behalf of the ÆSOP Study Group
Correspondence: Dr Craig Morgan, Division of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.Tel: +44 (0)20 7848 0351; e-mail spjucrm{at}iop.kcl.ac.uk
See Part 2, pp.
290296, this
issue.
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ABSTRACT |
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Aims To establish whether AfricanCaribbean 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 firstepisode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (ÆSOP) study. For this analysis we included all White British, other White, AfricanCaribbean and Black African patients from the ÆSOP sampling frame. Clinical, socio-demographic and pathways to care data were collected frompatients, relatives and case notes.
Results AfricanCaribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. AfricanCaribbean 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 AfricanCaribbean and Black African patients.
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INTRODUCTION |
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We therefore sought to investigate the relationship between ethnicity and pathways to mental health services in two UK centres in a large cohort of patients with a first episode of psychosis. In this paper our focus is specifically on ethnicity and compulsory admission, the aim being to test the hypothesis that there is an association between compulsory admission and ethnicity at first presentation, independent of socio-demographic characteristics, aspects of clinical presentation and how patients came into contact with services.
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METHOD |
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Data collection
Socio-demographic characteristics
Data on ethnicity, gender, educational level achieved, employment status,
living circumstances and relationship status were collected by interview with
patients or (for patients not interviewed) from case notes, using the Medical
Research Council Socio-demographic Schedule
(Mallett, 1997).
Clinical data
Clinical data were collected using the Schedules for Clinical Assessment in
Neuropsychiatry (SCAN; World Health
Organization, 1992b) and the Personal and Psychiatric
History Schedule (PPHS; World Health
Organization, 1996). The SCAN incorporates the Present State
Examination version 2.0, which was used to elicit symptom-related data at the
time of presentation. Where an interview with the patient was not possible,
case notes were used to complete the Item Group Checklist part of the SCAN.
Diagnoses according to ICD10 criteria were determined using the SCAN
data on the basis of consensus meetings involving one of the ÆSOP
studys principal investigators (J.L. or R. Murray in London and P.J. in
Nottingham) and other members of the research team. For the analysis, patients
were grouped into three diagnostic categories: broad schizophrenia and other
psychoses (codes F2029), manic psychosis (F3031) and depressive
psychosis (F3233). There was an assessment for possible bias between
the principal psychiatrists. Each independently formulated a diagnosis for 20
patients based on the same summary SCAN information; there was 80% agreement
on diagnostic category (=0.630.75, P<0.001).
The PPHS, previously used in World Health Organization multicentre studies of the incidence and outcome of schizophrenia (Jablensky et al, 1992) and in previous studies of pathways to care (Burnett et al, 1999), was used to collate further clinical data, specifically relating to duration of untreated psychosis and reasons for admission. Duration of untreated psychosis was defined as the period from the first clear description of psychotic phenomena, from any source, to first contact with statutory mental health services; it was analysed as a dichotomous variable, cut into short and long around the median of 66 days. Reasons for admission considered in the analysis were act of self-harm, perceived risk to self, act of violence and perceived risk to others.
Pathways to care
Data relating to pathways to care and mode of contact with services were
collated using the PPHS. The section on pathways to care was extended to
include an item on who initiated help-seeking and to allow a detailed
narrative description of the pathway to care. The relevant variables derived
from these data were: the person who initiated help-seeking; involvement of
criminal justice agencies (police, courts, prisons) and general practitioners
in the pathway; source of referral to services; and mode of contact
(non-compulsory v. compulsory).
Ethnicity
Patients assigned to one of the following four ethnic groups were included
in the analysis:
There was no patient of mixed CaribbeanAfrican parentage in the study, and patients of other ethnicities were excluded from the analysis.
In assigning patients to ethnic groups, a number of data sources were used. The primary source was self-ascribed ethnicity, collected as part of the socio-demographic interview. If this was not available other sources were used, including other informants and case notes. Where there was ambiguity, a consensus rating was made by members of the research team; this always included those with long-standing expertise in the study of ethnicity and mental health (R. Mallett, G.H.).
Analysis
Chi-squared tests were used to compare ethnic groups in each study centre
according to the key study variables. The data were stratified by study centre
at this point to assess whether there were any marked differences between the
samples drawn from the two distinct service settings. Logistic regression was
used to analyse the relationship between ethnicity and compulsory admission
while controlling for potential confounders, thereby addressing the primary
study hypothesis. A logistic regression model was constructed, with compulsory
admission as the dependent variable, using the following steps. First, to
identify crude associations between compulsory admission and other variables,
unadjusted odds ratios were calculated. Second, using MantelHaenszel
analyses with the test for homogeneity, potential effect modifiers for the
association between ethnicity and compulsory admission were identified. Third,
a logistic regression model with the primary outcome (compulsory admission),
exposure (ethnicity) and a variable for study centre was fitted, and variables
found to be crudely associated with compulsory admission at P<0.10
were added one by one, starting with the strongest. Finally, interaction terms
for ethnicity and potential effect modifiers, identified using
MantelHaenszel analyses, were fitted. For each new variable or
interaction term fitted, a likelihood ratio test was conducted by checking
each nested model against the new potential model. Variables and interaction
terms were retained in the model if the P value for the likelihood
ratio test was <0.10. At each point, a liberal value of P=0.10 was
used as a cut-off point to ensure that potentially important factors were not
removed from the analysis. All analyses were conducted using STATA version 8
(Stata, 2003).
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RESULTS |
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Of the 462 patients included in the analysis, 301 (65.2%) were interviewed. Of those not interviewed, 66 (14.3%) were included in a leakage study that was conducted at the end of the period of patient recruitment to pick up all patients meeting the inclusion criteria who were not initially identified. There was no consistent reason why patients identified as part of the leakage study were initially missed, and these patients were not approached to be interviewed. Ninety-five (20.5%) could not be successfully contacted following presentation or refused to be interviewed. Of the 301 patients interviewed, 118 (39.2%) had a close relative with whom they had been in recent contact and who agreed to be interviewed. Case notes were scrutinised for all patients. The basic socio-demographic, clinical and pathway-related variables were compared between those who were interviewed and those were not interviewed, and between those with and those without a relative interview, to assess whether they differed in any key respects. There were no statistically significant differences between the groups. In particular, there was no difference in the proportions of patients or relatives interviewed in each ethnic group.
Sample characteristics
Socio-demographic and clinical characteristics of the sample are summarised
by study site and ethnicity in Tables
1 and
2.
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Socio-demographic characteristics
In south-east London, AfricanCaribbean patients were significantly
less likely than the other three ethnic groups to be educated beyond school
level, this being particularly evident in the small number of
AfricanCaribbean patients who were educated at university level. Levels
of unemployment were higher in all ethnic minority groups than in the White
British group, although this only reached statistical significance for the
AfricanCaribbean group. Both AfricanCaribbean and Black African
patients were significantly more likely to live alone than White British
patients, and AfricanCaribbean patients were significantly more likely
to be single than White British patients. In the Nottingham sample, there were
similar differences between White British and AfricanCaribbean
patients, but the relatively small number of the latter meant these
differences did not reach statistical significance.
Clinical data
For the clinical variables considered, there were few ethnic differences in
either centre; for example, there was no difference between the ethnic groups
in duration of untreated psychosis. The main difference between the ethnic
groups in south-east London was in the reasons for admission, with
AfricanCaribbean patients being significantly more likely than all
other groups to be involved in a violent incident and/or be perceived as
threatening by others. This was less evident in the Nottingham sample,
although AfricanCaribbean patients were more likely to be perceived as
threatening (39.1% v. 25.0%; 2=2.01, d.f.=1,
P=0.16).
Mode of contact and pathways to care
Data relating to pathways to care and mode of contact with services are
presented in Table 3.
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Mode of contact
In both south-east London and Nottingham, AfricanCaribbean patients
were significantly more likely to be compulsorily admitted than White British
patients. The proportion of patients in each of these ethnic groups who were
compulsorily admitted was remarkably similar in the two centres: in south-east
London, 23.8% White British v. 51.9% AfricanCaribbean
(unadjusted odds ratio 3.46; 95% CI 1.846.51, P<0.01); in
Nottingham, 28.8% White British v. 50.0% AfricanCaribbean
(unadjusted odds ratio 2.48; 95% CI 1.035.93; P=0.04). Given
this similarity, for stratified and multivariable analyses focusing on
ethnicity and compulsory admission, data from the two centres were combined.
In south-east London, the proportion of Black African patients who were
compulsorily admitted was even higher than for AfricanCaribbean
patients, at 54.8% (unadjusted odds ratio 3.89; 95% CI 1.917.89;
P<0.01).
When proportions of compulsory admissions among the different ethnic groups are broken down by gender and age the picture becomes more complex. The odds of compulsory admission among AfricanCaribbean patients in south-east London varied by age and gender, variations that held when the data were combined with those from Nottingham. Across the two sites, the odds ratio for compulsory admission, with White British patients as the baseline group, was 4.75 for AfricanCaribbean men and 1.69 for AfricanCaribbean women (Table 4). The odds ratio for compulsory admission was 4.36 for AfricanCaribbean patients aged 1629 years and 1.91 for AfricanCaribbean patients aged 3065 years (Table 4). There was no evidence of similar effects for gender and age on the relationship between Black African ethnicity and compulsory admission in south-east London.
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The proportions compulsorily admitted did not vary significantly within the
south-east London sample between AfricanCaribbean patients born in the
UK and those born in the Caribbean (57.3% v. 41.2%;
2=2.38, d.f.=1, P=0.12). There was a trend for Black
African patients born in the UK to be compulsorily admitted more often than
those born in Africa (73.3% v. 46.3%;
2=3.28, d.f.=1,
P=0.07). The number of non-UK-born AfricanCaribbean patients
in Nottingham was too small for comparisons to be made (n=4).
Pathways to care
In terms of the pathway to care, further differences were apparent (see
Table 3 for selected pathways
data). These data are of particular interest here as potential confounders of
the relationship between ethnicity and compulsory admission.
Compulsory admission and ethnicity
Table 5 presents the
unadjusted odds ratios for compulsory admission by each independent variable
using combined data for south-east London and Nottingham. It shows that, in
addition to ethnicity, nine variables were associated with an increase or
decrease in the odds of compulsory admission, at P<0.10. A
logistic regression model was fitted, as detailed above. Following this
procedure, five of the nine variables crudely associated with compulsory
admission were selected for inclusion: being unemployed, criminal justice
referral, perceived risk to others, self-initiated help-seeking and diagnosis.
As there was evidence that the relationship between AfricanCaribbean
ethnicity and compulsory admission was modified by gender and age, interaction
terms were fitted, first for gender and AfricanCaribbean ethnicity and
second for age and AfricanCaribbean ethnicity. A likelihood ratio test
was conducted to assess whether each interaction term significantly improved
the model; on this basis, an interaction term for gender and
AfricanCaribbean ethnicity was included in the final model
(2=3.02, d.f.=1, P=0.08), but not for age and
AfricanCaribbean ethnicity (
2=1.96, d.f.=1,
P=0.16). Table 6
presents the final logistic regression model both with main effects only and
with the interaction term included. This shows that, when adjusting for the
other variables in the model, the odds of compulsory admission are 3.5 times
greater for AfricanCaribbean male patients than for White British male
patients. There is some attenuation of the unadjusted odds ratio, suggesting
some confounding by the other variables in the model. However, among men,
AfricanCaribbean ethnicity retains a strong independent effect on the
odds of compulsory admission. The increased odds of compulsory admission
observed among AfricanCaribbean men do not hold for
AfricanCaribbean women. Black African ethnicity also retains a strong
independent effect on the odds of compulsory admission after adjusting for the
other variables in the model. The other factors that were independently
associated with increased or decreased odds of compulsory admission were being
unemployed, criminal justice referral, perceived risk to others,
self-initiated help-seeking and a diagnosis of mania.
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DISCUSSION |
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Ethnicity and compulsory admission at first contact
In contrast to the findings of Cole et al
(1995) and Burnett et
al (1999), we found
important differences in proportions of compulsory admissions between ethnic
groups in both south-east London and Nottingham at first presentation to
services. The most striking of these relate to AfricanCaribbean men.
When a range of factors that might explain these high proportions are adjusted
for, including criminal justice referral, the odds of compulsory admission for
AfricanCaribbean men remain over 3 times greater than for White British
men. Other studies have reported an excess of compulsory admissions among
AfricanCaribbean men. Bebbington et al
(1994), for example, reported
compulsory admissions for AfricanCaribbean men to be respectively 13
and 8 times greater than for White men in two London boroughs; for
AfricanCaribbean women the proportions were 3 and 5 times greater than
for White women. Most previous studies, however, have included both first and
subsequent admissions, and the studies by Cole et al
(1995) and Burnett et
al (1999) did not report
proportions of compulsory admission in different ethnic groups by age and
gender.
The proportion of Black African patients compulsorily admitted in south-east London was similar to that of AfricanCaribbean patients; there was, however, no variation by age or gender. When other factors were controlled for, the odds of compulsory admission for Black African patients were over 4 times greater than those for White British patients. Only a small number of studies have reported levels of compulsory admission among specifically Black African patients. These have also tended to find high levels of compulsory admissions among this group. Davies et al (1996), for example, in a study of a representative sample of patients with a psychotic mental illness in contact with services during a 1-year period, found that Black African patients were almost 3 times more likely to be compulsorily admitted than White patients.
Taken together, these findings point to there being an increased risk of compulsory admission for AfricanCaribbean and Black African patients with a psychotic mental illness at first contact with mental health services, contrary to the conclusions drawn by Cole et al (1995) and Burnett et al (1999).
Explaining the differences
Clinical presentation
One of the earliest explanations put forward to account for the high
proportion of compulsory admissions among AfricanCaribbean patients was
that, for some reason, they presented as more disturbed than White patients
(Rwegellera, 1980). Defining
severity of disturbance at presentation is far from straightforward and
previous researchers have used different indicators, including challenging
behaviour, violence and poor insight. The evidence has been mixed (e.g.
Owens et al, 1991;
Pipe et al, 1991). We
collected data relating to a number of possible indicators of disturbance at
presentation, including diagnosis, violence and perceived threat; a diagnosis
of manic psychosis and both actual and perceived risk of violence were
associated with compulsory admission. However, although diagnosis and
perceived risk were independently associated with compulsory admission after
adjustment for other factors, neither accounted for the excess of compulsory
admissions among either AfricanCaribbean men or Black African
patients.
Social isolation
A number of previous studies have found compulsory admission to be
associated with socio-demographic variables such as unemployment and living
alone (Szmukler et al,
1981). Both Cole et al
(1995) and Burnett et
al (1999) found such
variables to be particularly important in predicting aversive pathways to care
and compulsory admission at first contact. One interpretation of these data is
that such variables are proxies for social isolation, and that the absence of
significant others to facilitate help-seeking increases the risk of compulsory
admission. In relation to this, it is also noteworthy that we found absence of
family involvement in seeking help was associated with compulsory admission.
In this study, AfricanCaribbean patients in both centres and Black
African patients in south-east London were more likely to live alone and be
unemployed than White British patients. Both of these variables, moreover,
were associated with compulsory admission. However, although being unemployed
was independently associated with compulsory admission, this did not account
for the ethnic variations in proportions of compulsory admission in either
centre: that is, although this study confirms the association between
compulsory admission and variables such as living alone and unemployment,
these at best account for only a small proportion of the variance between
ethnic groups. Further, there was no difference between
AfricanCaribbean and White patients in either study centre in levels of
family involvement in the pathway to care, although White patients were more
likely to seek help themselves.
The pathway to care
Intuitively, the route by which a patient is referred to services will
influence the nature of the contact. For example, criminal justice agency
involvement or referral is already suggestive of resistance to intervention
and, from the point of view of an assessing psychiatrist, referral through the
police suggests a possible need for restraint and containment. It is not
surprising, then, that criminal justice agency involvement and referral should
be very strongly and independently correlated with compulsory
admission. Conversely, successful general practitioner referral signifies a
willingness on the part of the patient to accept intervention by mental health
services. The expected influence of source of referral is found, to a degree,
in our study. In particular, criminal justice agency referrals were more
common among the AfricanCaribbean and Black African patients and
general practitioner referrals were less common. However, again these
differences in the source of referral do not fully account for ethnic
variations in compulsory admissions. The question thus remains: what processes
are operating prior to or at the point of first contact with
mental health services that increase the risk of compulsory admission for
AfricanCaribbean patients, particularly men, and Black African
patients? Extending the analysis to consider the pathway to first contact with
mental health services may offer some further clues (see Part 2:
Morgan et al, 2005,
this issue).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Members of the ÆSOP Study Group are as follows. Bristol: G. Harrison, F. Muga and J. Holloway. Cambridge: A. Fung, J. Mietunen, M. Ashby and H. Hayhurst. London: J. Leff, R. Murray, T. Craig, R. Mallett, P. Fearon, C. Morgan, K. Morgan, P. Dazzan, J. MacCabe, C. Samele, M. Sharpley, S. Vearnals, G. Hutchinson, R. Burnett, J. Boydell, K. Orr, J. Salvo, K. Greenwood, M. Lambri, S. Auer, P. Rohebak and L. McIntosh. Nottingham: P. Jones, G. Doody, J. Tarrant, S. Window, P. Williams, T. Lloyd, H. Bagalkote, B. Dow, D. Boot, A. Farrant, S. Jones, J. Simpson, R. Moanette, S. Suranim, M. Ruddell, J. Brewin and I. Medley.
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Received for publication July 12, 2004. Revision received October 14, 2004. Accepted for publication October 18, 2004.