Royal College of Psychiatrists' Research Unit, London, UK
Correspondence: Bernard Audini, Royal College of Psychiatrists' Research Unit, 6th floor, 83 Victoria Street, London SWIH 0HW, UK. Tel: +44 (0)171 235 2351; e-mail: bernard.audini{at}virgin.net
Declaration of interest The study was funded by the Department of Health.
See editorial, pp.
198199, this issue.
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ABSTRACT |
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Aims To use existing data-sets to examine detentions under Part II of the Act.
Method Data from 26 areas, with a combined population of 9.2 million, were combined. Population census data were used to standardise rates of detention by age, gender and ethnicity.
Results The 31 702 detentions are distributed bimodally with peaks at age 25-34 years and at over age 80 years. In the younger age group rates of detention are higher for men. The excess of women in the older group is no longer apparent when rates are standardised for age and gender. Detentions are over six times more likely to be of Black people than of White (450 v. 68 per standardised 100 000 population).
Conclusions The difference in rates of detention between Black and White people is greater than previously thought. The excess of older women detained under Part II of the Act is largely due to the lower life expectancy of men.
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INTRODUCTION |
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METHOD |
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Census data
Demographic data were obtained from the Manchester Information and
Associated Services (MIMAS) data centre at the enumeration district level.
These data are based on the national census and include information about the
composition of population in terms of age, gender and ethnicity.
Data management and missing data
The data from local authorities, which used a variety of formats and codes,
were reformatted, redefined and merged. This involved dialogue with those in
the local authorities and trusts who were responsible for managing the data
locally. Ethnicity was recorded in a number of ways (the number of categories
ranged from four to 16). To achieve a common denominator, ethnicity was
recoded to one of four categories. The census data were also recoded to the
same categories. The category White included White people of
European, North American or Australasian origin; Black included
those described as Black African, AfricanCaribbean, Black British or
Black Other; Asian included those of Indian, Bangladeshi,
Pakistani, Chinese and Japanese origin; and Other included
people of South American, Middle Eastern and North African origin.
Most sites had some missing data. Reasons for this included refusal by individual approved social workers to participate, and temporary suspension of data collection during staff absences. The research team interviewed local data managers to estimate the extent of missing returns for each site. The total amount of missing data was calculated to be about 14%. Estimates for individual sites ranged from 0% to 50% (median 10%). These estimates were used to weight the data.
Census data were aggregated from the level of the enumeration district to that of the local authority.
Data analysis
The analyses reported here relate to the use of Sections 2, 3 and 4 of the
Act. For some analyses, census data were used to standardise the rates of
sectioning for specific subgroups of the population defined by age, gender and
ethnicity. Data were analysed using SPSS version 8
(SPSS, 1997) and STATA version
5 (StataCorp, 1997).
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RESULTS |
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How representative are the sites?
The Office for National Statistics (ONS) has created a classification of
English local authorities based on census and other social demographic
variables (Office for National Statistics,
1996). These provide a simple indicator of the similarity between
areas for comparative or targeting purposes. Nine of the eleven ONS
classification groups were represented among the 20 organisations whose
catchment areas were coterminous with an English local authority area. The two
ONS groupings not represented are two of the more affluent ones: most
prosperous and resort and retirement. Jarman
underprivileged area scores (Jarman,
1983) for the 20 English local authorities ranged from 92 to 154.
The distribution of scores confirmed that the most socially privileged areas
of the country were slightly under-represented.
Some personal demographic characteristics of the population of the 20 English local authority areas could be compared with those of the population of England as a whole using data from MIMAS. These suggested that the sample was representative of the national picture in terms of gender (48.3% male for the sample v. 48.4% male for the population as a whole), marital status (46.6% v. 45.6% married) and ethnicity (1.8% v. 1.9% Black; 3.4% v. 3.7% Asian and 0.6% v. 0.6% Other).
Detentions under Part II of the Act
The mean number of years over which the 26 local authorities and trusts
collected data was 5.6 (median 5, range 2-11). All data related to the period
between 1988 and 1998. The final data-set contained information about 31 702
episodes of detention under Part II of the Act.
Forty-nine per cent of the detentions were of men (n=15 418). Of those detentions for which ethnicity data were available (n=29 860), 8% were of Black people (n=2279), 4% of Asian people (n=1213) and 2% of people from another ethnic minority group (n=529).
Age and gender
The number of detentions per year under the Mental Health Act is shown for
men and women and by age groups in Fig.
1.
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Figure 2 shows the effect of standardising Part II detentions to age- and gender-specific population rates.
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Ethnicity
When rates of sectioning are standardised as number per unit of ethnically
specific population, there are striking differences between the ethnic groups.
Detentions are over six times more likely to be of Black people than of White
people (450 v. 68 per 100 000 population); the rate of detentions
involving Asian people is 65% higher than those involving White people (112
per 100 000). The rate of detentions of people from other ethnic minority
groups is intermediate between that for Asian people and Black people (324 per
100 000). Detentions of Black men are eight times more frequent than
detentions of White men (553 v. 69 per 100 000). As
Fig. 3 shows, the pattern of
differences in rates of sectioning between ethnic groups is present at all
ages. The census data permit age and ethnicity to be analysed only in broad
age bands. Also, only a relatively small number of detentions (529) were of
people from the ethnic groups assigned to the Other category,
with 54 detentions in those aged over 61 years.
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Among the Black sub-population, detentions of men are more frequent than detentions of women (553 v. 353 per 100 000).
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DISCUSSION |
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The data were collected about individual detentions under the Act and so provide a level of detail that central aggregated returns cannot. However, some limitations remain. Perhaps most important is the inability to link detentions over time. In the absence of a unique case identifier, it is not possible to identify individuals who were detained under the Act more than once during the data collection period, or those who were detained under one section of the Act and subsequently had their detention converted to another section. The latter would have been recorded as two separate detentions. One effect of this would be that subgroups of people who have high rates of repeated detention under the Act would be overrepresented in the sample.
The quality of the data was controlled by the local managers who were responsible for collecting it. On close examination, none of the local data-sets was found to be complete. The method for weighting for missing data was chosen because nearly all applications for admission under Sections 2, 3 and 4 of the Act are made by an approved social worker. When discussing the completeness of returns with local data managers, the research team found no reason to believe that the practice of social workers whose activity was not recorded differed markedly from those whose activity was recorded.
The data were collected over a period of 11 years. During this time, there have been changes in how ethnic and racial groups are categorised and assigned. Furthermore, a variety of systems for classifying ethnicity were used in different sites. Given that data were collected during the course of Mental Health Act assessments, it is likely that in most cases the assignment of ethnicity was made by the approved social worker rather than by the person concerned (McKenzie & Crowcroft, 1996). The final groupings are not consistent with current best practice; for example, people from South Asia are placed in the same category as people from East Asia. However, those groupings represent the best that can be made with the data available.
Even with these caveats, the study provides unique information about the use of the Act which could not be obtained from aggregate returns or from smaller studies of detentions from single, localised catchment populations (McKenzie et al, 1995; Davies et al, 1996; Wall et al, 1999).
Overrepresentation of Black and ethnic minority groups
The differences in rates of detention between ethnic groups in perhaps the
most striking finding of this study. Previous studies have found that Black
people admitted to a psychiatric hospital are about twice as likely to be
detained under the Mental Health Act as White people
(Wall et al, 1999).
African and AfricanCaribbean people who have a psychotic illness and
who live in London are between four and eight times more likely to be detained
than their White counterparts (McKenzie
et al, 1995; Davies
et al, 1996). These studies, however, are of small,
localised cohorts and do not relate rates of detention to the size of the base
populations. When this is done, the difference appears to be towards the upper
end of the ranges reported. The rate of use of Part II found in this study
might be exaggerated by the underenumeration of Black people, and particularly
young Black men, in the census. However, this effect is likely to be small,
perhaps accounting for 5% of the difference
(Office of Population Censuses and
Surveys, 1993).
The possible causes of overrepresentation of Black people in the population of detained in-patients include a higher prevalence of severe mental illness, in particular schizophrenia; mistrust of services, leading to delay in seeking help and presentation at a later and more severe stage of illness; poorer compliance with medication; greater contact with police; a more frequent history of violence (Wall et al, 1999); and differences in the way in which mental health care workers respond to people from different ethnic minority groups. The relative weight of the contribution of these factors is unknown.
Whatever the causes, mental health services whose catchment areas contain significant numbers of Black people must make provision both for higher numbers of formal admissions and to meet the specific needs of Black patients. The latter might include advocacy services and recruitment practices designed to ensure a corresponding ethnic mix among the staff.
Differences related to age and gender
In this sample, slightly fewer detentions under Part II were of men than of
women (except for the Black sub-population, where more detentions were of
men). This appears to contradict a recent review which concludes that men are
more likely to be sectioned than women
(Wall et al, 1999).
The explanation for this might be that many of the studies reviewed were based
on samples drawn from general psychiatry and so would contain fewer older
people, among whom women predominate. Our findings are consistent with the
aggregated returns of the Department of Health which include all ages
(Department of Health, 1999).
These show that the balance between the genders has switched in recent years.
Up to 1994-1995, more women than men were detained under Part II of the Act;
after that time, slightly more men were detained (the ratio of men to women in
1988-1989 was 0.75; in 1998-1999 it was 1.02). The sample in our study spans
this period.
This study confirms the gender and age differences in absolute numbers of detentions under Part II (Hatfield & Mohamad, 1994). It shows that young men are more at risk of being detained than young women are. It suggests, however, that the excess of women among older people detained under Part II is largely accounted for by the fact that the population of older people contains more women that is, it is due to the lower life expectancy of men.
Need for better monitoring of formal admissions
It is likely that within 5 years the Mental Health Act 1983 will have been
replaced by new legislation. This study demonstrates the importance of also
revising the way in which the use of mental health legislation is monitored.
The effect of age, gender and ethnicity, and changes in these effects over
time, can only be evaluated if data are collected at the case level. The
introduction of the proposed new mental health minimum data-set would enable
this (Glover, 1995).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication September 1, 2000. Revision received February 21, 2001. Accepted for publication March 7, 2001.
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