Compulsory admission at first presentation to services for psychosis: does ethnicity still matter? Findings from two population-based studies of first episode psychosis

In this population-based study of compulsory admission at first presentation for psychosis in south London, UK, we found, contrary to our hypothesis, that the odds of compulsory admission by ethnicity have remained largely unchanged. The most striking findings were in black African patients, for whom the odds of compulsory admission remained three times higher, compared with white British patients, between the two time periods, from 1997 to 1999 and from 2010 to 2012. We found insufficient evidence of reduced odds of compulsory admission for black Caribbean patients compared with findings of 15 years ago. However, we found that overall the proportions of compulsory admissions have gone down, for black African (54.1% vs. 34%), black Caribbean (50.1% vs. 20.9%), white Other (30.8% vs. 18.7%) and white British (24.4% vs. 17.3%) patients, between the two time periods in this study. There was no evidence of effect modifications between the main effects only and with interaction term for ethnicity and compulsory admission across the AESOP and CRIS-FEP samples. However, we found that CRIS-FEP patients were less likely to be compulsorily detained.

The key strengths of this study are its large sample size and the comparison of two datasets collected in the same catchment area at different time points. These allowed the investigation of ethnic differences in compulsory admission during FEP at two different time points in the UK. Our large sample sizes also enabled us to control for several factors that may explain the higher rates of compulsory admission. Our study adds to the steadily growing number of large epidemiological studies with sufficient power to investigate the issue of compulsory admissions among black Caribbean and black African patients as separate ethnic groups. In addition, we applied traditional epidemiological research methods used in the AESOP study to the CRIS electronic health records and we successfully identified FEP cases within the CRIS system.

While our study has a number of advantages over previous studies, there are still a number of limitations. The missing data, particularly in the multivariable analyses may have affected our results. Further, our results should be treated with caution due to the wide confidence intervals particularly for the black Caribbean patients. The use of multiple imputations could have provided a more complete estimation of the odds of compulsory admission particularly for this group. However, given that the missing values for the educational qualifications and employments status variables did not differ by compulsory admissions outcome, the complete case analyses that we employed were considered appropriate. It is also noteworthy that the CRIS clinical data are recorded by clinicians for clinical purposes and not collected for research; therefore, the accuracy of information depends on the quality of clinicians’ documentation, particularly socioeconomic information. However, given that our outcome data (compulsory admission) are statutory data, it is unlikely that anyone admitted under the Mental Health Act would have not been recorded in the electronic health records/CRIS. In addition, given this is a single-centre study, our findings may not be generalizable to other areas.

A key methodological issue in epidemiological research is selection bias. The database used in the CRIS-FEP study is representative of the population of South London. This is because SLaM is the only mental healthcare provider for our study catchment area, and people presenting with major mental health issues such as psychosis tend to present to specialist mental health services directly or are referred by their general practitioners or emergency department to specialist mental health services, as private sector provision is minimal. This means that psychosis cases and compulsory admission data in our study can be considered complete of case ascertainment, and the likelihood of bias is minimal.

Our findings are consistent with previous studies [8, 13, 18, 30]. Mann and colleagues (2014) found in a sample of 674 patients that black African patients had threefold increased odds of being compulsorily admitted at first contact, but they did not find this association in black Caribbean patients. Similarly, Lawlor and colleagues (2012) in a sample of 287 women admitted to inpatient and crisis services found higher rates of compulsory admission among black African patients. Evidence from the rest of Europe also suggests a similar trend. For example, in a Dutch cohort study of psychotic patients, Van der Post et al. (2012), having adjusted for a sociodemographic confounders, also replicated UK findings that sub-Saharan African patients were more likely to be detained compulsorily (adj. OR = 3.0; 95% CI = 1.4–6.4). Another Dutch study showed that Surinamese patients were three times more likely to be compulsorily detained compared with the native Dutch patients [31]. Our finding of no association between black Caribbean ethnicity and compulsory admission are in keeping with previous research [32‐34]. In addition, consistent with previous studies was our finding of no difference in compulsory admission between white British and white Other patients [13]. Adjusting for socioeconomic status as a confounder has been argued as important for studies investigating the relationship between ethnicity and mental health [35]. We were able to do so in this study. In contrast to some previous studies that reported associations between men of black Caribbean and black African ethnicity with compulsory admission [7, 13], we did not find evidence to support this.

Making sense of the striking ethnic differences in compulsory admission in this study may be considered in three key ways. First, over a few decades, the way UK mental health services are structured and provided has changed considerably. Hospital beds have been reduced significantly and there has been a shift towards community-based treatment [3, 36]. A number of community-based and crisis resolution initiatives such as early intervention for psychosis, home treatment and outreach services were introduced in the early 2000s, with a view to managing patients that would normally require acute hospital admission, at home [4]. These services are responsible for assessing, treating and supporting people in psychiatric emergencies in their own homes and are available 24 h a day. Consequently, the focus on hospital admissions is on prevention and speedy discharge. For a patient to be admitted to hospital, they have to be extremely unwell [4], possibly posing danger to themselves and others, and, therefore, requiring compulsory admission. A number of these new services were not operational during the period the AESOP study was conducted. This may explain the overall reduction in the rate of compulsory admissions between the two study periods. It may also explain the higher rates of admission and compulsory admission among both black African and black Caribbean patients in the AESOP sample. For example, the introduction of early intervention psychosis was anticipated to make a significant contribution to earlier treatment, less coercive care and so improve outcomes [5].

Second, social disadvantage factors, which have been linked to the higher rate of psychosis and coercive pathways to care during FEP [37‐39] are important markers of health inequalities in our society [40, 41]. For example, our data show that compared with 15 years ago, the proportion of black Caribbean patients who were unemployed rose from 69.8% (AESOP) to 80.4% (CRIS-FEP). The increase in unemployment between the two samples may reflect the UK economic landscape following the global financial crisis in 2008, during which youth employment declined and those at the margins of the society were hit the hardest [42]. Similarly, the proportion of patients with insecure living arrangements such as homeless hostel also rose for black African, 9.8% (AESOP) to 11.8% (CRIS-FEP) and black Caribbean, 0% (AESOP) to 9.1% (CRIS-FEP). Although, both unemployment and living circumstances were associated with compulsory admission in the AESOP sample, they may explain only a proportion of the ethnic variations. Furthermore, our data suggest that the proportion of people in relationship or living with others compared with 15 years ago have improved. For example, although we did not specifically measure generational status in our study, given that black Caribbean people have mostly settled in the UK post-World War II [1, 38], it is possible that there may have been a few generations of black Caribbean people, as noted in the wider UK population [43]. Therefore, it is plausible that the black Caribbean group may have developed cumulative community social networks that encourage mutual support, a sense of belonging and enriched social relationships through social capital and acculturation [44, 45]. The absence of these factors has been well documented as post-migratory risk factors of psychosis [41, 46, 47]. Such risks may still be present for the black African population, whose integration into the UK society may not be as established as those of the black Caribbean ethnic group.

Third, we found no evidence of an association between compulsory admissions and white Other patients in both AESOP and CRIS-FEP samples. While this finding is consistent with previous studies [8, 13, 48], it is intriguing, given the arrival of a large number of white migrants from Eastern Europe into the UK since the expansion of the EU in 2004 [2]. During the same periods, black African people were also arriving in the UK, resulting in around a 2.4% increase in the black African population in London [49]. We found the most striking odds of being compulsorily detained in the black African ethnic group. This is important, black African patients may perceive seeking help from mental health services as stigmatising, unfair, and discriminatory, as has been reported in previous studies [50‐52] and so they may be reluctant to come into hospital voluntarily. However, the association of compulsory admission with black African and black Caribbean ethnicity also draws attention to the social structures and processes, including institutional discrimination that shape access to material resources and health services, which in turn contribute to differences in health outcomes. Our findings of involuntary admission among black African patients are consistent with findings of wider inequalities in many marginalised and disadvantage groups [53]. By contrast, we found no differences in the odds of compulsory admission between the white ‘Other’ and white British patients. This may be explained from immigration regulations and socioeconomic circumstances perspective. For example, it is possible that the white ‘Other’ (mainly European) population in the UK experience less stressful acculturation process and lower perceived discrimination [54], since they have full legal entitlement to free health care and the labour market [55] compared with other migrants from elsewhere who may experience insecure immigration status, e.g. asylum seekers or refugees. Although not measured in our study, we speculate that, given the potential differences in the aforementioned immigration status between non-UK-born people of black African and white ‘Other’ ethnicity, it could be argued that the potential insecurities faced by those who migrated to the UK from outside of Europe may contribute to poorer health outcomes [55].

There are further nuances in our data that are noteworthy. For example, the data hint at the disparity between white British and black Caribbean patients may be narrowing as the proportions of compulsory detention between the two groups are now relatively similar (17.3% vs. 20.9%, respectively). This may suggest that the factors that contributed to differences in previously reported findings such as a lack of understanding of health services, distrust in mental health services and reduced family involvement [50, 51] may no longer be as relevant to the black Caribbean groups. It is also possible that black Caribbean people are more confident in navigating the healthcare services when seeking help and so may be persuaded to come involuntarily.