| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
|
|
|
||||||||||
|
||||||||||||
University Medical Centre Rotterdam, Department of Psychiatry, Rotterdam, Mental Helath Group Europoort, Barendrecht, and Municipal Health Centre Rotterdam and surroundings, Rotterdam
University Medical Centre Rotterdam, Department of Health Policy and Management, Rotterdam
Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Centre Utrecht, Utrecht, The Netherlands
Correspondence: Dr C. L. Mulder, Mental Health Group Europoort, PO Box 245, 2990 AE Barendrecht, The Netherlands. Tel: +31180 643500; e-mail: niels.clmulderniels.clmulder{at}wxs.nl
Declaration of interest None. Funding detailed in Acknowledgements.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Aims To compare the risk of contact with psychiatric emergency services and of compulsory admission between immigrant groups to The Netherlands and Dutch natives, and to determine the unique contribution of ethnicity to compulsory admission.
Method Study of 720 people referred to emergency psychiatric services in Greater Rotterdam, The Netherlands.
Results The relative risks (RRs) for contacts with psychiatric emergency services, for having a psychotic disorder and for compulsory admission were significantly higher in most immigrant groups. Moroccans, Surinamese and Dutch Antilleans had the highest risks of compulsory admission. After controlling for symptom severity, danger, motivation for treatment and level of social functioning, non-Western origin was no longer associated with compulsory admission.
Conclusions Non-Western immigrant groups were overrepresented in psychiatric emergency care and were admitted compulsorily more frequently, possibly owing to a different clinical presentation.
|
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
METHOD |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
2=13.27; P<0.01). There was no significant
difference between participating and non-participating clinicians with respect
to the percentage of physicians, psychiatrists or nurses. Together, the
participants completed 30% of day and night shifts, including weekends, and
filled out patient record forms for all their assessments in 2001. The study
was approved by the local medical ethics committee.
Patients
Patients (aged 18–65 years) were examined where they were at the time
of referral, e.g. at their home, at a police station or at a community mental
health centre. In The Netherlands the police are not allowed to take
psychiatrically disturbed individuals to a psychiatric hospital and usually
request an assessment by the emergency service staff at the police station.
After the examination of the patient, the clinician decides whether admission
(voluntary or compulsory) to a psychiatric hospital is necessary. In The
Netherlands compulsory admission is officially ordered by the local authority
(mayor) upon advice from a physician, usually a psychiatrist. The criterion
for compulsory admission is danger to self or others, not the need for
treatment.
Variables
Information was collected on age, gender and country of birth of the
patients and their parents. Clinical characteristics included admissions (yes
or no) during the previous 2 years, severity of problems as assessed by the
Severity of Psychiatric Illness scale (SPI;
Lyons, 1998) and the Global
Assessment of Functioning (GAF; Endicott
et al, 1976). The SPI is an observer-rated decision
support tool to assess the need for services, especially in-patient care. We
assessed
The SPI items were scored on a four-point scale from 0 (no problem) to 3 (severe problem). Severity of symptoms included phenomena such as hallucinations, delusions, depression, mania or anxiety. The validity of the SPI has been established (Lyons, 1998) and the interrater reliability of the Dutch translation of the SPI was satisfactory (overall k=0.76; Mulder et al, 2005).
The psychiatric emergency service clinicians had followed an SPI training programme as described in the manual (Lyons, 1998), followed by a booster training 2 months later. The diagnoses were grouped into five categories: psychosis, depression, mania, psychosocial problems and ‘other’. All consecutive patients seen during the shifts of the participating clinicians were included, thereby preventing selection bias. If the same patient was seen more than once, data from the first assessment were used. Patients of unknown country of origin (n=106; 15%) were analysed as a separate group. The socio-economic status of the patient’s neighbourhood was determined by using the mean income in that postal code area. Patients with an unknown postal code (n=42; 6%) were excluded from relevant analyses. Very few values were missing for other variables (0–5%) and they were not replaced.
Population estimates
Population denominators for Greater Rotterdam, divided by age and gender,
were derived from the Dutch Central Bureau of Statistics. The Bureau
classifies citizens according to country of birth rather than ethnicity, and
combines first- and second-generation immigrants. A Dutchborn citizen is
considered a second-generation immigrant if at least one parent was born
abroad. Natives are Dutch-born citizens whose parents were also born in The
Netherlands. The most important immigrant groups are from Morocco, Turkey,
Surinam and the Dutch Antilles. First- or second-generation immigrants from
other countries can be of Western origin (parents born in western, northern or
southern Europe, the USA, Canada, Australia, New Zealand, Japan and Israel) or
of non-Western origin. For all individuals residing legally in The Netherlands
registration with municipal authorities is compulsory and a prerequisite for
essential documents (e.g. residence and work permits) and possible aid (e.g.
income support). The Dutch Central Bureau of Statistics figures do not cover
an unknown but small proportion of immigrants whose residence is illegal (less
than 10%). Therefore, we did not correct for the number of illegal immigrants.
Importantly, a large group of immigrants to The Netherlands, people from the
Dutch Antilles, have no reason not to register since they are Dutch
citizens.
We compared the distribution of immigrant groups within the sample of emergency psychiatric patients with the distribution of the same immigrant groups within the population.
Analysis
We did not distinguish between first- and second-generation immigrants, and
defined eight groups: Dutch natives, Moroccans, Turks, Surinamese, Dutch
Antilleans, immigrants from other Western countries, those from other
non-Western countries and those of unknown origin. Gender- and age-adjusted
relative risks (RRs) for psychiatric emergency contacts, for having a
psychotic disorder, and compulsory admission were calculated by Poisson
regression analyses, using Egret (Cytel Software, 1999,
http://www.cytel.com/products/egret).
Immigrant status as a risk factor for compulsory admission was assessed using three logistic regression analyses, combining non-Western immigrants into one group (Moroccans, Surinamese, Dutch Antilleans and other non-Western immigrants), and assessing first the association between non-Western ethnicity and compulsory admission, without controlling for confounding factors; second, entering demographic factors (age, gender, socioeconomic status of neighbourhood) into the model; and third, entering demographic and clinical factors into the model, including previous admissions (yes or no), eight SPI scores, GAF score and a diagnosis of psychosis (yes or no).
|
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
Risk of contacts with psychiatric emergency service
Gender- and age-adjusted relative risks for contact with the psychiatric
emergency services for any psychiatric disorder were significantly higher in
all immigrant groups than in Dutch natives, with the exception of immigrants
from Turkey and Western countries (Table
2). The highest risks were found for Dutch Antilleans, Moroccans
and individuals from other non-Western countries. The risk of contact for
psychotic disorders was significantly higher among immigrants from Morocco,
Turkey, Surinam, the Dutch Antilles and other non-Western countries. Finally,
the risk of compulsory admission was significantly higher among immigrants
from non-Western countries, with the exception of Turkey.
|
Country of origin as an independent risk factor for compulsory admission
We examined which variables predicted compulsory admission in members of
those immigrant groups that had an increased relative risk of compulsory
admission (Moroccans, Surinamese, Dutch Antilleans and other non-Western
immigrants). Using three models we analysed the association between
non-Western ethnicity (these immigrant groups combined v. Dutch
natives) and compulsory admission: not controlling for confounding factors,
controlling for demographic factors, and finally controlling for demographic
and clinical factors (Table
3).
|
Non-Western origin was found to be significantly associated with compulsory admission in the first model only. Male gender was associated with compulsory admission in the second model. Finally, in the third model, severity of symptoms, danger to others, lack of motivation for treatment and low GAF scores were positively associated with compulsory admission. Overall, the percentage of correctly predicted cases in model 3 was 93% (Nagelkerke r2=0.72). When these analyses were repeated for patients with psychotic disorders (n=323, of whom 120 were admitted compulsorily), danger to others (odds ratio 4.1, 95% CI 2.22–7.67), motivation for treatment (OR=11.34, 95% CI 3.49–36.89) and low GAF score (OR=0.95, 95% CI 0.89–0.99) were significantly associated with compulsory admission, not severity of symptoms or migrant status. Overall, the percentage of correctly predicted cases was 88% (Nagelkerke r2=0.77).
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Risk of contact with services
The higher risk of contact with psychiatric emergency services for
non-Western immigrants is in line with previous findings in the UK
(Bhui et al, 2003).
The higher risk was largely due to a higher risk of psychotic disorders among
these groups, which is consistent with the findings of epidemiological studies
in Belgium and The Netherlands (Selten et al,
1997,
2001;
Fossion et al, 2002).
It is also possible that some immigrants do not follow the usual pathway to
psychiatric care and seek help at a later stage
(Morgan et al, 2004).
Indeed, Dutch Antilleans and patients from ‘other non-Western
countries’ had fewer previous out-patient contacts than Dutch natives,
but this was not true for immigrants from Turkey, Morocco or Surinam (see
Table 1).
Compulsory admission and clinical presentation
When considering possible explanations for the higher risk of compulsory
admission among immigrants from non-Western countries, it may be useful to
distinguish between symptoms (e.g. hearing voices) and clinical presentation
(e.g. aggression, as a response to hearing voices, or lack of motivation for
treatment) (Morgan et al,
2004). The staff of the emergency psychiatric services evaluated
these immigrant groups as more dangerous and less motivated to receive
treatment than Dutch natives (see Table
1). If these assessments were valid, the immigrants presented
their symptoms, verbally or non-verbally, in a different way, which was
sometimes characterised by higher levels of aggression or less motivation for
treatment. This may explain why, in the multivariate analyses, severity of
symptoms, greater level of threat, lack of treatment motivation and lower
level of functioning were associated with involuntary admission, and not
migrant status or having a psychotic disorder. It might be that such
differences in clinical presentation between natives and immigrants from
non-Western countries are associated with the clinician’s decision to
admit these patients under compulsion.
Ethnic bias
Another explanation for the higher rates of compulsory admission among
immigrants is that the clinicians–approximately 90% of whom were
Dutch–were ethnically biased. Evidence for such bias has been reported
by Lewis et al (1990):
although British psychiatrists did not more readily detain patients
compulsorily merely on the grounds of ‘race’, Black patients were
judged as potentially more violent than White patients. As stated above, in
our study, unfamiliarity with the way these immigrants present symptoms might
have led to misinterpretation and to a greater perceived threat and more
symptoms. Although danger to others and other clinical variables were measured
using a structured assessment tool (SPI), this does not guarantee that these
assessments were free from observation bias. Furthermore, it is important to
note that the clinicians who decided upon compulsory admission also filled out
the SPI. In future studies therefore, it would be preferable to use
independent raters, separating those who decide on (in)voluntary admission
from those who assess patient characteristics using an instrument such as the
SPI. To our knowledge, however, this is the first study of its kind to examine
the unique contribution of migrant status to compulsory admission, controlling
for clinical and behavioural characteristics. Interestingly, in the
multivariate analyses, lack of awareness of illness was not associated with
compulsory admission, indicating that this variable may be less important in
the involuntary admission process than poor motivation for treatment.
Involuntary admission for psychotic disorder
When we repeated the analyses for patients with psychotic disorders only,
we found that danger to others, lack of motivation for treatment and GAF
score, not ethnicity or severity of symptoms, were significant predictors of
compulsory admission. This is the most important group in terms of emergency
admissions and for comparison with other studies
(Bhui et al, 2003). It
may be that in the subgroup of patients with psychotic disorders we did not
find an association with ethnicity and severity of symptoms owing to lack of
power. Another possibility is that in this group of patients, as compared with
patients with other Axis I diagnoses, dangerous behaviour was relatively more
important than severity of psychotic symptoms for compulsory admission.
Limitations of the study
Only 30% of the clinicians working in the psychiatric emergency services
volunteered to participate in the study. The other clinicians did not
participate for various reasons, for example lack of time or reluctance to
work with a structured assessment tool. The majority of the participating
clinicians were men. However, one can only speculate about whether this could
lead to an information bias. In most other studies, the gender of the
clinician who gathers information is not taken into account. Since the
participating clinicians filled out record forms for all consecutive patients,
and in view of the random nature of their work roster, we have no reason to
think that this situation led to information bias.
The psychiatric diagnosis was based on a clinical interview, not on a standardised diagnostic interview. The latter is difficult to apply in an emergency situation, given the limited amount of time and the pressure on the clinicians, whose primary tasks are triage, containment and referral (Mulder et al, 2005). Usually, the diagnosis of a psychotic disorder was based on the presence of delusions and/or hallucinations. Socioeconomic status was based on the mean income levels of postal code areas, not on the socio-economic status of individual participants. Another limitation of the study is the small number of patients in some of the immigrant groups, thereby lowering the statistical power of the study, and possibly causing negative findings in the analyses. Finally, other factors that could explain the increased rates of involuntary admissions among non-Western immigrants, such as the quality of their social networks or their beliefs about mental illness, were not taken into account (Morgan et al, 2004).
Implications for future studies
The results of this study may reflect differences in clinical presentation
between non-Western immigrants and Dutch natives, and/or ethnic bias on the
part of staff. The results may imply that clinicians should be aware of the
possibility that they consider patients from non-Western immigrant groups as
more dangerous and less motivated. Given the limitations mentioned above,
however, the results need to be interpreted cautiously and confirmed by
subsequent studies. These studies should focus on understanding the possible
differences in clinical presentation between Western and non-Western emergency
psychiatric patients. In addition, it is important to investigate whether the
raised risk of compulsory admission among non-Western immigrants is caused by
their having more mental health or behavioural problems, or by Western
clinicians misinterpreting a seemingly more severe clinical presentation.
Longitudinal studies are needed following emergency psychiatric contacts and
compulsory admissions, to assess differences in the course and presentation of
psychiatric illness between Western and non-Western emergency psychiatric
patients. Finally, future studies should take into account the effects of
social network, cultural context and beliefs about mental illness on the risk
of contact with psychiatric emergency services and compulsory admission.
|
|
Clinical Implications and Limitations |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
LIMITATIONS
|
|
ACKNOWLEDGMENTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
|
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Davies, S., Thornicroft, G., Leese, M., et al
(1996) Ethnic differences in risk of compulsory psychiatric
admission among representative cases of psychosis in London.
BMJ, 312, 533
–537.
Endicott, J., Spitzer, R. L., Fleiss, J. L., et al (1976) The Global Assessment Scale. Archives of General Psychiatry, 33, 766 –771.[Abstract]
Fossion, P., Ledoux, Y., Valente, F., et al (2002) Psychiatric disorders and social characteristics among second-generation Moroccan migrants in Belgium: an age- and gender-controlled study conducted in a psychiatric emergency department. European Psychiatry, 17, 443 –450.[Medline]
Lewis, G., Croft-Jeffreys, C. D. A. & David, A.
(1990) Are British psychiatrists racist? British
Journal of Psychiatry, 157, 410
–415.
Lyons, J. S. (1998) The Severity and Acuity of Psychiatric Illness Scales. An Outcomes Management and Decision Support System. Adult Version, Manual. San Antonio, TX: Psychological Corporation/Harcourt.
Morgan, C., Mallet, R., Hutchinson, G., et al (2004) Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry. Social Science and Medicine, 58, 739 –752.[CrossRef]
Mulder, C. L., Koopmans, G. T. & Lyons, J. L.
(2005) The admission process untangled. Determinants of
indicated versus actual admission in emergency psychiatry.
Psychiatric Services,
56, 452
–457.
Selten, J. P., Slaets, J. P. & Kahn, R. S. (1997) Schizophrenia in Surinamese and Dutch Antillean immigrants to The Netherlands: evidence of an increased incidence. Psychological Medicine, 27, 807 –811.[CrossRef][Medline]
Selten, J. P., Veen, N., Feller, W., et al
(2001) Incidence of psychotic disorders in immigrant groups
to The Netherlands. British Journal of Psychiatry,
178, 367
–372.
Received for publication November 5, 2004. Revision received June 29, 2005. Accepted for publication July 13, 2005.
Related articles in BJP:
This article has been cited by other articles:
|
|
 |
|
  A. Llacer, M. V. Zunzunegui, J. del Amo, L. Mazarrasa, and F. Bolumar The contribution of a gender perspective to the understanding of migrants' health J. Epidemiol. Community Health, December 1, 2007; 61(Suppl_2): ii4 - ii10. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. P. SINGH, N. GREENWOOD, S. WHITE, and R. CHURCHILL Ethnicity and the Mental Health Act 1983 The British Journal of Psychiatry, August 1, 2007; 191(2): 99 - 105. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
