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REVIEW ARTICLE |
Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry
Department of Mental Health, St George’s University of London
Institute of Psychiatry, London, UK
Correspondence: Swaran P. Singh, Health Sciences Research Institute, Warwick Medical School, Coventry CV4 7AL, UK. Email: S.P.Singh{at}warwick.ac.uk
*Studies that were part of the meta-analysis
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To systematically review detention and ethnicity, with meta-analyses of detention rates for BME groups, and to explore the explanations offered for ethnic differences in detention rates.
Method Literature search and meta-analysis. Explanations offered were categorised, supporting literature was accessed and the strength of the evidence evaluated.
Results In all, 49 studies met inclusion criteria; of these, 19 were included in the meta-analyses. Compared with White patients, Black patients were 3.83 times, BME patients 3.35 times and Asian patients 2.06 times more likely to be detained. The most common explanations related to misdiagnosis and discrimination against BME patients, higher incidence of psychosis and differences in illness expression. Many explanations, including that of racism within mental health services, were not supported by clear evidence.
Conclusions Although BME status predicts psychiatric detention in the UK, most explanations offered for the excess detention of BME patients are largely unsupported.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Several hypotheses have been put forward to explain this excess. These can be broadly divided into patient-related and service-related explanations (Littlewood, 1986). Patient-related explanations include higher rates of psychosis (Bebbington et al, 1994), perceptions of Black and minority ethnic patients being at greater risk (Lewis et al, 1990) and poorer insight in this group (van Os et al, 1996). Greater stigma associated with mental illness within minority communities leading to delays in help-seeking and more severe symptoms at presentation have also been offered as explanations (Harrison et al, 1989). Service-related explanations have focused on inherent racism within psychiatry (Littlewood & Lipsedge, 1997) with associated ‘Eurocentric’ misdiagnosis (Fernando, 1988) and perceptions among Black patients of services being inaccessible and inappropriate (Cochrane & Sashidharan, 1996). There are two narrative reviews of such explanations (Littlewood, 1986; Spector, 2001), but a systematic and structured review determining the strength of evidence for the various explanations for this excess is lacking. We conducted a systematic review of all UK literature on ethnicity and detention to:
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Inclusion criteria
Studies had to fulfil the following inclusion criteria: publication in
English; reference made to the use of compulsion to detain a person under the
Mental Health Act 1983 in England and Wales; provision of original data
relating to the Mental Health Act; and inclusion of two or more ethnic groups
in the study.
The relevance of the literature was initially ascertained from the titles. N.G. and S.S. independently looked at the titles of the first 250 studies in the database searches and agreed on the relevance of all but one article. Discussion of this article led to an improved understanding of the criteria and N.G. then continued with the remaining articles. Where titles appeared relevant, abstracts or equivalent summary information were studied. Just over two hundred (n=210) hard copies of studies appearing pertinent from the abstracts were obtained. Further analysis of the full articles revealed that many of these did not fit the inclusion criteria and they were then excluded. Selected articles were read and the inclusion criteria applied independently by both N.G. and S.S. before the final selection was made.
Personal communication with experts
Once the articles for the review had been selected, 24 experts were sent
the list of included studies and asked whether there were any further studies
they could suggest. Five experts responded; however, their suggestions for
additional studies had already been considered. One expert did not provide any
studies, but expressed unhappiness that we had excluded case histories and
therefore considered our review to be ‘invalid’. We did explain
that this was a meta-analysis of data-based studies and by definition case
studies could not be included.
Quality ratings
Literature quality was assessed using an adaptation of a scale (see data
supplement 1 to the online version of this article) previously used in a
similar review (Bhui et al,
2003). The resulting quality scores ranged from 0 to 14 and were
divided into low (0–5), medium (6–10) and high (11–14). N.G.
and S.S. rated five articles together to ensure consistent application of the
scale and then the rest were rated independently. There was agreement on all
but five studies, but discussion revealed that these differences were due to
differing interpretations of the scale. Once this was resolved, complete
consensus was reached on appropriate ratings for each study.
Data extraction
For meta-analysis, raw data were extracted independently by N.G. and S.S.
Categories of explanatory evidence emerged as successive papers were studied;
data regarding explanations were extracted independently by N.G. and S.S. and
consensus was reached regarding categorisation of explanations. Explanations
were recorded as presented in the original paper and no attempt was made to
interpret the text to fit any a priori hypothesis. Only explanations
relating specifically to ethnic differences in detention rates were included.
For instance in papers discussing ethnic differences in admission rates in
general rather than Mental Health Act detention rates specifically,
explanations were not included in the results. Some explanations were
difficult to categorise, such as poor adherence, which could potentially be
assigned to more than one category; a judgement was made in these cases as to
the most appropriate category. Study authors sometimes offered similar
explanations but for different reasons, especially for complex phenomena such
as delay in help-seeking among Black patients, which in turn might lead to
more disturbed presentation with greater risk of detention. Some authors
attributed this delay to lack of social support, whereas others attributed it
to denial of illness. Such explanations therefore appear in more than one
category. Perception of Black and minority ethnic patients as more violent or
at higher risk was categorised separately from studies showing differences in
clinical presentation between ethnic groups.
Level of evidence
Each study providing an explanation was scrutinised for the level of
evidence for the explanation. Evidence was further categorised as primary
evidence, secondary evidence or no evidence. Primary evidence was defined as
direct evidence for an explanation provided by a study using its own data.
This was further categorised as evidence at the level of an
‘association’ if the data demonstrated correlation between
variables where confounders were not controlled and causal interpretations
could not be made. An example would be studies where Black and minority ethnic
patients were more likely to be detained but also more likely to be diagnosed
with psychosis and it was not certain whether ethnicity or psychotic illness
was the primary reason for the excess of detentions (especially if tests of
association such as chi-squared tests rather than regression had been
employed). Secondary evidence was defined as citations of other papers to
support an explanation. These secondary citations were perused and key
findings summarised, including (where possible) the strength of evidence for
relevant conclusions drawn. A few authors discussed explanations for detention
rates among Asian patients and these are distinguished from other
explanations.
Analyses
Meta-analyses were performed where aggregate data of minority ethnic and
White compulsorily admitted patients were provided. Pooled odds ratios were
calculated for the overall comparisons using the fixed-effects model. The
chi-squared test for heterogeneity was then performed to determine whether
there was significant heterogeneity in the odds ratios between studies. For
comparisons in which there was significant heterogeneity, four possible source
variables for the heterogeneity were investigated. These were patient type
(civil, forensic, mixed), episode (first episode, mixed episode), quality
rating (high, medium, low) and year of publication. Pooled odds ratios and 95%
confidence intervals are presented for studies within each grouping created by
the categorical variables. Year of publication was categorised as studies from
1980s, from the period 1990 to 1994, from 1995 to 1999 and from 2000 onwards.
Meta-regression was performed, plotting the log odds ratio for each study
against year of publication, using appropriate weighting. All meta-analysis
was carried out using Comprehensive Meta-Analysis version 2.2 for Windows.
One study (Goater et al, 1999) included three sets of data (at admission, year 1 and year 5), each of which reported different detention rates among Black and minority ethnic patients. Each set was treated as independent and included separately in the meta-analyses.
Terminology
In this paper the term ‘Black and minority ethnic’ is used to
refer to participants of any ethnic group other than White. The term
‘Black’ refers to people of Black African, Black Caribbean and
‘Black other’ groups. The term ‘Asian’ is used for
people originating from the Indian subcontinent (India, Pakistan, Bangladesh
and Sri Lanka). Although all such terms have limitations and obscure important
intra-group differences, this review is restricted by these terms as these are
the most frequently used categories in such research.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Figure 1 is a forest plot of the studies included in the meta-analyses, with odds ratios and 95% confidence intervals for each study on a horizontal plane and the pooled effect displayed with a diamond marker. Table 1 provides a summary of the meta-analyses of four main ethnic group comparisons: Black and minority ethnic (BME) compared with White; Black compared with White; Asian compared with White; and Asian compared with Black. Within these ethnic group comparisons and where there were sufficient data, subgroups such as patient types and illness episodes were also analysed.
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Ethnicity
Overall pooled odds ratios for BME compared with White (3.35, 95% CI
3.05–3.73, P < 0.0001) and Black compared with White (3.83,
95% CI 3.42–4.29, P < 0.0001) were similar. The odds for
Asian compared with White (2.06, 95% CI 1.60–2.65, P <
0.0001) and Black compared with Asian (2.25, 95% CI 1.72–2.94,
P < 0.0001) were both close to 2. Put slightly differently,
compared with White patients, Asian patients were approximately twice as
likely and Black patients approximately four times as likely to be
detained.
Civil and forensic detentions
The pooled odds ratios of detention type showed that the excesses of BME
(4.03, 95% CI 3.37–4.81, P < 0.0001) and Black (4.48, 95% CI
3.71–5.41, P < 0.0001) patients compared with White patients
for civil detentions are greater than for forensic detentions (BME: 2.29, 95%
CI 1.50–3.50, P < 0.0001; Black: 2.45, 95% CI
1.57–3.82, P < 0.001). The odds ratios differ significantly
between the patient type groups for the Black v. White
(P=0.031) and the BME v. White comparisons
(P=0.017). The Black v. Asian comparison was non-significant
(P=0.115) and although the Asian v. White comparison was
statistically significant, this should be viewed with caution because only one
forensic study was included.
Illness episode
There was also an effect for illness episode across different ethnic
comparisons, with first-episode BME (2.15, 95% CI 1.55–2.98, P
< 0.0001) and Black patients (2.42, 95% CI 1.74–3.38, P <
0.001) less likely to be detained than later mixed-episode BME (3.53, 95% CI
3.16–3.95, P < 0.0001) and Black patients (4.06, 95% CI
3.60–4.59, P < 0.0001).
Quality
Studies rated as high quality in both the BME v. White and Black
v. White comparisons showed lower summarised odds than low- and
medium-quality studies. This effect was statistically significant in the Black
v. White comparison (P=0.03), but not in the BME v.
White comparison (P=0.16).
Publication date
Overall the odds ratio decreased significantly with study publication date
for both the BME v. White (P=0.001) and Black v.
White comparisons (P=0.001). The Asian v. White comparison
approached significance (P=0.06) whereas the Black v. Asian
comparison was non-significant (P=0.55). There was a statistical
correlation between higher quality and recency of publication (P <
0.01).
Explanations for the excess
Five categories of explanations emerged from the 49 studies included in the
review. These were categorised as ‘patient-related’,
‘illness-related’, ‘service-related’,
‘culture-related’ and ‘patient–service interaction
related’. Each category of explanation and literature offered to support
it are presented in separate tables (Tables DS2.2–2.6 in data supplement
2 to the online version of this paper). The right-hand columns in each table
describe the level of evidence offered for each explanation. Papers presenting
evidence against that particular explanation are grouped at the end of each
table.
Patient-related explanations
Patient-related explanations (Table DS2.2) included theories that higher
rates of detention occur because Black and minority ethnic patients have
higher rates of psychoses, are perceived as being at greater risk of violence
and disturbed behaviour, have higher rates of comorbid drug use and have
greater delays in help-seeking. Much of the evidence for these explanations
came from secondary citations, with little primary evidence, especially for
explanations such as comorbid drug use and delayed help-seeking. A few studies
reported primary evidence that the effect of ethnicity could be entirely
explained by an interaction between diagnosis and challenging behaviour. Some
studies found that even when such variables were controlled for, BME status
remained a predictor of detention.
Illness-related explanations explanations
Explanations in this category (online Table DS2.3) related to different
illness expression in Black and minority ethnic patients, with more
challenging behaviour or violence, association with offending behaviour,
poorer adherence and greater denial of illness, all of which could account for
higher rates of detention. Much of the evidence was of a secondary nature,
with one study reporting no ethnic difference in clinical presentation of
psychotic disorders.
Service-related explanations
Service-related explanations (online Table DS2.4) included the
possibilities that excess detentions could be explained by under-recognition
and misdiagnosis of mental illness in Black and minority ethnic patients,
lower likelihood of referral to specialist services, greater contact with the
police, and racial stereotyping and discrimination within both the mental
health and the criminal justice system. There was some secondary evidence of
underrecognition of psychiatric problems in such patients and the possible
role of racial stereotyping.
Other explanations explanations
The other two sets of explanations, culture-related (online Table DS2.5)
and patient–service interaction (online Table DS2.6), included a mixed
set of explanations ranging from cultural differences in explanatory models of
illness, stigma of mental illness in Black and minority ethnic communities,
alienation from and mistrust of services due to negative perceptions and
experiences, and unwillingness to seek help. Of all these explanatory
categories, culture-related explanations had the fewest supporting citations.
Negative perceptions of services, with mistrust and poor engagement, dominated
the service–patient interface explanations, but there was lack of
supportive primary evidence.
Overall, racial stereotyping, labelling and discrimination against Black and minority ethnic patients was the most often cited explanation and appeared in 15 papers (31%); this was followed by alienation, dissatisfaction, negative perceptions and mistrust of psychiatric services (in 26% papers), greater perception of violence (22%), higher rates of psychosis (22%), delay in help-seeking and poor social support (18%) and misdiagnosis, underrecognition of mental illness with lower referral rates to specialist services (16%). If the perception of Black patients as more violent or at greater risk is considered as part of the ‘racial stereotyping’ category, then this ‘race-based’ explanation was offered in 53% of the studies. There was no primary evidence provided by most studies to confirm any of these explanations, and some papers presented data that contradicted these explanations – for instance, some studies showed that the effect of ethnicity could be accounted for by an interaction between age, gender, diagnosis and challenging behaviour.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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This review confirms earlier findings of an excess of compulsory detentions among Black and minority ethnic patients (Churchill et al, 1999; Bhui et al, 2003; Morgan et al, 2004). However, our findings go further in identifying variations in detention rates between different minority groups, and also reveal differences between first and later illness episodes, and between civil and forensic patients, publication dates and research quality ratings. The finding that studies rated as high quality (a rating that included an assessment of degree of control of possible confounders) tended to report a reduced excess of detentions supports the hypothesis that at least some of the excess is accounted for by confounding variables. The reasons for differences between minority ethnic groups remain unexplored and warrant further scrutiny as to whether these are related to socio-economic, cultural or help-seeking differences between groups, or different experiences and perception of racism. Our finding that forensic detention rates for BME v. White and Black v. White comparisons were lower than the rates for civil detentions was unexpected, given previous results of the overrepresentation of BME patients in secure psychiatric care (Lelliott et al, 2001). However, meta-analysis results should be interpreted with caution as only two datasets were included for the forensic sections.
The increasing detention rate across time, with lower rates for first-episode illness, suggests that the relationship between Black and minority ethnic patients and mental health services deteriorates over time. Parkman et al (1997) found that although Black and minority ethnic patients had decreasing satisfaction with each hospital admission, whether the admissions were compulsory or not did not have an independent effect on patient satisfaction. The relationship between engagement, satisfaction and detention needs to be further explored in order to identify both general concerns and those specific to Black and minority ethnic groups, using longitudinal, mixed-methods studies exploring the process and experience of care and detention over time.
We found that racism and racial stereo-typing of Black and minority ethnic patients were the most common explanations offered for excess detentions, but without primary supportive evidence to justify these assertions. The second most common explanation was that these patients are alienated, mistrust mental health services and are dissatisfied with services. This also had little supporting evidence from the papers itself. Overall, few studies were hypothesis-driven or methodologically based on a testable theoretical or conceptual model. Even where ethnic differences were found, there was a disjunction between reported findings and proposed explanations, with no attempt to link or explore complex multidimensional interactions between variables.
One possible reason why explanations such as racism have become accepted as the ‘cause’ of excess detention is that authors of early papers that reported excess detentions speculated on several possible explanations for this new finding. Instead of robustly testing these hypotheses, subsequent research has presented these speculations as ‘evidence from previous research’. Although this often happens in scientific research, in politically sensitive and emotionally charged areas such as detention and ethnicity it is critical to distinguish fact from opinion and hypothesis from evidence. Racial discrimination undoubtedly occurs in British society and leads to much personal suffering and possibly also to mental illnesses (Bhui, 2002; Karlsen & Nazroo, 2002). Racism may indeed play a part in ethnic inequalities in mental healthcare, but this needs to be scientifically explored rather than accepted as the only cause of such differences (Singh & Burns, 2006).
Inclusion of publication dates in meta-analyses for the BME v. White and Black v. White comparisons shows a reduction in the excess of detention rate with later publication date. This can be interpreted in two ways. Either the excess rates for Black and minority ethnic patients have reduced over time, or with better control of confounders in later studies the effect of ethnicity is partly accounted for by confounding variables.
There is also an important issue of possible publication bias, in which research reporting significant differences between groups is more likely to be published, be cited by other authors and to produce multiple publications than research not finding such differences. The former studies are therefore more likely to be identified in systematic reviews, which potentially leads to bias (Sterne et al, 2001; Dubben & Beck-Bornholdt, 2005). It was noteworthy here that some studies not finding differences in detention rates did not attempt to explain this finding (Holloway et al, 1988; King et al, 1994; Harrison et al, 1999; Riordan et al, 2004), although this was in contradiction to much of the available literature. This suggests that statistically non-significant differences are perceived as less worthy of comment. Presumably, reporting and commenting on an absence of difference in rates was even less likely among authors whose main focus was not ethnicity and the Mental Health Act. This would mean their findings might not have been reported and therefore not included in this review and meta-analyses.
Internationally there is nearly twenty-fold variation in detention rates across Europe, with rates rising in England, Austria and The Netherlands (Zinkler & Priebe, 2002; Salize & Dressing, 2004). In The Netherlands immigrants from Morocco, Surinam and the Dutch Antilles have among the highest rates of psychiatric detention, but this excess is accounted for by the presence of more severe symptoms, risk behaviours, lack of treatment motivation and poor functioning in these groups (Mulder et al, 2006). Although there is no major difference in the attitudes of mental health workers and society with regard to the compulsory detention of people with mental illness across several European countries (Lepping et al, 2004; Steinert et al, 2005), it has been suggested that in England the mass-media-generated public concern about the dangers posed by the mentally ill, along with the high level of personal responsibility that psychiatrists are expected to carry, may influence decision-making and increase the tendency to detain (Turner et al, 1999; Szmukler & Holloway, 2000). A common ethical and legal framework is needed to harmonise these critical decisions and their outcomes across Europe.
Agenda for the future
In order to make studies comparable, there must be consistency in ethnic
categories adopted and in their classification. We recommend using a formal
standardised approach to classifying that should be adopted in future studies.
In-depth, longitudinal, mixed-methods studies using both qualitative and
quantitative techniques would improve understanding of patients’
experiences and their journey through the services, pathways to care and why
compulsory admission is more frequently required in later admissions among
Black and minority ethnic patients. Studies should be hypothesis-driven and
also explore the process of application of the Mental Health Act. The true
denominator for Mental Health Act studies is the population assessed for
detention under the Act, not only the subgroup that is detained. Data relating
to both assessment and detention should be routinely and centrally collected.
Finally, as we have argued elsewhere
(Singh & Burns, 2006),
factors that contribute to excess detention even in the first episode of
mental illness operate before presentation to mental health services. Hence,
any potential solutions must go beyond the health sector and involve statutory
as well as voluntary and community agencies.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Received for publication August 25, 2006. Revision received January 30, 2007. Accepted for publication February 21, 2007.
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