It is well documented that there are differences in how patients are treated, depending on their ethnicity. Previous inquiries in the UK have suggested that the NHS is institutionally racist (Blofeld et al, 2003). Some groups, for example those from African Caribbean or Aboriginal descent, experience more coercive care and poor outcomes, including higher doses of psychotropic medication, more detentions under the Mental Health Act, increased length of stay, and more secure placements (NHS Confederation, 2012).

Therefore, first contact with mental health services is incredibly important in retaining trust and preventing coercion, but also in enabling timely and effective support towards recovery. It is known that more coercive routes to care increase the likelihood of people disengaging from services, and prevent opportunities for recovery in those with a history of contact with mental health services.

A new review by Anderson and colleagues aims to examine ethnic differences in pathways to care for first episode psychosis in developed countries.

Methods

The authors conducted a systematic literature review of Medline, HealthStar, Embase and PsycINFO. Literature was included in line with inclusion/exclusion criteria. Meta-analysis of data produced odds ratios with the Metan procedure. The analysis focused on three specific pathways into care:

1. GP involvement
2. Police involvement
3. Involuntary admissions

Results

• 8 papers of 7 studies were included (2 from Canada, 5 from UK)
• Compared to White patients:
  • Black patients had a decreased likelihood of GP involvement (OR = 0.70, 0.57 to 0.86)
  • Black patients had an increased likelihood (twice as likely) of Police involvement (OR = 2.11, 1.67 to 2.66)
• Black patients may be more likely to have involuntary admissions, however the analysis wasn’t possible
• There were no statistically significant differences for Asian patients

Conclusions

The authors concluded:

Black patients are less likely to have GP involvement and more likely to have contact with police on the pathway to care, as compared to White patients.

Discussion

The continued mistrust of mental health services by the Black community clearly impacts on their experiences of diagnosis and treatment. But more importantly if first contact with mental health services is the result of coercive measures a bad precedent is set for future contacts. Fast access to health care is clearly important, firstly it makes it less likely that coercive means will be used by mental health services, and undoubtedly leads to better opportunities for recovery.

The author’s don’t really unpick why these different pathways exist or are able to drill down in sufficient detail beyond the broad descriptors of Black, White, and Asian. However, previous studies have highlighted the institutional racism and differential treatment of the African Caribbean community, particularly those of second or third generations (CQC, 2011).

Limitations

This study had a number of limitations:

• The focus on GP interventions meant that only a small number of developed countries have produced relevant research
• There was no analysis beyond Black, White or Asian groups. There is clear evidence of differences within these groups, particularly in those from African Caribbean descent
• Most studies appear to have been historically underpowered
• Finally, pathways to care are difficult to define and measure. The authors concluded that more qualitative research would be helpful in unpicking these differences in pathways to care

Links

Anderson KK, Flora N, Archie S, Morgan C, McKenzie K. A meta-analysis of ethnic differences in pathways to care at the first episode of psychosis. Acta Psychiatr Scand. 2014 Feb 28. doi: 10.1111/acps.12254. [Epub ahead of print] [PubMed abstract]

Blofeld, J. et al Independent Inquiry into the death of David Bennett (PDF). Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, Dec 2003.

Race equality in mental health (PDF). NHS Confederation Mental Health Network, May 2012.

Count me in 2010: results of the 2010 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales (PDF). Care Quality Commission, Apr 2011.

Rehman H, Owen D. Mental health survey of ethnic minorities: research report (PDF). Ethnos Research and Consultancy, Oct 2013.