Around 1 in 6 adults in England meet the criteria for a common mental disorder (CMD) with around 39% of these accessing treatment (NHS Digital, 2016). Inequalities in mental health have become a prominent issue in recent years, in the UK. It is known that there are differences in CMD prevalence between ethnicities. In England, White British ethnicity has lower rates of CMD compared to ethnic minorities (NHS Digital, 2016).
A 2007 survey showed that there are inequalities in the type of treatment that individuals get, with ethnic minorities less likely to receive them (NHS Digital, 2009). Why is there a treatment inequality between ethnicities in England? It may be that there is discrimination affecting whether treatment options are offered equitably across ethnic groups (Clark et al, 2009). Likewise, due to cultural variations, those from ethnic minorities may be less likely to present to their GP with their symptoms.
To reduce inequalities in mental health and ethnicity, it is vital to acknowledge and understand them. This blog summarises a recent study exploring associations between ethnicity, CMD, and treatment receipts (Ahmad et al, 2021).
The Adult Psychiatric Morbidity Survey (APMS), a cross-sectional survey, was used to explore the differences in common mental disorders (CMD) and their treatments, stratified by ethnicity. Two waves of data were used (2007 and 2014) to determine if trends had changed over time.
Due to data availability, ethnicity was broken down into 5 broad categories:
- White British
- White Other
Outcomes were CMD and treatment receipt. CMD was assessed using the Clinical Interview Schedule – Revised, which scores participants on their answers to a set of questions, that focuses on the last month. A variable was constructed to assess treatment receipt.
Only complete cases were used in the analysis. Bivariable analysis was used to describe differences in the distribution of mental health outcomes and confounders, Pearson’s χ2-tests were used to explore associations between ethnicity and outcomes, and multivariate logistic regression was used to assess differences in CMD prevalence and treatment receipt by ethnicity. Unadjusted and adjusted analyses were performed, with the final model adjusted for both demographic and socio-economic factors.
14,600 cases were included in the analysis.
Unadjusted analysis between ethnicity and CMD indicated that Black people were the only ethnicity with significantly different odds compared to people in the White British category. People with Black ethnicity included in the survey had 52% increased odds of CMD compared to people in the White British category. For treatment type, White British people had the highest proportion of people taking antidepressants. Black people had the lowest proportion of people who had seen their GP for a mental, emotional, or nervous complaint in the past year.
When adjusted for all variables, there was no longer an association between ethnicity and CMD suggesting demographic and socioeconomic factors explained the relationship seen in the unadjusted model.
However, for any treatment type, associations remained after controlling for possible confounders. All ethnicities were at a reduced odds of treatment compared to White British, but Mixed/Multiple/Other did not show significant associations. Black individuals have 77% reduced odds of treatment compared to White British. Due to the differences between years, there is evidence to suggest that inequality in treatment has increased for White Other and Black individuals.
The authors concluded that:
Although no significant changes in the prevalence of CMDs have been found over time, persisting, if not widening, CMD treatment inequalities continue, which are not explained by known demographic and socioeconomic confounders, particularly for Black people.
Strengths and limitations
This study provided a much-needed update on ethnicity, CMD and treatment receipts using a large, representative dataset. Equally, the study used clinically validated tools to assess CMD and the study was able to compare across time points to determine how prevalence and odds have changed.
However, the study uses cross-sectional data which has many limitations, including that it only accounts for one specific time point. This is a particular problem in this survey as it focuses purely on the preceding month, with an emphasis on the last week, with no account for any timeframe before this. Although it reduces recall bias, it does introduce information bias.
Likewise, CMDs are self-reported and may be underreported due to respondents giving, what they perceive, as socially acceptable responses, which could be more prevalent in ethnic minority populations.
The authors themselves acknowledge the methodological limitations of their study. Socioeconomic factors often lie on the causal pathway between ethnicity and the outcomes which may have affected the results when adjusted for. Previous research has shown that migrant status may have an interaction with ethnicity and mental health, and therefore, studies should, where possible, stratify by this. Due to data availability, this study was not stratified. The combination of the mixed, multiple, and other ethnicities may also hide true results within this group, but the data was not available for each ethnicity.
Implications for practice
For me, the key messages from this study are:
- There are differences in common mental disorder prevalence between ethnicities, but these can be explained by socioeconomic factors;
- Differences in odds of treatment receipt cannot be explained by socioeconomic factors, and significant associations remain with ethnic minorities having worse odds compared to White British;
- Treatment inequality has increased and must be addressed.
This research is important for researchers, clinicians, and policymakers alike. The differences in ethnicities must be taken into account in primary care, especially when treatment options are being considered. Clinicians must ensure all individuals are treated equally whilst fully explaining what each treatment is, and what it would involve, to ensure individuals have a complete understanding and reduced fear of the treatments available. Mental health services must be designed to be inclusive and accessible to all. The reasons why inequalities in treatment are widening must be explored further.
Statement of interests
No conflict of interest.
Ahmad G, McManus S, Cooper C, et al. 2021. Prevalence of common mental disorders and treatment receipt for people from ethnic minority backgrounds in England: repeated cross-sectional surveys of the general population in 2007 and 2014. The British Journal of Psychiatry. 2021; 1-8. https://doi.org/10.1192/bjp.2021.179
Clark DM, Layard R, Smithies R, et al. 2009. Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy. 2009; 47(11):910-20. https://doi.org/10.1016%2Fj.brat.2009.07.010
NHS Digital. Adult Psychiatric Morbidity in England – 2007, Results of a household survey. 2009. Retrieved from: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-in-england-2007-results-of-a-household-survey
NHS Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. 2016. Retrieved from: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014