The RCPsych Article of the Month for January is ‘Ethnic inequalities in involuntary admission under the Mental Health Act: an exploration of mediation effects of clinical care prior to the first admission’ and the blog is written by authors Daniela Fonseca Freitas, Susan Walker, Patrick Nyikavaranda, Johnny Downs, Rashmi Patel, Mizanur Khondoker, Kamaldeep Bhui and Richard D. Hayes. The article is published in The British Journal of Psychiatry.

Minoritised ethnic groups face higher rates of involuntary psychiatric hospital admission, under the Mental Health Act (MHA), than White British people. The causes of this ongoing and consistently recorded inequity remain unclear. A frequently used explanation indicates a lack of engagement with services, but the evidence is limited. We used data from the electronic health records from the South London and Maudsley (SLaM) NHS Foundation Trust, a large provider of secondary mental healthcare, to investigate if differences in access to care explained the ethnic inequities in involuntary admission and to identify potential types of practices that could reduce the risk of involuntary admission.

There are several key findings from this study. We observed that 10 of the 14 minoritised ethnic groups analysed in the study had higher odds for involuntary admission than White British after controlling for a wide range of socio-demographic factors and clinical diagnoses. Only people of White Irish or mixed-race backgrounds had similar odds for detention as White British.

Although there were some ethnic inequities in the frequency and type of care in the 12 months before admission, their influence on the odds of involuntary admission was minimal.

Minoritised ethnic groups did not receive fewer secondary mental healthcare appointments than their White British counterparts did in the 12 months before admission. On the contrary, when disparities were observed, they indicated that some minoritised ethnic groups were likely to have more appointments before admission. However, having more appointments was not associated with reduced odds of involuntary admission. In fact, adjusting for clinical diagnoses and socio-demographic factors, people who had between 6 to 11 appointments in the 12 months before admission were at greater odds for involuntary admission than those without any appointments. Furthermore, those who had received home treatment were more likely to be involuntarily admitted than those who did not receive this care. While we acknowledge some residual confounding regarding severity of illness (as we adjusted for psychiatric diagnoses only), and we might expect those more severely ill to need more contact with healthcare services and home treatment, these findings highlight the need for further research into what clinical input will help to prevent involuntary hospitalisations.

People who have received psychological therapies had lower odds of involuntary admission and some minoritised ethnic groups had lower access to these types of care. As there is potential for self-selection and residual confounding concerning severity of illness, which could mean that only those less severely ill were given and/or accepted psychological therapies, more research is needed to verify if these therapies can reduce the involuntary admission.

Furthermore, the odds of involuntary admission were lower among people with a record of a care plan. This result suggests that giving patients’ opportunity to discuss and plan their treatment, fostering a good therapeutic alliance, could reduce the risk of involuntary admission.

In summary, the findings lead us to refute the claim that the lack of engagement with services is a reason for higher rates of involuntary admission among minoritised ethnic groups. If people from minoritised ethnic groups are engaging with services and are still subject to more involuntary admissions, then what must services do differently? Our results suggest that preventing involuntary admission is not a simple matter of having access to care. Research and clinical practice could focus on the qualities of good experiences of care (such as shared decision-making and a trusting therapeutic relationship) which may make someone less likely to be hospitalised involuntarily.

Our article of the month focuses on the impact of ethnicity and prior clinical care on involuntary admission under the Mental Health Act.  This important work seeks to connect and examine together two previous findings in the literature: namely, that there are ethnic inequalities in the rates of involuntary admission, and also in the types of clinical care offered minoritized ethnic groups.  Using a large clinical data set from the South London and Maudsley NHS Foundation Trust, the authors show that 10 out of the 14 ethnic minority groups had higher rates of involuntary admission compared with White British people, and that prior clinical care, such as working with a crisis or home treatment team, or having a shared care plan, had minimal impact on these differences.  This paper demonstrates that further work is needed to explain the relationship between ethnicity and involuntary care, but also that the efficacy of psychological therapies and care plans in reducing these inequalities on admission warrants further investigation.

Matthew Broome

Deputy Editor, The British Journal of Psychiatry