Mental health section rates a migrant, not ethnic, issue

Mental health services not racist but society could do better. Flickr/image munky

Ethnic minorities aren’t more likely to be detained or “sectioned” under the Mental Health Act because of institutional racism, according to a new study.

A relatively higher number of black and minority ethnic (BME) people are detained under the law, which allows someone to be admitted, detained and treated in hospital against their wishes. But this has more to do with factors in society such as discrimination and family breakdown, researchers from Warwick University said.

The study, published in Psychological Medicine, looked at information from more than 4,000 mental health assessments in Birmingham, Oxfordshire and west London between 2008-11. Although around two thirds of these led to patients being detained under the act, a person’s ethnicity didn’t make them more likely to be detained.

Figures on BME groups in mental health show that in 2011, 23% of people on mental health wards were from BME groups - despite representing less of the overall population.

The figures vary but in general, Asian peopleare around twice as likely to be detained as the native, white population in England and Wales. Black people - and particularly young men from black Caribbean backgrounds - are nearly three times more likely.

“Ethnic minorities do have higher rates of detention,” lead author Professor Swaran Singh said. “But it’s a migrant issue not an ethnic issue. Migrants are exposed to factors that greatly increase your risk of mental health problems like psychosis, such as being excluded, facing discrimination and family breakdown. The more of these you have, the higher your risk.” Irish people are also around twice as likely to be detained as white people born and brought up in England and Wales.

Singh added: “There’s racism but it’s in society, not necessarily in mental health services. It’s like looking at a rise in diabetes and blaming doctors - it’s just the symptom of a wider problem.”

The problem is exacerbated, Singh said, because many that could be helped at an earlier stage hold back from seeking help because of a historical mistrust of psychiatric services.

The death of Rocky Bennett

Accusations of racism in mental health were widely made after the death of Rocky Bennett, who died while being restrained by nurses in October 1998. A strongly worded 2004 report into his death officially branded the NHS - and particularly its mental health services - institutionally racist.

Since then, the label has stuck, Singh said, despite services moving on. “A study from Bristol in the late 1980s showed particularly high rates of schizophrenia and psychosis,” Singh said. “It caused quite a stir and the belief that it was a manifestation of white psychiatrists misdiagnosing mental health problems in ethnic minorities. It was repeated until it became received wisdom. And people get very cross if you challenge the orthodoxy - and in psychiatry it’s become an orthodoxy.”

He added: “Instead of saying let’s deal with the real problem out there and why people are getting ill in the first place, people are avoiding help because there’s this mistrust in psychiatry.”

A viscious circle?

Dr Saffron Karlsen, a senior research fellow at UCL, said there was mistrust of mental health services because of high-profile cases such as Bennett’s, but said it wasn’t clear cut how racism might play out in mental health services.

“There’s definitely evidence that experience of racism in society leads to poor mental health and those problems also lead to health differences between ethnic groups,” she said. “But it’s probably difficult to pinpoint racism and say that’s it right there. There are definitely ethnic inequalities in how minorities access services and are treated.”

Aversive racism - as opposed to overt racism - can play a part, where services are designed and staff act on more subconscious beliefs or stereotypes. This could play out in the way BME groups come to use mental health services.

“Black men for example have higher levels of compulsory admittance, for example coming to services through the police, not GPs,” said Karlsen. “There’s also a difference in treatment, for example being on locked wards rather than appointments to see a psychologist. People are using services in different ways … it could well be that someone goes to their GP and another doesn’t and then it gets to the point where they access services at a more [disruptive] point. For example, if you go for a health screening and pick up something earlier, it might be less invasive and offset a crisis later. Distrust in health services can encourage these delays.”

She added: “At the same time if health staff and police percieve a black person for example as more threatening, they may well act or engage them in a different way.”

Gail Coleman, honorary professor at Sheffield University’s clinical psychology unit, said stories of bad experiences led to fear. “In the 90s there were a lot of stereotypes - for example of black men - and fears from staff that they would be more aggressive,” she said. “People hear from relatives about their experience, of being locked up and possibly being killed.”

Coleman agreed with Karlsen that getting people to engage with services in a different way was a good thing, but said it was wrong to dismiss fears. “People won’t trust services to access them early and might delay, but the reality is that if they do access them early they might still get different treatment. You can’t say it’s complete paranoia.”

She added: “I think there is still potential there for bias. Staff need training to reflect on the prejudices they have - as we all do. The system could be a lot better and focus more on prevention.”

While there are differences in claims of no institutional racism, Karlsen and Coleman both acknowledge the wider problem in society that lead to higher risk of bad mental health. “There are lots of social inequalities - social exclusion, direct racism, disempowerment and even issues around child protection,” Coleman said.

Mental health isn’t equal

Using assessments taken in Birmingham, Oxfordishire and West London, the researchers found that you’re more likely to be detained under the Mental Health Act in London, though it is unclear whether this is due to how services are organised, resources and deprivation.

“Most studies have been done in London and then applied to other places, like Cumbria, despite completely different needs,” Singh said.

“The problem with the institutional racism argument is that it considers BME people as a homogeneous group that passively sits under the dictates of white society. There are differences in mental illness in groups.”

Singh points to higher rates of liver cirrhosis in the Sikh community, coronary disease in South Asian men generally, and problems with depression in South Asian women.

“In medicine and epidemiology that there are different rates of illness in different groups,” Singh said. “But in mental health it must be egalitarian, we must all suffer the same.”

The answer is not to look at reducing quotas but to assure communities that mental health services are on their side. For instance, he said: “We’re trying to engage imams: by all means perform your ceremonies but ask them to also go and see a doctor. I see the impact of untreated illness in ethnic communities and that’s a tragedy.”