Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Abstract

BackgroundBlack and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.Aims and objectivesStudy 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.MethodsStudy 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’ResultsThere were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.ConclusionsStatutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses

“…As most incidence data is based on treated cases, due consideration needs to be afforded to the common pathways to mental health care for ethnic minority groups. Despite research showing that compulsory admission is particularly high for Black ethnic groups [29,30,78,80], compulsory admission rates are not necessarily associated with incidence per se. These admissions are based on the subjective perceptions of authorities, rather than confirmed incidence cases, that the persons in question may be at risk to themselves or others due to mental health concerns.…”

“…The AMSTAR checklist was used to assess quality of previous reviews (Online Resource 2). For primary studies included in our refined meta-analyses, we adapted a verified [11,15] and recently adapted [21] 5-item quality assessment tool and added an item to assess the specificity or clarity of the use of ethnic/national categories in the studies' analyses taken from another verified [29] and replicated [30] tool (Online Resource 3).…”

Stigma- and non-stigma-related treatment barriers to mental healthcare reported by service users and caregivers

“…Third, we did not include Asian participants therefore the findings cannot necessarily be applied to this group. UK research comparing barriers to care in Asian, Black and White ethnic groups found that Asian service users and caregivers were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations, although second-generation Asian patients were less likely to have supernatural attributions (Singh et al, 2013). The same study reported that most White respondents sought help in consultation within the nuclear family, whereas in Black and Asian groups help was sought in consultation with larger family networks (aunts, uncles, grandparents, and cousins) and through community organisations.…”

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“…5 Misperceptions breed misattributions. In the ENRICH programme, 6 we found that for similar experiences of inadequate mental health care, white patients and families attributed poor care to bad service, whereas black patients and their carers considered services racist.…”