How to serve our ethnic minority communities better

On Jan 9, 2017, Theresa May, the British Prime Minister, gave a speech about “the burning injustice of mental illness”, mentioning “injustices in the way black people with mental ill health in particular are treated”, and promising that politicians would “take action to put things right.” In response to three decades of UK research on ethnic differences in mental health, such emotionally charged rhetoric has been commonplace, but has rarely produced meaningful change. Mental health care in ethnic minorities is complex, and needs dispassionate and objective scrutiny of evidence and its limitations, with careful disentanglement of the interactions between ethnicity, culture, community histories, legacies of racism, and the labyrinthine service structures that people with mental illness and their families must navigate to get appropriate help. In The Lancet Psychiatry, Phoebe Barnett and colleagues present findings from a systematic review and meta-analysis of ethnicity and legal detention of people with mental illness, an impressive attempt at providing just such scrutiny. Although the findings are not strikingly different from what is known, this comprehensive paper is a timely reminder of how far we are from fully understanding the problem—let alone solving it—and why the stated political intention to put things right might be easy to promise but hard to deliver

Black and minority ethnic people are more likely to be detained under the Mental Health Act 1983 : no clear evidence why

Question: Compared with White people, how frequently are people from Black and Minority Ethnic groups detained under the Mental Health Act 1983? Outcomes: Rates of compulsory detention under the Mental Health Act. METHODS Design: Systematic review with meta-analysis. Data sources: MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, SIGLE, HMIC, Web of Science, Cochrane database and the National Research Register; 1984 to April 2005. CD-ROM for the British National Bibliography was also searched for relevant literature. Study selection and analysis: English language studies relating to compulsory detention under the Mental Health Act 1983 and including terms related to mental illness or forensic psychiatry, and with inclusion of 2 ethnic groups (any non-White). Odds of compulsory detention of people from Black and Minority Ethnic (BME) groups compared with White groups were combined using a fixed effects meta-analysis. Meta-regression was then used to explore reasons for heterogeneity between studies. It was based on subgroup analyses according to episode (first, second, etc), patient type (for example, civil or forensic), study quality, and year of publication. The authors then narratively discuss the possible theories for the difference in detention rates

Transition of care from child to adult mental health services : the great divide

Purpose of review: Adolescents with mental health problems often require transition of care from child and adolescent to adult mental health services. This review is a synthesis of current research and policy literature on transition to describe the barriers at the interface between child and adolescent mental health services and adult mental health services and outcomes of poor transition. Recent findings: Adolescence is a risk period for emergence of serious mental disorders. Child and adolescent mental health services and adult mental health services use rigid age cut-offs to delineate service boundaries, creating discontinuities in provision of care. Adolescent mental health services are patchy across the world. Several recent studies have confirmed that problems occur during transition in diverse settings across several countries. In physical health, there are emerging models of practice to improve the process and outcomes of transition, but there is very little comparable literature in mental healthcare. Summary: Poor transition leads to disruption in continuity of care, disengagement from services and is likely to lead to poorer clinical outcomes. Some young people, such as those with neurodevelopmental disorders and complex needs, are at a greater risk of falling through the care gap during transition. Services need robust and high-quality evidence on the process and outcomes of transition so that effective intervention strategies can be developed

Race and mental health : there is more to race than racism

Some minority ethnic groups in England and Wales have higher rates of admission for mental illness and more adverse pathways to care. Are the resulting accusations of institutional racism within psychiatry justified

Ethnicity and the Mental Health Act 1983

Background Black and minority ethnic (BME) patients are disproportionately detained under the Mental Health Act 1983. There has been no systematic exploration of differences within and between ethnic groups, nor of the explanations put forward for this excess. Aims To systematically review detention and ethnicity, with meta-analyses of detention rates for BME groups, and to explore the explanations offered for ethnic differences in detention rates. Method Literature search and meta-analysis. Explanations offered were categorised, supporting literature was accessed and the strength of the evidence evaluated. Results In all, 49 studies met inclusion criteria; of these, 19 were included in the meta-analyses. Compared with White patients, Black patients were 3.83 times, BME patients 3.35 times and Asian patients 2.06 times more likely to be detained. The most common explanations related to misdiagnosis and discrimination against BME patients, higher incidence of psychosis and differences in illness expression. Many explanations, including that of racism within mental health services, were not supported by clear evidence. Conclusions Although BME status predicts psychiatric detention in the UK, most explanations offered for the excess detention of BME patients are largely unsupported

“I’m just a long history of people rejecting referrals” experiences of young people who fell through the gap between child and adult mental health services

The paediatric-adult split in mental health care necessitates young people to make a transition between services when they reach the upper end of child and adolescent mental health services (CAMHS). However, we know that this transition is often poor, and not all young people who require ongoing support are able to continue care in adult mental health services (AMHS). These young people are said to have fallen through the gap between services. This research aimed to explore the reasons why young people fall through the gap between CAMHS and AMHS, and what effect his has had on them and their families. Narrative interviews were conducted with 15 young people and 15 parents, representing 19 unique transition stories. Themes were identified collaboatively using thematic analysis. Reasons for falling through the gap were grouped into systemic problems and problems with the quality of care received. Effects of alling through the gap were grouped into separate themes for young people (feeling abandoned; struggling to manage without continued care; problems with medication) and parents (emotional impact of care ending; parents taking an active role in the young person’s care). To our knowledge, this is the firt qualitative study that has focused only on the experiences of young people who have fallen through the gap between services. This research adds novel findings o existing literature regarding barriers to transition and the effectsof discontinuity of care

Self and suffering in Indian thought : implications for clinicians

The four main Indian religions – Hinduism, Buddhism, Jainism and Sikhism – have several shared concepts about self and suffering, which are salient to the world-view of the followers of these faiths. Understanding the concepts of mind, self and suffering in these faiths can help clinicians build better rapport and gain deeper understanding of the inner world of patients of these faiths. This article highlights the broad cultural and religious beliefs of these groups, with the hope that increased knowledge among clinicians might lead to better therapeutic engagement

Sakshi and Dhyana : the origin of mindfulness-based therapies

Mindfulness-based therapies (MBTs) have shown promising results in non-psychotic disorders. Unlike most other psychotherapy models, which are claimed to be Western in origin, MBTs are firmly based in Indian philosophy and traditions. This paper summarises the concepts of the observer self (sakshi) and attention (dhyana) that underlie the principles and practice of MBT, correcting some erroneous assumptions in the process. It is argued that better understanding of these concepts is beneficial not just for specialist psychotherapists, but for all clinicians interested in the craft of healing

Mentally disordered young offenders in transition from child and adolescent to adult mental health services across England and Wales

This paper provides an overview of transitions across forensic child and adolescent mental health services in England and Wales. The aim of this paper is to delineate the national secure services system for young people in contact with the youth justice system. This paper reviews findings from the existing literature of transitions across forensic child and adolescent mental health services, drawing attention to present facilitators and barriers to optimal transition. We examine the infrastructure of current services and highlight gaps between child and adult service continuity and evaluate the impact of poor transitions on young offenders’ mental health and wellbeing. Young offenders experience a broad range of difficulties, from the multiple interfaces with the legal system, untreated mental health problems, and poor transition to adult services. Barriers such as long waiting lists, lack of coordination between services and lack of transition preparation impede significantly smooth transitions. We need to develop, test and evaluate models of transitional care that improve mental health and wellbeing of this group. Mapping young offenders’ care pathway will help to understand their needs and also to impact current policy and practice. Key workers in forensic services should facilitate the transition process by developing sustainable relationships with the young person and creating a safe clinical environment. Transition of care from forensic child and adolescent mental health services is a neglected area. This paper attempts to highlight the nature and magnitude of the problems at the transition interface in a forensic context

Stairway to heaven : a first-person account of noesis

Mystical and spiritual experiences have been reported throughout human history. Causal explanations for these range from psychopathology of mental illness, drugs such as hallucinogens, neurological disorders including temporal lobe epilepsy, and genuine mystical or spiritual awakening. There is a common core of phenomena in such experiences, as described both in historical accounts and recent research, but also evidence of cultural specificity. This article is a personal account of such an experience, which occurred in a postanesthetic state. A striking feature of the experience was noesis: a sense of revelation and complete understanding. I argue that while there must be a neural basis to these phenomena, it is difficult to reduce the subjective meaning of the experience purely to a brain dysfunction. Reconciling mechanism and meaning of such experiences remains a challenge for both neuroscience and philosophy