Race discrimination in mental health

I read this in the Guardian Schizophrenia 'epidemic' among African Caribbeans spurs prevention policy change (http://www.guardian.co.uk/society/2009/dec/09/african-caribbean-schizophrenia-policy#start-of-comments ) and it seems strange to me that it has never occurred to me that race discrimination would be a problem; but then I am British and white and I guess that I’m not really that good at thinking outside of our own experience. If I had been black or of an ethic minority it would probably have been all too obvious, but then maybe it wouldn’t.

So for all of you are perfectly well aware of the problems please forgive my ignorance and as I fear I might be far from alone in knowing about it I thought I would look into it a bit.

 So the question is what are the problems associated with Race and mental health?

Essentially

There is a sizable body of evidence detailing the over-representation and disproportionately negative experiences of BME people within secure mental health settings http://www.mind.org.uk/assets/0000/4965/mind_think_report_4.pdf

However at the time of writing this MIND had no clear evidence as to how bad the situation really was. Since then the Government put together an action plan:

Delivering race equality in mental health care: An action plan for reform inside and outside services and the Government's response to the Independent inquiry into the death of David Bennett http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100773 Sir Nigel Crisp's 10-point race equality action plan in the NHS is listed on this page and it contains (BME Black and minority ethic, including those of Irish or Mediterranean origin and east European migrants)

That would evaluate and hopefully reduce the perceived problems. The Count me in census was set up and collected annually from 2005 with the last one completed 2010. (The final report and comparison since its beginning can be found here http://www.cqc.org.uk/sites/default/files/media/documents/count_me_in_2010_final_tagged.pdf)

There is a lot of information in this document however I’m only going to pick out a few things

·         The overall proportion of patients from minority ethnic groups increased from 20% to 23%. (2005-2010)

Admission rates showed similar patterns across all censuses:

·         Lower than average rates among the White British, Indian and Chinese groups.

·         About average rates among the Pakistani and Bangladeshi groups.

·         Higher than average rates among other minority ethnic groups – particularly in the Black and White/Black Mixed groups, for whom rates were two or more times higher than average in 2010. The Other Black group continues to have exceptionally high rates of admission (even after the apparent reduction since 2005, see next point).

·         Although admission rates for many ethnic groups show relatively little change since 2005, the rate for the Other Black group is considerably lower in 2010 (six times higher than average) compared with 2005 (12 times higher than average). However, rates for the other Black and White/Black Mixed groups show small increases

·         There was a steady increase in the overall proportion of patients subject to the Mental Health Act. Compared with 40% in 2005, 49% of all patients were subject to the Mental Health Act in 2010 (53% if outpatients on a CTO –community treatment order- are excluded).

·         Detention rates have been higher than average among the Black Caribbean, Black African and Other Black groups in all six censuses, and almost consistently higher in the White/Black Caribbean Mixed and Other White groups. Rates have been average for other minority ethnic groups

·         A consistent pattern was the higher than average detention rate under section 37/41 for the Black Caribbean and Other Black groups

·         Although there have been annual fluctuations in seclusion rates, they have been higher than average for the Black and White/Black Mixed groups, and the Other White group, in at least three of the six censuses. Other minority ethnic groups did not show high rates

The consistency of the statement higher than average for Black and White/Black within the text suggests that for these groups there is a big problem and therefore it could reasonably be concluded that the action plan failed miserably to achieve many of it’s objectives.

 Unfortunately I still question whether it was a complete failure. Yes the numbers of BWE patients did not fall, there were not fewer detentions/ restraints or CTOs however we did not know what the population statistics were before this affirmative action was taken and just because the percentages didn’t fall doesn’t mean numbers did not reduce. The opening statement of the report states

the numbers of inpatients overall have fallen since 2005

So what do I think is an improvement?

Not only do we know far more about the people who use the facilities we also know how that has changed because of what has been attempted and although it hasn’t brought the desired effect it means we have something to work with.

However the information gleaned from this does not really explain anything about why and certainly nothing that it did appears to have made any difference to the proportion of people admitted. So why?

Well first off what are the suggestions.

•              Staff prejudice including, stereotyping this minority as dangerous or aggressive

•              Higher than average rates of ill health with more severe illness

Realistically it could be either, however I feel it’s more likely to be both. For a start so little is known about mental illness, why it occurs and what promotes the patients downturns that stereotypes are very likely. See this article http://psychcentral.com/news/2012/04/02/is-adhd-overdiagnosed/36813.html Is ADHD over diagnosed? You might wonder why it’s got nothing to do with this. Well yes in some ways you might be right however it does highlight one important thing that some physicians will choose to diagnose based purely on gender rather than diagnostic criteria and that in this case being male will mean you get a diagnosis of ADHD and not for a girl.

So being black and mentally ill may well make a difference to the way you are perceived by others. The question is does being black and mentally ill mean dangerous or is it simply that these people are actually dangerous? And I would love to see some evidence that this prejudice is there however I feel it unlikely to be there for me to find. Certainly Suman Fernando feels so (see this article in the Guardian Black and minority ethnic mental health patients 'marginalised' under coalition http://www.guardian.co.uk/society/2012/apr/17/bme-mental-health-patients-marginalised) where he is quoted

has suggested that the health service could be "institutionally racist", arguing that "inherited" ideas about racial stereotypes among mental health professionals – such as the "perceived dangerousness" of black men – has produced a skewed diagnostic and treatment system

and

Alongside other campaigners, Fernando has repeatedly called attention to these and other race-related data, such as the fact that black men in Britain are much more likely to be sectioned under the Mental Health Act and that once in a psychiatric institution they tend to be held for longer than their white counterparts. Add to this disparities in access to "talking therapies" and higher-than-average rates of supervised community treatment orders for some BME groups, and what emerges is "clear evidence" of a system in need of reform, Fernando says.

Which does suggest that there is a problem somewhere and as such an exploration of what is causing this is required. Mr Fernando is strident in his opposition of the government

They have walked away from it completely," he says of the coalition's attitude to addressing racial disparities in mental health diagnosis and treatment. "You can't mention equalities [within the Department of Health]. There is a sense that race is off the agenda. It's the idea of 'post-race'. That is what they are saying. [But] that's not the case, and it's very worrying."

The problem certainly needs to be addressed and on his website you will find out what his next project is http://www.sumanfernando.com/news.html however I wouldn’t be too quick to blame either the government or the medical profession there could be other explanations.

So to me my second point about increased mentally illness and severity of illness in people from these groups, as I am unconvinced that actually there aren’t other factors besides prejudice based on race that could explain the higher than average admissions and the treatment of these minorities. This is not to say that there is no race prejudice just that other things may compound the problem.

For my thoughts please see the next post.