Mental Health

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Key Trends

• In April 2010 the Care Quality Commission’s (CQC) review of the final Count Me In1 Census showed that little progress had been made in reducing the mental health admission rate for Black and other minority groups. 23% of inpatients in mental health services in 2010 belonged to these groups despite efforts over the previous 6 years to reduce admissions. The rates of admission, detention and seclusion were effectively unchanged and evidence from the Census outlined the following:
» Admission rates remain higher than average among some racial groups, especially those recorded as being Black or mixed race (White/Black) for whom rates were two or more times higher than average in 2010. In contrast, admission rates were consistently lower than average among the Indian and Chinese groups, and about average in the Pakistani and Bangladeshi groups.
» Detention rates had almost consistently been higher than average among those recorded as Black or mixed race (White/Black) as well as those classed as ‘Other White’. The rates for being placed on a Community Treatment Order (CTO) were higher among the South Asian and Black groups.
» Seclusion rates were higher than average for the Black, Mixed (White/Black) groups and Other White groups, in at least three of the six censuses The above were also identified as recurring themes in a subsequent report ‘Monitoring the Mental Health Act in 2011/12’2 which used data available quarterly from the Mental Health Minimum Data Set (MHMDS).
• A 2008 study by the Independent Police Complaints Commission on the use of Section 1363 found that the rate of detention for BME people was almost twice as high as that for white people.
• Within mental health settings, higher rates of formal admissions under the Mental Health Act amongst the Black and minority ethnic population also significantly affect BME men.4
• There is a substantial body of evidence pointing to a negative relationship between mental health services and African and Caribbean men, who are under-represented
as users of enabling services and over-represented in the population of patients who are admitted to, compulsorily detained in, and treated by mental health services.
The consequences of this are poor engagement with mainstream services, restricted choices and high levels of dissatisfaction with mainstream care.4,5
• Research relating to the Irish community shows the following:6,7
» The Irish population in Britain has a history of higher rates of mental ill-health than the general population.
» Irish people are substantially over-represented as users of psychiatric services, particularly for depression and alcohol related disorders.
» They are more than twice as likely to be hospitalized for mental health problems as native-born people in England and Wales.
» Irish rates of schizophrenia are second only to those of African-Caribbean people.
» Studies have shown that Irish-born people living in the UK have a higher rate of suicide than any other minority ethnic group living in the country.
» A study carried out in Birmingham8 in 2008 looked specifically at the mental health needs of Irish women. One of the themes which came through strongly was the stigma which was attached to mental ill-health, especially among older women.

• For disadvantaged groups with transitory lifestyles - such as Gypsies and Irish Travellers - difficulty registering with a GP is a barrier to accessing primary care. There
is also some evidence that health care providers and staff working within primary care settings may restrict access to such services for certain communities. This is
also relevant to preventative programmes. Moving from a transitory lifestyle to housing can exacerbate mental ill-health.9,10
• Common mental disorders such as depression and anxiety are not considered as serious or disabling for the individual as psychotic disorders such as schizophrenia or bipolar disorder. However, as the disorders are far more common, they affect more people, and have a much greater impact on the community. One estimate suggested that they account for one third of days lost from work due to ill health. The Labour Force Survey suggests that common mental disorders such as depression and anxiety plus stress account for more than 40 per cent of days lost to ill health.11
• Disparities exist in both access to and quality of mental health care for Black and other minority groups. Examples of these disparities include the under-utilization of psychiatric services by persons from minority groups, problems in getting people from these groups to seek treatment, and the inappropriate prescribing of antipsychotic medications.
• The stigma attached to mental health problems within some groups and cultures may result in people avoiding acknowledging their mental health problems and seeking help, e.g. Jewish, Asian and Gypsy and Travellercommunities. This can result in under-diagnosis, undertreatment and poorer prognosis for recovery.
• Research conducted by Mind has found that despite experiencing high levels of mental distress, refugees and asylum-seekers face many challenges accessing
mental health services in England and Wales. Such challenges are further exacerbated by restrictive policies on such areas as healthcare.12
• Long term physical conditions are associated with increased risk of mental health problems. For instance, rates of depression are doubled in diabetes, hypertension, coronary artery disease and heart failure, tripled in end-stage renal failure, chronic obstructive pulmonary disease and cerebrovascular disease and seven times more common among those with two or more chronic physical conditions compared to healthy controls.13,14
• There is strong evidence of a higher prevalence of mental health problems among people living with HIV, compared with the general population. People who have been diagnosed with HIV are more likely to develop a mental health problem, for example anxiety or depression.14,15
• There is a link between sight loss and reduced wellbeing. For example, over one-third of older people with sight loss are also living with depression.16

Measures to tackle disparities

Access to Services
• For those individuals living with a psychotic illness such as schizophrenia there should be improved access to GP services and adequate hospital care in an environment that allows space and the opportunity to recover.
• GP surgeries should provide specialist mental health services to enable those service users who need additional support to receive that in their own community rather than face being placed in a hospital setting with the prospect of isolation and potential regression in their state of health.
• It is necessary to raise the awareness of mental health issues in communities in order to reduce stigma and facilitate early access to appropriate support. Education about mental disorders and the treatment process is critical to reducing barriers to treatment among Black and other minority groups. The national ‘Time for Change’ programme is currently tackling these issues but there is a need to critically monitor the impact of this programme on Black and other minority groups. Suggestions for overcoming these barriers include a local public education campaign, educational presentations at community venues, and open information sessions at local mental health clinics. The recruitment of mental health champions within particular communities was proposed as a way of targeting the education programme and tackling the taboos about mental health that are held by some racial groups.
• Health promotion campaigns should be targeted at particular groups such as Gypsies and Travellers, refugees and asylum seekers, and Irish women, particularly as these groups were reluctant to approach, or did not know of, the health services available.
• Ensure that mental health services take account of the specific needs of refugees and asylum seekers. This requires an approach where dealing with practical needs
through casework or good signposting occurs alongside any therapeutic interventions.

Diagnosis, Treatment and Quality of Services
• Research from the Delivering Race Equality (DRE)17 community engagement programme (2005-2008) identified the following factors that facilitate recovery: support from family and friends, ‘keeping busy’, a positive attitude, faith and religion, and medication. On the other hand the following were identified as obstacles to recovery: lack of support from family and friends, the stigma of mental illness, a return to an unchanged environment after treatment, a poor experience of treatment and disbelief that recovery is possible.
• The research also identified that service user and carer satisfaction with mental health services were key to recovery. As one of the community organisations commented: ‘Where someone’s illness was explained and understood and a choice of treatment offered, in general people had a much better perception of the mental health services provided.’ The research also recognised that a more active role for BME communities and service users could help to provide effective support and help people to manage
the discharge home. They could also provide an early intervention support network.
• Service users need to be confident that when they come into contact with the NHS (particularly through primary care) they are going to be given appropriate advice from an experienced practitioner as to the best treatment options available to them. The current trend that puts a heavy reliance on medication of individuals with a psychosis needs reviewing.
• It should be recognised that medication may work well for some people but have a negative effect on others who may benefit more from group work or access to talking or other therapies. There is a tendency for over medication of Black African/Caribbean men who enter mental health services via the criminal justice system and lack of information about the long term effects of such medication. A greater access to psychological therapies is needed.
• The criteria used to determine that an individual is suffering with a psychosis should be reviewed as this has resulted in the over-representation of Black men being stigmatised as having schizophrenia. The behaviour of some groups can be misinterpreted because of a lack of understanding of cultural norms and language by those conducting assessments.
• The role of carers should be reviewed to ensure that a carer’s assessment reflects the role of a carer as a partner in decision making about an individual’s health and not as someone who is informed as an afterthought. Carers and the individual concerned should be given information about what is happening when a decision is made to section a person.
• Recovery for some racial groups requires an understanding of the impact of negative social experiences caused by racial discrimination or harassment and identifying ways to overcome these and rebuild an individual’s self-esteem and confidence. An improved understanding is needed of specific cultural issues and the impact racism and discrimination may have on some Black and other minority groups that may have led to their ill health.
• There needs to be meaningful communication between service providers and those groups that are overrepresented in the mental health system (Black, mixed race and Irish individuals) so that services are more responsive and understand social and cultural issues thereby improving the service user experience. Equally the involvement of service users in the design and provision of services should be encouraged.

• Control and choices should be improved by identifying alternatives to hospital admission, increasing access to psychological therapies and assisting individuals to make choices about accommodation and seeking employment. There should be a greater emphasis on providing information about mental health issues and services so that those groups that are over-represented in the system become knowledgeable users of mental health services and are more involved in decision making.
• Good practice developed by community based BME mental health provision should be acknowledged and embedded into mainstream provision to develop a mainstream service that is responsive to different racial groups.
• Increasing the number of under-represented groups in the health professions can help address health care disparities by both improving access and responding more effectively to the needs of minority populations. Greater health professions diversity will also provide increased opportunities for minority patients to see practitioners with whom they share a common race, ethnicity, or language. Race, ethnicity, and language concordance is associated with better patient practitioner relationships and communication, and increases patients’ likelihood of receiving and accepting appropriate medical care.
• Culturally sensitive care can help providers understand what complementary and alternative treatments patients might be using, to recognize mental health problems that
might otherwise be hidden, and to address concerns about sensitive issues such as sexuality and end-of-life care that are not easily discussed.
• The provision of culturally and linguistically appropriate information materials and translation services are also essential to ensuring that Black and other minority groups can navigate the health care system effectively and access all the benefits to which they are entitled.

Aftercare following treatment
• Support should be provided to individuals to address social problems through identifying and securing accommodation, opening up routes into employment and providing access to welfare rights information.
• The services of BME mental health agencies should be made available to provide support to individuals, if requested.
• Evidence has consistently shown that employment is better for mental and physical health than unemployment. However, this only applies to good quality work which is characterised by a living wage, having control over work, being respected and rewarded, being provided with good quality in-work services such as occupational health services, and with adequate support to return to work after absence.18

Commissioning of services
• Future commissioning for mental health services should acknowledge the contribution of Black and other minority groups in the voluntary sector and maintain their role in assisting service users, some of whom may have had negative experiences of mainstream psychiatric services
• A Health & Wellbeing Board and the CCGs should have specific strategies to address the mental health needs of Black and other minority groups and address any issues of over-representation and the provision of a health service that meets their needs.
• There has been further investment in Improving Access to Psychological Therapies (IAPT) in an effort to integrate talking therapies into individuals’ treatment; however, in relation to Black and other minority groups, there needs to be a radical change in the way the NHS commissions talking therapies to allow more involvement of a wider range of therapies. In order to move to a new model of mental health treatment real choice in talking therapies needs to be available. For example, with the increase of older people living with HIV, provision should reflect the need for counselling services to improve emotional well-being in older people with HIV, particularly Black African women.

Data Collection
• Significantly, the CQC noted that many service providers did not collect data which would have permitted it to monitor equality and anti-discriminatory compliance. This consequently limited the impact of strategies designed to reduce inequalities
• The Delivering Racial Equality review (DRE), published in December 2010, made clear that better monitoring and collection of information and better use of data to inform commissioning and provision intentions in health and social care is required. This should focus on what works for which communities; and how it can be captured in order to change and improve existing systems and processes.
• The report further stated that ‘collecting and analysing valid and reliable data regarding these disparities provides the building blocks for identifying differences in care and developing targeted interventions to improve the quality of care delivered to specific population groups’. This is required regardless of whether those population groups are identified by geography, disability, socioeconomic status, race or ethnicity.
• There needs to be improvement in the monitoring of compliance with the Equality Act. The Equality Delivery System (EDS) is a framework that is supposed to include monitoring as one of its goals, within NHS trusts, but currently fails to identify corrective action that is required to change some of the trends outlined in this report.


1. Care Quality Commission, (2009) Count me in, Results of the 2009 national census of inpatients on supervised community treatment in mental health and learning disability services in England and Wales.
2. Care Quality Commission (2011), Monitoring the Use of the Mental Health Act in 2011/12
3. IPPC (2010) Police Custody as a ‘Place of Safety’. Examining the use of Section 136 of the Mental Health Act 1983
4. Wilkins D, Kemple M (2010), Delivering Male: Effective practice in male mental health, Men’s Health Forum
5. Mtetezi,(2007) Developing Mental Health advocacy with African and Caribbean men
6. Fitzpatrick, M., 2005, Profiling mental health needs: what about your Irish patients? British Journal of General Practice, October 2005.
7. Bracken P, Greenslade L, Griffin B & Smyth M (1998) Mental health and ethnicity: an Irish dimension British Journal of Psychiatry 172 pp.103-105
8. UCLAN (2008) Report Of The Community Led Research Project Focusing On The Mental Health Needs Of Irish Women In Birmingham
9. J Attenbury, (August 2010) Fair Access for All? Gypsies and Travellers in Sussex, GP Surgeries and Barriers to Primary Healthcare
10. Shelter, (February 2008) Good Practice Guide: Working with Housed Gypsies and Travellers
11. Health & Safety Executive (2009) Health and Safety Statistics 2008/09, Health and Safety Executive
12. Mind (2009) A Civilised Society, Mental Health Provision for Refugees and Asylum-seekers in England and Wales
13. NICE (2010) Depression in adults with a chronic physical health
14. Kings Fund, Long-term Conditions and Mental health, The cost of co-morbidities,
15. NAT (2010) Psychological Support for People living with HIV, National Aids Trust
16. RNIB,Sight Loss Facts and Figures (Online)
17. Fountain J, Hicks J (2010) Delivering Race Equality in Mental Health Care: report on the findings and outcomes of the community engagement programme 2005-2008, University of Central Lancashire
18. Marmot M. Fair society, health lives: the Marmot review; strategic review of health inequalities in England post-2010. The Marmot Review 2010

General References:
The Schizophrenia Commission (2012) The Abandoned Illness: A report from the Schizophrenia Commission. London: Rethink Mental Illness.

1. Evidence to March 2010 on cancer inequalities in England,
2. Cancer and Health Inequalities: An introduction to current evidence, Cancer Research UK (Online)
3. Federation of Irish Societies (2011) Cancer Awareness within the Irish community
4. Middlesex University,( 2009) The Forgotten Irish,
5. National Cancer Intelligence Network and Cancer Research UK (2009). Cancer incidence and Survival by Major
Ethnic Group, England 2002-2006