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Rates of voluntary and compulsory psychiatric in-patient treatment in England: An ecological study investigating associations with deprivation and demographics

  • Patrick Keown (a1), Orla McBride (a2), Liz Twigg (a3), David Crepaz-Keay (a4), Eva Cyhlarova (a5), Helen Parsons (a6), Jan Scott (a1), Kamaldeep Bhui (a7) and Scott Weich (a8)...

Abstract

Background

Individual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment.

Aims

To describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation.

Method

Secondary analysis of 2010/11 data from the Mental Health Minimum Dataset.

Results

Areas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20–39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant.

Conclusions

Age structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas.

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Copyright

Corresponding author

Patrick Keown, Northumberland, Tyne and Wear NHS Trust & Newcastle University, Tranwell Unit, Queen Elizabeth Hospital, Gateshead NE10 9RW, UK. Email: patrick.keown@newcastle.ac.uk

Footnotes

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See editorial, pp. 97–98, this issue.

Declaration of interest

None.

Footnotes

References

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Rates of voluntary and compulsory psychiatric in-patient treatment in England: An ecological study investigating associations with deprivation and demographics

  • Patrick Keown (a1), Orla McBride (a2), Liz Twigg (a3), David Crepaz-Keay (a4), Eva Cyhlarova (a5), Helen Parsons (a6), Jan Scott (a1), Kamaldeep Bhui (a7) and Scott Weich (a8)...
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eLetters

Ethnic density - meaning and implications

James Rodger, Consultant Child & Adolescent Psychiatrist, South Devon CAMHS
05 September 2016

While the ecological study by Keown et al. (2016) is undoubtedly of value, both methodologically and in relation to the further exposition as to how "structural and social issues can shape mental health," as Burns and Rugkåsa (2016, p97) note in their related editorial, some clarification of Keown at al.'s use and operationalisation of the term "ethnic density" is required to more fully understand the study's implications and limitations.

The study documents "a positive association between ethnicity and compulsory in-patient treatment" in urban areas (p158 ) but since the denominator of population analysis is relatively large (divided by PCTs with an average population of 350,000) it is unclear whether "ethnic density" is defined in their study according to the overall prevalence of different ethnic groups within these relatively large unit PCT populations under study, or whether smaller and more relevant unit neighbourhood-level measures of ethic density have been used (cf. Das-Munshi et al. 2012).

An important earlier study, using such neighbourhood-level measures, by Das- Munshi et al. (2012) demonstrated that "people resident in neighbourhoods of higher own-group density experience ‘buffering’ effects from the social risk factors for psychosis" (p282). Since psychotic presentations are more likely to result in compulsory admission, Das-Munshi et al.'s findings would be expected to predict, when controlling for other variables highlighted by Keown et al. – in particular age and deprivation indices – that higher ethnic density, through "buffering effects," would lead to lower levels of compulsory admission. While it is possible that findings of Das-Munshi et al. and Keown et al. are therefore in contradiction it seems more likely that the Keown et al. study did not measure ethnic density at the more relevant neighbourhood level in which buffering-effects are manifest, and therefore their measure of "ethnic density" is less meaningful.

Ecological studies, by definition, attempt to attend to these more proximal influences on the immediate living environment (cf. Jadhav et al 2015), and while the data set used by Keown et al. no doubt precluded this, the contingent limitations of such data, if this was the case, are therefore important to further acknowledge. Neighbourhood level ethnic density data would also be needed to confirm the significance of Keown et al's unexpected finding of a lack of association between ethnicity and compulsion in rural areas, where genuine neighbourhood-level ethic density might be expected to be low, at least in some areas. Nonetheless, Keown's et al's study alerts us to the importance of attending to both social and cultural factors, influencing the genesis, precipitation and maintenance, of mental illness, including psychosis, which may be variously protective or risk-amplifying, and interact together in complex, sometimes counterintuitive ways influencing prognosis (Rodger and Steel 2016), hospitalisation and compulsion.

References:

Burns, Tom, and Jorun Rugkåsa. 2016. “Hospitalisation and Compulsion: The Research Agenda.” The British Journal of Psychiatry 209 (2): 97–98. doi:10.1192/bjp.bp.116.181297.

Das-Munshi, Jayati, Laia Bécares, Jane E. Boydell, Michael E. Dewey, Craig Morgan, Stephen A. Stansfeld, and Martin J. Prince. 2012. “Ethnic Density as a Buffer for Psychotic Experiences: Findings from a National Survey (EMPIRIC).” The British Journal of Psychiatry 201 (4): 282–90. doi:10.1192/bjp.bp.111.102376.

Jadhav, Sushrut, Sumeet Jain, Nanda Kannuri, Clement Bayetti, and Maan Barua. 2015. “Ecologies of Suffering.” Economic and Political Weekly (20): 12–15.

Keown, Patrick, Orla McBride, Liz Twigg, David Crepaz-Keay, Eva Cyhlarova, Helen Parsons, Jan Scott, Kamaldeep Bhui, and Scott Weich. 2016. “Rates of Voluntary and Compulsory Psychiatric in-Patient Treatment in England: An Ecological Study Investigating Associations with Deprivation and Demographics.” The British Journal of Psychiatry 209 (2): 157–61. doi:10.1192/bjp.bp.115.171009.

Rodger, James, and Zachary Steel. 2016. Between Trauma and the Sacred: The Cultural Shaping of Remitting-Relapsing Psychosis in Post-Conflict Timor-Leste. Cultural Studies of Science and Medicine. Cham, Switzerland: Springer International Publishing. http://link.springer.com/10.1007/978-3-319-24424-2.

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Conflict of interest: None Declared

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