Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography.

BACKGROUND: Evidence regarding the presence and persistence of ethnic inequalities in mental healthcare is well established. The reasons for these inequalities and lack of progress in diminishing them are less understood. This meta-ethnography aims to provide a new conceptual understanding of how ethnic inequalities are created and sustained; this is essential to develop effective interventions. Specifically, we sought to understand why people from ethnic minority groups are underrepresented in primary care mental health service provision and overrepresented in crisis pathways and detention. METHODS AND FINDINGS: Following eMERGe guidelines for meta-ethnographies, we searched OpenGrey, Kings Fund, CINAHL, Medline, PsycINFO, and Social Care Online databases for qualitative articles published from database inception until October 2, 2022, using broad categories of search terms relating to "ethnicity AND (mental illness/mental health/emotional distress) AND (help-seeking/service utilisation/experience/perception/view)." We included all conceptually rich articles that used qualitative methods of data collection and analysis and excluded non-UK studies and those that focused solely on causation of mental illness. Our patient, public, and practitioner lived experience advisory group provided feedback and input on key stages of the project including search terms, research questions, data analysis, and dissemination. A total of 14,142 articles were identified; 66 met the inclusion criteria. We used reciprocal, refutational, and line of argument analytical approaches to identify convergence and divergence between studies. The synthesis showed that current models of statutory mental healthcare are experienced as a major barrier to the delivery of person-centred care to those in ethnic minority groups due to the perceived dominance of monocultural and reductionist frameworks of assessment and treatment (described as "medical" and "Eurocentric") and direct experiences of racist practice. The lack of socially oriented and holistic frameworks of knowledge and understanding in medical training and services is experienced as epistemic injustice, particularly among those who attribute their mental illness to experiences of migration, systemic racism, and complex trauma. Fear of harm, concerns about treatment suitability, and negative experiences with health providers such as racist care and medical neglect/injury contribute to avoidance of, and disengagement from, mainstream healthcare. The lack of progress in tackling ethnic inequalities is attributed to failures in coproduction and insufficient adoption of existing recommendations within services. Study limitations include insufficient recording of participant characteristics relating to generational status and social class in primary studies, which prevented exploration of these intersections. CONCLUSIONS: In this study, we found that the delivery of safe and equitable person-centred care requires a model of mental health that is responsive to the lived experiences of people in ethnic minority groups. For the people considered in this review, this requires better alignment of mental health services with social and anti-racist models of care. Our findings suggest that intersections related to experiences of racism, migration, religion, and complex trauma might be more relevant than crude ethnic group classifications. Strategies to tackle ethnic inequalities in mental healthcare require an evaluation of individual, systemic, and structural obstacles to authentic and meaningful coproduction and implementation of existing community recommendations in services.

Paths and detours in the trajectory of the Brazilian psychiatric reform.

This article looks at the principles and guidelines of the Unified Health System as well as the current situation and the limitations and possibilities of Brazilian mental health policy. Based on a review of national and international government documents and the scientific literature from 2015-2020, the study observed positive advances in mental health. However, the psychiatric reform has experienced setbacks, and the balance of mental health care has swung towards hospital-centered treatment. These changes have impeded the implementation of the Psychosocial Care Network, as well as the development of therapeutic practices and strategies focused on the person's experience, their daily life and their relations with the health promotion network. By questioning the supremacy of medical-psychiatric knowledge in the treatment of "mental illness" in the public health care system, the psychiatric reform cleared a path for the construction of new ways of addressing psychological suffering. These gains are currently at risk, making a wider debate on the current trends in mental health care in Brazil essential.

Este artículo aborda los principios y lineamientos del Sistema Único de Salud y revisa la actual política brasileña de salud mental, sus limitaciones y posibilidades. A partir de una revisión de documentos gubernamentales nacionales e internacionales y de la bibliografía científica desde año 2015 hasta 2020, confirmamos avances positivos en el cuidado de la salud mental. Sin embargo, la reforma psiquiátrica se ha retrasado y el equilibrio de la atención de la salud mental se ha desplazado a favor del tratamiento centrado en el hospital. Esto ha frenado la implementación de la Red de Atención Psicosocial, y el desarrollo de prácticas y estrategias terapéuticas enfocadas en la experiencia de la persona, su vida diaria y sus relaciones con la red de promoción de la salud. Al cuestionar la supremacía del conocimiento médico-psiquiátrico en el tratamiento de las "enfermedades mentales" por parte de la atención pública, la reforma psiquiátrica abrió el camino para la creación de nuevas formas de abordar el sufrimiento psicológico. Esto está en riesgo ahora y pedimos un debate más amplio sobre las tendencias actuales en la atención de la salud mental en Brasil.

Caminos y desvíos en la trayectoria de la reforma psiquiátrica brasileña / Paths and detours in the trajectory of the Brazilian psychiatric reform

RESUMEN Este artículo aborda los principios y lineamientos del Sistema Único de Salud y revisa la actual política brasileña de salud mental, sus limitaciones y posibilidades. A partir de una revisión de documentos gubernamentales nacionales e internacionales y de la bibliografía científica desde año 2015 hasta 2020, confirmamos avances positivos en el cuidado de la salud mental. Sin embargo, la reforma psiquiátrica se ha retrasado y el equilibrio de la atención de la salud mental se ha desplazado a favor del tratamiento centrado en el hospital. Esto ha frenado la implementación de la Red de Atención Psicosocial, y el desarrollo de prácticas y estrategias terapéuticas enfocadas en la experiencia de la persona, su vida diaria y sus relaciones con la red de promoción de la salud. Al cuestionar la supremacía del conocimiento médico-psiquiátrico en el tratamiento de las "enfermedades mentales" por parte de la atención pública, la reforma psiquiátrica abrió el camino para la creación de nuevas formas de abordar el sufrimiento psicológico. Esto está en riesgo ahora y pedimos un debate más amplio sobre las tendencias actuales en la atención de la salud mental en Brasil.

ABSTRACT: This article looks at the principles and guidelines of the Unified Health System as well as the current situation and the limitations and possibilities of Brazilian mental health policy. Based on a review of national and international government documents and the scientific literature from 2015-2020, the study observed positive advances in mental health. However, the psychiatric reform has experienced setbacks, and the balance of mental health care has swung towards hospital-centered treatment. These changes have impeded the implementation of the Psychosocial Care Network, as well as the development of therapeutic practices and strategies focused on the person's experience, their daily life and their relations with the health promotion network. By questioning the supremacy of medical-psychiatric knowledge in the treatment of "mental illness" in the public health care system, the psychiatric reform cleared a path for the construction of new ways of addressing psychological suffering. These gains are currently at risk, making a wider debate on the current trends in mental health care in Brazil essential.

Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study.

OBJECTIVES: The presence and extent of mental health inequalities in Scotland is unclear. We investigated ethnic variations in psychiatric hospitalisations and compulsory treatment in relation to socioeconomic indicators. DESIGN: In a retrospective cohort study design, using data linkage methods, we examined ethnic variations in psychiatric [any psychiatric, mood (affective), and psychotic disorders) hospitalisations and use of the Mental Health (Care and Treatment) (Scotland) Act 2003 (Emergency Detentions (ED), Short-Term Detentions (STD) and Compulsory Treatment Orders (CTO)] using age (and sex for compulsory treatment), car ownership, and housing tenure adjusted risk ratios (RR). 95% CIs for the data below exclude the reference White Scottish group value (100). RESULTS: Compared to the White Scottish population, Other White British men and women had lower hospitalisation from any psychiatric disorder (RR = 77.8, 95% CI: 71.0-85.2 and 85.8, 95% CI: 79.3-92.9), mood disorder (91.2, 95% CI: 86.9-95.8 and 83.6, 95% CI: 75.1-93.1), psychotic disorder (67.1, 95% CI: 59.9-75.2 and 78.5, 95% CI: 67.6-91.1), CTO (84.6, 95% CI: 72.4-98.9) and STD (88.2, 95% CI: 78.6-99.0). Any Mixed Background women had higher hospitalisation from any psychiatric disorder (137.2, 95% CI: 110.9-169.6) and men and women had a higher risk of psychotic disorder (200.6, 95% CI: 105.7-380.7 and 175.5, 95% CI: 102.3-301.2), CTO (263.0, 95% CI: 105.4-656.3), ED (245.6, 95% CI: 141.6-426.1) and STD (311.7, 95% CI: 190.2-510.7). Indian women had lower risk of any psychiatric disorder (43.2, 95% CI: 28.0-66.7). Pakistani men had lower risk of any psychiatric disorder (78.7, 95% CI: 69.3-89.3), and higher risk of mood disorders (117.5, 95% CI: 100.2-137.9). Pakistani women had similar risk of any psychiatric and mood disorder however, a twofold excess risk of psychotic disorder (227.3, 95% CI: 195.8-263.8). Risk of STD was higher in South Asians (136.9, 95% CI: 109.0-171.9). Chinese men and women had the lowest risk of hospitalisation for any psychiatric disorder (35.3, 95% CI: 23.2-53.7 and 44.5, 95% CI: 30.3-65.5) and mood disorder (51.5, 95% CI: 31.0-85.4 and 47.5, 95% CI: 23.2-97.4) but not psychotic disorders and higher risk for CTO (181.4, 95% CI: 121.0-271.0). African women had higher risk of any psychiatric disorder (139.4, 95% CI: 119.0-163.2). African men and women had the highest risk for psychotic disorders (230.8, 95% CI: 177.8-299.5 and 240.7, 95% CI: 163.8-353.9) and were also overrepresented in STD (214.3, 95% CI: 122.4-375.0) and CTO (486.6, 95% CI: 231.9-1021.1). Differences in hospitalisations were not fully attenuated when adjusted for car ownership and housing tenure and the effect of these adjustments varied by ethnic group. CONCLUSION: Our data show disparate patterns of psychiatric hospitalisations by ethnic group in Scotland providing new observations concerning the mental health care experience of Chinese, Mixed background and White subgroups not fully explained by socioeconomic indicators. For South Asian and Chinese groups in particular, our data indicate under and late utilisation of mental health services. These data call for monitoring and review of services.