Mental illness in immigrants to England and Wales: An analysis of mental hospital admissions, 1971

Summary A study has been made of all admissions to mental hospitals in England and Wales in 1971 by place of birth. After age/sex standardization of rates and reallocating those patients for whom place of birth was not recorded to appropriate categories, several surprising findings emerged. Compared to the native born, those born in Ireland and Scotland had very high rates of mental hospital admission. Poles also had high rates but West Indians and those born in the U. S. A. had rates comparable to the native born. Rates of mental hospital admission for immigrants from India, Pakistan, Germany and Italy were much lower than native born rates. All immigrant groups studied had higher rates of admission for schizophrenia than natives but much of this discrepancy can be explained by the age structures of the populations being compared. The Irish and Scots had extremely high rates of alcohol and drug related disorders and personality and behaviour disorders but West Indians were underrepresented in these diagnostic categories. Various explanations for these and other results are considered and it is concluded that the most tenable hypothesis is one of differential selection for migration — where migration is relatively easy the less stable members of a population self select for migration but where migration is relatively difficult only the most stable individuals can achieve migration.     

Mental hospital admission rates of immigrants to England: A comparison of 1971 and 1981

Summary The present study compares admissions to mental hospitals in England in 1981 with comparable figures obtained for 1971. Patients were classified by place of birth and the two data sets reveal interesting similarities a decade apart. With schizophrenia the trend in 1981, as in 1971, is for the foreign born to have higher rates of admission in comparison to the native born; and as in 1971 the groups with the highest rate of admission are the Irish born and those born in the Caribbean and Poland. Overall rates of admission in 1981 for immigrants from India, Pakistan, Germany and Italy (like 1971) are lower than the native born rates. As in 1971 the Irish and Scots have extremely high rates of alcohol and drug related disorders, and although they also have high rates of personality disorders they are not as high as the 1971 rates. Those born in the Caribbean continue to show relatively low rates of admission for alcohol, drug and personality disorders. For Indian born males the 1981 figure for alcohol related admissions is twice that of 1971. There is an apparent increase in the rates of depression in 1981 compared to 1971 across all the groups which is affected by changes in recording procedures. There are other findings which are peculiar to only one sub-group, such as the very low re-admission rates for Pakistani women compared to the other groups. This paper provides some possible explanations to account for these variations in rates of admission.     

Poverty,poor services,and compulsory psychiatric admission in England

Background Compulsory admission is a central feature of psychiatric systems internationally but the factors determining its use within different legal systems are not understood. Numbers of compulsory psychiatric admissions vary widely between areas in England. We examined the hypothesis that variation in rates of detention is related to social deprivation and also to the functioning of local mental health services. Methods Rates of detention under sections 2 and 3 of the Mental Health Act (1983) in 1998/9 were obtained in 34 mental health sectors in eight Trusts in England. Measures of socio-economic deprivation and measures of service function were used to conduct an ecological analysis. Results Compulsory admission is associated with measures of deprivation but there is unexplained variation. The range in rates is higher than allowed for by the resource allocation formula. Some indicators of service quality are independently associated with rates of detention. Conclusions Variation in detention rates and its relation to service function need further explanation if the use of compulsion is to be reduced. Accepted: 8 March 2002     

Migration and schizophrenia: an examination of five hypotheses

Summary Data are presented on rates of admission for schizophrenia for the native born and the four largest foreign born populations living in England in 1981 (Irish, Indian, Pakistani and Caribbean born). These data show that, in general, the foreign born have higher rates of admission for schizophrenia, and a higher proportion of all diagnoses accounted for by this disorder than do the native born. The exception is Pakistani born women who have conspicuously low rates. Five hypotheses are examined to account for these differences. The apparently high rates of schizophrenia found for the Indian born of both sexes, and Pakistani born men can be accounted for to a large extent by the demographic differences that exist between them and the native born. The Irish born residents of England have rates comparable with the Irish in Ireland who also show much higher rates than do the native English. There is no completely satisfactory account for the very high rates found for Caribbean born men and women but a combination of adverse post migration experiences and tendency to misdiagnose schizophrenia in this group is offered as a tentative explanation for at least some of the excess. The low rates of admission for schizophrenia of Pakistani women is attributed to a tendency on their part to opt out of the formal mental health system after an initial encounter, possibly to return to their native land.     

Community psychiatric services in England and Finland

Summary The study deals with the development of community psychiatric services in England and Finland, and in two urban areas (Camberwell and Turku) of these countries. The comparison between England and Finland is based on the official statistics for the countries since 1950, and the comparison between Camberwell and Turku on the samples of patients in contact with psychiatric facilities in 1965, 1970, 1975 or 1980. In England, the in-patient rates decreased steadily from the peak of 344 per 100,000 in 1954 to 161 in 1980. In Finland, the rates increased from 235 in 1954 to 425 in 1972, but thereafter decreased to 362 in 1980. During the 1970s, the number of old long-stay patients decreased in England but slightly increased in Finland. There are more day-hospital places in England than in Finland. On the other hand out-patient care increased more rapidly in Finland than in England in the 1960s and 1970s. In Camberwell, where there are more facilities for psychiatric patients than in most English districts, the combined rate for in-patients and those attending day hospitals, day centres or workshops remained quite stable during the 1970s. In Turku, where the out-patient care is more extensive but where other extramural facilities are less available than in Camberwell, the rates for long-stay and elderly in-patients did not decrease in the 1970s as they did in Camberwell. The results of this study support the view that overall the number of psychiatric beds (in-patients) is determined by the policy of health authorities and the government. In the 1950s and 1960s local authorities in Finland, encouraged by the government, built new hospitals for chronic psychiatric patients, while the official policy of the British government since the beginning of the 1960s has been to reduce the number of beds in mental hospitals. In Finland the same policy was not adopted until the 1970s. In Finland, extramural care, which has been based on Community Mental Health Centres operating mainly as out-patient clinics without beds, has not prevented the continued accumulation of long-stay and elderly in-patients. In England, on the other hand, extramural care includes day hospitals, day centres, workshops, hostels and group homes, and thus offers more social support than out-patient care alone. This may partly account for the fact that the number of long-stay and elderly in-patients in English mental hospitals is decreasing.     

Mental illness in Northern Ireland

Summary First and all admissions to psychiatric hospitals and units during 1981 were obtained from the DHSS in England, Scotland and Northern Ireland. Age and sex stadardized rates were calculated for each country. Possible reasons for observed rate differences are discussed. Whilst overall high rates of admissions in Northern Ireland are most likely attributable to provision and use of beds, these factors may not entirely account for high rates of admissions for neurotic disorder, particularly among males.The research reported in this paper was supported by an ESRC linked studentship held by the first author at the Department of Psychology, The Queens University of Belfast.     

The relationship between national levels of unemployment and the rate of admission to mental hospitals in England and Wales, 1950–1976

Summary Using a retrospective design based on archival data the hypothesis that there exists an inverse relationship between the level of economic activity as indexed by the rate of unemployment and the rate of first admissions to mental hospitals was tested. It was found that between 1950 and 1976 other economic indicators (such as economic growth and expenditure on welfare) had substantially stronger relationships with first admission rates than did unemployment. When these other factors were controlled a positive relationship was found, for both sexes, between the rate of unemployment and the mental hospital first admissions rate. However, the relationship for males was statistically significant only for those aged 25–44 years and for females only for those aged between 20 and 54 years. Contrary to findings in the United States, introducing a time lag between changes in unemployment and changes in hospital admissions did not produce a stronger relationship, and in Britain females were more sensitive to economic fluctuations than were males.     

Relationship between country of birth and psychiatric admissions in Western Australia

The rates of admissions in 1976–78 to all hospitals in Western Australia, both psychiatric and non-psychiatric, of patients with a primary psychiatric diagnosis were analysed specifically for country of birth and whether they lived in Perth or in country areas. Eastern European migrants had the highest hospitalization rates, and Southern European migrants the lowest. Rates for schizophrenia were high in the Eastern Europeans, and for alcoholism low in Southern European and Asian females and high in Northern European males. The United Kingdom migrants were most like the Australian born in regards to admission rates, diagnostic composition, and in the distribution of hospitalization patterns between psychiatrists and non-psychiatrists. Women, especially Southern European, in the country areas are at special risk to be admitted for neurosis/personality disorder.     

Social exclusion and risk of emergency compulsory admission. A case-control study

Abstract Background Emergency detentions under section 4 of the Mental Health Act 1983 are more frequent in socially deprived areas of England and Wales. However, it is not clear whether individual socio-economic disadvantage increases likelihood of emergency detention. Therefore, this study tests the hypothesis that a higher proportion of people who are socially excluded will be admitted to hospital under section 4 than those who are not. Methods A total of 300 mental health act assessments in two London boroughs with different rates of section 4 admissions were studied by retrospective case note review in a case-control design. An index of social exclusion was created and piloted for this study. Results The logistic regression analysis discovered four risk factors for section 4 admissions: presenting with a risk to self or others at the mental health act assessment, bi-polar affective disorder, non-White British ethnicity and low social support. There were no significant differences between the two boroughs on these variables. Risk factors for any compulsory admission were: presenting with a risk, psychosis and non-White British ethnicity. Conclusion This study found low social support to be the only social exclusion indicator that increases likelihood of admission under section 4. While individual-level variables explain some of the variation in section 4 rates, it is likely that, as indicated by other studies, different configurations of mental health services affect rates to a greater degree.     

Effects of climate on admission rates of schizophrenia patients to psychiatric hospitals.

Data on admissions of schizophrenia- and schizoaffective disorder patients to Tel-Aviv's seven public psychiatric hospitals during 11 consecutive years were obtained along with relevant meteorological information. Mean monthly admission rates were significantly higher during the summer (for schizophrenia patients) and fall (for schizoaffective patients). Schizophrenia patients' mean monthly admission rates correlated with mean maximal monthly environmental temperature (R = 0.35, N = 132 months, P <0.001). The present study may indicate that persistent high environmental temperature may be a contributing factor for psychotic exacerbation in schizophrenia patients and their consequent admission to mental hospitals.     

Determinants of nocturnal enuresis in England and Scotland in the'90s

The aim of this study was to assess whether changes have occurred in the determinants of nocturnal enuresis in Scotland and England in comparison with previous studies. The study was based on 22 study areas from a representative English sample, 14 areas from a representative Scottish sample, and 20 areas from an English inner-city sample. A total of 14 674 subjects was included in the analysis from 16 835 eligible children in the age range 5 to 11 years. For the main analysis, an enuretic child was one who wet the bed at least once a week. As expected, the frequency of enuresis was higher in boys and decreased markedly with age in both sexes. Bedwetting was more frequent in: Afro-Caribbean children compared with white children in the representative samples (OR 1.72 95% CI 1.22 to 2.42); those whose mothers smoked at least 10 cigarettes at home compared with non-smokers (OR 1.58 95% CI 1.26 to 1.98); children who had disturbed sleep compared with those who slept well (OR 1.96 95% CI 1.53 to 2.51); those with mothers aged less than 20 years at the child's birth compared with mothers in the age range 25 to 34 (OR 1.63 95% CI 1.20 to 2.22); and in the second- or third-born in the family in comparison with the first-born (OR 1.42 95% CI 1.17 to 1.72). Father's social class was associated with enuresis only in girls. Only 50% of the parents consulted a doctor for enuresis in their child. The percentage was even lower in Afro-Caribbean families (33%). Enuresis continues to be a highly prevalent problem and has not decreased over the last 45 years. We confirm that environmental factors are still important in the a etiology of enuresis. It is surprising that despite the availability of effective treatment only half of parents consult a doctor about the problem.     

Hospital admission and community treatment of mental disorders in England from 1998 to 2012

Objective

The number of psychiatric hospital beds in England has declined since the 1950s. Since the early 2000s, mental health staff increasingly work in community treatment teams.We analysed recent trends in hospital and community treatment in England for eight mental health diagnoses.

Method

We obtained data from the UK Government Health and Social Care Information Centre covering the period 1998 to 2012. We analysed hospital admissions and length of stay for each diagnosis each year using linear regression. We studied associations among admissions, community treatment and hospital bed availability each year using structural equation modeling.

Results

The number of mental health beds fell 39%, from 37,000 in 1998 to 22,300 in 2012.Hospital admissions for five diagnoses declined significantly (depression, bipolar disorder, schizophrenia, dementia and obsessive compulsive disorder, P< .01 or P< .001). The strongest decline for depression involved 1000 fewer admissions each year. Admissions for three disorders increased significantly (posttraumatic stress disorder, eating disorders and alcohol-related disorders, P< .01 or P< .001). Alcohol-related admissions increased most strongly, by more than 1700 a year, and were significantly associated with increasing liver fibrosis and cirrhosis admissions (Pearson's r=0.89, P< .001) across the National Health Service (NHS) and the affordability of alcohol (Pearson's r=0.76, P< .01).The median length of stay declined significantly for four diagnoses (P< .001); the other four diagnoses did not change significantly. Depression had the steepest decline of almost 1 less day in hospital per admission per year.Almost 300 more patients were sectioned under the Mental Health Act each year.Community activity had relatively little effect on admissions, and its direct effect was not significantly different from zero. Years with more psychiatric beds had more admissions.

Conclusions

Mental health bed numbers have declined significantly in England. Annual admissions and lengths of stay declined for a range of severe mental disorders including schizophrenia, bipolar disorder and depression.The fall in available beds can account for much of the decline in admissions. National reports of crisis team activity are not associated with declines in hospital admissions.There may be significant needs, especially of depressive patients, not being met by secondary community services, such as 24-hour observation and care. This calls for policy review and further epidemiological study of morbidity, mortality and health needs associated with mental disorder in the community.     

The future pattern of psychiatric provision in England

The events that led to a reduction in both the size and number of mental hospitals in the United Kingdom are reviewed, and the mental hospitals remaining are shown to be mainly providing care in specialised units. Studies of mental hospital closure have shown that care in the community is generally preferred by patients, although for the “old long stay” the total costs are broadly similar. However, for patients with new illnesses care is undoubtedly much cheaper, and patients acquire fewer secondary handicaps of their psychotic illness. Hospital beds are still needed for a community mental health service; and in inner city areas, where prevalence rates for psychotic illness are higher, there are often too few beds to run an efficient service so that patients needing admission may either not be admitted at all, or be admitted to a distant hospital. The allocation of funds for mental illness to local health authorities takes some account of socio-demographic indicators of illness, but authorities are free to spend more or less than their allocation on the mental illness service. One study suggests that there is an optimal number of beds for a given location and that costs of the service increase if there are either too few or too many beds available. It is argued that for care in the community to succeed there must be adequate numbers of beds available, a range of sheltered residential accomodation in the community, as well as enought staff to provide a service for them. Future changes to the way in which the National Health Service is funded – with resource being allocated by groups of general practitioners – make it likely that there will be a shift of resources towards primary care services.     

Self-harm in England: a tale of three cities

Background Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres. Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England. Method Data on self-harm presentations to general hospitals in Oxford (one hospital), Manchester (three hospitals) and Leeds (two hospitals), collected through monitoring systems in each centre, were analysed for the 18-month period March 2000 to August 2001. Results The findings were based on 7344 persons who presented following 10,498 episodes of self-harm. Gender and age patterns were similar in the three centres, 57.0% of patients being female and two-thirds (62.9%) under 35 years of age. The largest numbers by age groups were 15–19 year-old females and 20–24 year-old males. The female to male ratio decreased with age. Rates of self-harm were higher in Manchester than Oxford or Leeds, in keeping with local suicide rates. The proportion of patients receiving a specialist psychosocial assessment varied between centres and was strongly associated with admission to the general hospital. Approximately 80% of self-harm involved self-poisoning. Overdoses of paracetamol, the most frequent method, were more common in younger age groups, antidepressants in middle age groups, and benzodiazepines and sedatives in older age groups. Alcohol was involved in more than half (54.9%) of assessed episodes. The most common time of presentation to hospital was between 10 pm and 2 am. Conclusions Multicentre monitoring of self-harm in England has demonstrated similar overall patterns of self-harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates. Diurnal variation in time of presentation to hospital and the need for assessment of non-admitted patients have implications for service provision.     

A needs index for mental health care in England based on updatable data

Abstract. Background: Mathematical models relating rates of mental health care use to population characteristics such as social deprivation are widely used in both planning and researching mental health services. The models currently in wide use in England are based on data mostly derived from the 10-yearly population censuses. These are perceived to be out of date many years before new census data are available for their replacement. A new set of government deprivation monitoring statistics based mainly on annually updatable data has recently been developed. This study set out to produce a mental illness needs index based on these new data. Methods: A series of regression models were tested using individual domain scores from the DETR Index of Multiple Deprivation and the Office of National Statistics area-type classification as independent variables to predict 1998/9 psychiatric admission rates for broad diagnostic groups for 8251 of the 8414 electoral wards in England as dependent variables. Results: The distribution of admission numbers in wards showed a pattern of over-dispersion with an excessive number of zero values for conventional regression approaches. A two-stage hurdle model was, thus, adopted, predicting first the likelihood that wards would produce any admissions and second the probable number. This produced satisfactory predictive power, with residual variance showing strong geographical patterns associated with administrative areas, probably arising from differential resourcing or idiosyncratic clinical practice. Conclusions: A website providing data on the various indicators has been provided and its uses are indicated.     

The prevalence of multiple sclerosis in Tayside, Scotland: do latitudinal gradients really exist?

To determine the prevalence of multiple sclerosis (MS) in the Tayside Health Board Area, Scotland, we carried out a population-based survey using four intersecting sources (Neurology Department records, a survey of general practitioners, Scottish Morbidity Records of discharges from hospitals and visual evoked response requests). A two-source capture-recapture model estimated survey coverage, and direct age-sex standardisation was used to take account of different population structures. Comparisons were made between the prevalence in Scotland and that in the rest of the United Kingdom. A total of 727 (definite and probable) and 880 cases (early, probable and possible) were identified using the criteria of Poser et al. and those of Allison and Millar in a population of 395,600 (1995 mid-year estimate). The prevalence of MS on 1 September 1996 was 184/100,000 (95% confidence interval 171–198) and 222/100,000 (95% confidence interval 210–240), respectively. The two-source capture-recapture model estimated that the survey was between 93% and 99% complete. Age-sex standardisation eliminated certain north-south differences in prevalence when comparisons were made with previous surveys. Diagnostic misclassification may also have influenced reported prevalence statistics. The prevalence is similar to that found in revised figures from the Grampian region in Scotland but significantly higher than recent estimates from England and Wales. Methodological differences may account for most of the reported differences between north and south, although there is still evidence to suggest that MS is more prevalent in northern Great Britain and Northern Ireland than in England and Wales. Received: 12 October 1998 Received in revised form: 27 May 1999 Accepted: 8 June 1999     

Attitudes of mental health professionals and lay-people towards involuntary admission and treatment in England and Germany--a questionnaire analysis.

OBJECTIVES: To identify attitudes about involuntary admission and treatment in mental health professionals and lay-people and to compare results between England and Germany. METHOD: Three scenarios of potentially detainable patients were presented to identify attitudes. A questionnaire asked about attitudes towards involuntary admission as well as treatment. A questionnaire analysis was then performed. RESULTS: There were similar attitudes towards involuntary admission and treatment between lay-people and mental health professionals with the exception of professionals not actively involved in the detention process. The different legal frameworks between Germany and England did not influence attitudes much. Support for involuntary admission and treatment broadly increased with age. CONCLUSIONS: Psychiatrists and other mental health workers are in tune with society with regards to attitudes towards involuntary admission. People involved with mentally ill patients but not in the detention process have negative attitudes towards involuntary admission.     

Searching for the causes of schizophrenia: the role of migrant studies

There have been consistent reports in the literature of increased rates of hospital admissions for schizophrenia among Afro-Caribbean (West Indian) migrants to England. Recent evidence for even higher rates in the British-born second generation is reviewed, together with the methodological limitations of such studies. It is concluded that there is probably an epidemic of schizophrenia and related psychoses in this group of migrants although further prospective and longitudinal studies are required. The findings point to the potentially important role of migrant studies in determining environmental risk factors for schizophrenia.     

Proposal for a treatment law based on the Scottish model

Even after recent amendments and proposed modifications, the Dutch law on special admissions to psychiatric hospitals ('Bopz') is still primarily a law on admissions, whereas what psychiatry and society in general urgently require is a law on treatment. In October, 2005, in Scotland a new law concerning the care and treatment of psychiatric patients came into force: the Mental Health (Care and treatment) Act 2003 ('Act'). This new law can in fact be designated a treatment law. In this article the Scottish Act is compared to the Bopz. The comparison shows that Scotland has in fact developed a law which may provide an answer to the inadequacies of the Bopz.     

Factors affecting the decision to admit mental patients in a community hospital

Analysis of consecutive emergency referrals to a community mental hospital over a 2-month period indicates that admissions are affected by a combination of demographic, clinical, and time factors. Both referrals and admissions were slightly higher in men. The mean age at referral was 44 years and of admitted patients was 30 years. Although married subjects constituted the largest group of applicants, widowers and divorced people were hospitalized more often. Both referral and admission rates were inversely correlated with education and employment. Most of the applicants came to the emergency ward accompanied by an escort. A lower rate of admissions was observed among those who came unescorted. The main indications for admission were acute psychosis and a nonspecific clinical state when the patient was defined as "dangerous to himself or to others." The family constituted the main source of referral. Peak referrals were during the morning hours, but admission rates were highest at night. Referrals decreased gradually from Sunday to Saturday, but the rate of admission was practically steady throughout the week. We conclude that the decisions for admitting a patient to a mental institute are based not only on pure psychiatric criteria, but also on an intuitive approach, in which the admitting physician's personal and emotional factors may play a role.