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.     

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.     

Psychiatric morbidity in people born in Ireland

Background: Irish immigrants are reported to be over-represented in psychiatric admission statistics for England when compared to native whites. This study examines whether this finding is sustained for users of psychiatric services as a whole and explicates the reasons for any differential uptake of mental health care by comparison with community morbidity rates in the same population. Methods: Demographic and clinical data were collected from staff concerning all adults living in a multi-ethnic inner-city health district and using mental health services during a 6-month period. A separate interview-based survey of private household residents in the same area was undertaken to ascertain the prevalence of psychiatric disorder in the community. Results: Psychiatric service use was found to be greater for Irish-born people compared to the remainder of the white population. However, this finding only persisted for alcohol use disorders, the rates for schizophrenic and affective disorders being comparable in the two groups. Access to psychiatric care was also similar both with respect to overall morbidity as well as for affective and alcohol use disorders, levels of service use being attributable to patterns of morbidity in the population rather than nosocomial factors. Conclusions: The excess morbidity for alcohol use disorders reported in people born in Ireland is affirmed and the need for longitudinal and ethnographic research into this important public health issue emphasised. Accepted: 30 July 1999     

Depression prevalence in disadvantaged young black women

Abstract Background Research with Mexican Americans suggests that immigrants have lower rates of mental disorders than U. S.-born Mexican Americans. We examine the prevalence of depression, somatization, alcohol use and drug use among black American women, comparing rates of disorders among U. S.-born, Caribbean-born, and African-born subsamples. Methods Women in Women, Infants and Children (WIC) programs, county-run Title X family planning clinics, and low-income pediatric clinics were interviewed using the PRIME-MD. In total, 9,151 black women were interviewed; 7,965 were born in the U. S., 913 were born in Africa, and 273 were born in the Caribbean. Results Controlling for other predictors, U.S.-born black women had odds of probable depression that were 2.94 times greater than the African-born women (p<0.0001, 95% CI: 2.07, 4.18) and 2.49 times greater than Caribbean-born women (p<0.0016, 95% CI: 1.41, 4.39). Likelihood of somatization did not differ among women who were U. S. born, African born, or Caribbean born. Rates of alcohol and drug problems were exceedingly low among all three groups, with less than 1% of the women reporting either alcohol or drug problems. Conclusions These results mirror similar findings for Mexican immigrant as compared with American-born Mexican Americans. The findings suggest that living in the U. S. might increase depression among poor black women receiving services in county entitlement clinics. Further research with ethnically validated instruments is needed to identify protective and risk factors associated with depression in immigrant and U. S.-born poor black women.     

The pattern of psychiatric admissions of Caribbean-born immigrants in London

Summary Data from the mental health enquiry and the 1981 census are used to describe the age/sex specific pattern of first and total admissions of West Indian born patients to psychiatric hospitals in two Thames Regions. By contrast to native Britons, more young men, but not young women, appear to be admitted but the readmission rate for young patients of both sexes is high. Older West Indians of both sexes have a similar first admission rate to the native British. Older men but not older women have a low overall admission rate. Time trends suggest that there is a cohort of young men of whom the oldest are now in their early thirties who are at particular risk.     

Psychiatric disorders in selected immigrant groups in Camberwell

Summary This paper reports on psychiatric disorder amongst West Indians and Irish-born residents of Camberwell in South London. National figures suggest high rates of severe functional disorders in West Indians with relatively few minor disorders. Among the Irish, however, mania is rare, schizophrenia shows high rates in women but not in men and the milder affective disorders are more common than in the native born (Cochrane 1977). The current study uses both hospital-based data from the Camberwell registrar and data from a community survey and essentially substantiates these findings. It is suggested that these persistent opposing patterns in these two groups of immigrants could be in large part explained by culturally determined patterns of response to adversity.     

Psychiatric illness in the New Zealand Maori

This paper compares psychiatric illness in the contemporary Maori with that in the non-Maori New Zealander. The ethnic data available are all from secondary sources. The limitations of this and the problems of achieving a satisfactory definition of "a Maori" are discussed. The data suggest that the Maori have a slightly greater risk of psychiatric hospitalization than the non-Maori. First admission rates for schizophrenia are higher for the Maori, as are the readmission rates. First admission rates for major affective illness are roughly comparable in the two groups, and those for neuroses and neurotic depression are lower in the Maori. Rates of admission for alcohol abuse, alcohol dependence and personality disorders are much higher for the Maori male aged 20-40 years and this group is at greatest risk of psychiatric hospitalization. A larger proportion of Maori are admitted involuntarily, especially under the Criminal Justice Act. The median stay in hospital is not longer for the Maori but their re-admissions are more frequent. The Maori have shown an increase in first psychiatric admission rates since the 1950s, with rapid increases in the early 60s and the 80s. The rates for psychotic disorders have been relatively constant and the most significant changes have been for alcohol abuse, alcohol dependence and personality disorders. The author relates this historical change to socioeconomic and politico-cultural factors, particularly the stress of rapid urbanization.     

Trends in psychiatric hospitalization and changes in admission patterns in two counties in Denmark from 1977 to 1989

Summary Based on data from the nationwide Danish Psychiatric Case Register, trends in admission rates and treatment-day rates were studied in two Danish counties between 1977 and 1989. During the observation period, the number of availble beds in the counties investigated decreased from 1.78 to 1.10 per 1000 inhabitants aged 15 years or more. Over the same period, the admission rates decreased by 20% for in-patients and 38% for daypatients. At the same time, treatment-day rates for in-patients decreased by appoximately 50% and treatment-day rates for day-patients by 32%. The decrease was seen in all age groups both for admission rates and treatment-day-rates. Rates for short-term hospitalization showed a steeper decrease than those for long-term hospitalization. For schizophrenia, admission rates increased except among men under 25 years of age, and treatment-day rates decreased in all age groups. Affective disorders, neuroses, personality disorders, and alcohol and drug abuse showed the most pronounced decreases in admission rates and treatment-day rates. The same trend was seen for treatment-day rates for organic disorders. A marked decrease in admission rates was seen in the provincial towns. Treatment-day rates decreased markedly in city areas, and less so in rural areas.     

Mental illness in England,in Scotland and in Scots living in England

Summary Beginning from the observation that Scots living in England have much higher rates of mental hospital admission than do the English, several hypotheses are proposed to account for this. Much of the excess in rates of mental illness is accounted for by those diagnosed as having alcohol-related disorders and behaviour and personality problems. The results of an examination of offical statistics in the two countries enabled some explanations to be offered. It was found that rates of admissions to mental hospitals are higher in Scotland than in England but not as high as those found among Scots migrants who have a much higher rate of readmission to hospitals than either of the other groups. In fact, if first admissions only are considered the rates of admission in Scotland are not only higher than rates for English natives but also higher than for Scottish migrants. It seems that Scots living in England are somewhat less likely to become mental patients than Scots in Scotland but that once they do achieve this status they are very much more likely to be readmitted on subsequent occasions. It was concluded that there might be two fairly distinct groups of migrants from Scotland to England who have different backgrounds, different reasons for migrating and different psychological characteristics. On the one hand there are stable, economically motivated migrants who move south for definite employment related reasons and who show few psychological symptoms. While on the other hand there is a group of migrants who perhaps have psychological problems and who move more in hope than expectation without definite prospects and who account for the high rates of mental hospital admission found in Scottish migrants.     

Geographical analysis of the risk of psychiatric hospitalization in Hamburg from 1988 – 1994

The analysis of the geographical distribution of hospital cases is obviously important for the purpose of planning hospital services, but it is of even greater significance in the planning of psychiatric services. This concern motivated our seven-year-long study, which examined hospitalization risks among various categories of psychiatric disorders in the major German city of Hamburg. Our database encompassed 77% (n = 64,000) of all psychiatric admissions in a total of 41 hospitals, most of which are general hospitals. In order to carry out the geographical analysis we employed a new statistical method based on a mixture distribution model. According to our findings, the strongest indications of an increased frequency were among male cases of schizophrenia, drug abuse and organic psychoses, and female cases of neurotic disorders, personality disorders, drug abuse and schizophrenia. We found that some areas are exposed to a risk of hospitalization for these diagnostic categories which is more than 50% above the reference. Contrary to other authors we did not identify an increased frequency of admission concentrated in the inner-city area for any of the diagnostic groups. The risk of hospitalization for schizophrenics was almost entirely associated with the close proximity of psychiatric units, while the risks for neuroses and personality disorders, as well as alcohol and drug abuse, appeared to be concentrated in areas of low social status. However, a statistically relevant correlation between an increased risk of hospitalization and low social status could be determined only for drug abuse and alcoholism. In the end, we did identify two areas in which there was an increased risk of hospitalization for several diagnostic groups, and this information will undoubtedly facilitate the planning of hospital and psychiatric services. The fact that our findings deviate to some extent from other authors - especially with respect to neuroses and personality disorders, but also to addiction - can be attributed to the inclusion of psychiatric cases from general hospitals in our geographic analysis.     

Admission rates of patients with borderline personality disorder in a psychiatric unit in a General Hospital

This study examined the admission rates of patients with borderline personality disorder in a psychiatric unit within a General Hospital. The medical records of patients with DSM-IV borderline personality disorder who were admitted to the unit during the years 2004 and 2005 were retrospectively reviewed. The number of admissions of patients with borderline personality disorder was 78, involving 48 patients. The mean of admissions were 1.63 per patient. The comparison to the rest of the patient population (922 patients with a total of 1086 admissions) demonstrated that patients with borderline personality disorder were admitted more frequently than patients with major psychiatric disorders. The difference was statistically significant (P=0.042). The main reasons for admission were suicide attempts or threats and lack of out-patient facilities. The introduction of out-patient psychiatric facilities may contribute to the reduction of the admissions and to the better management of the disorder.     

The prognosis in early adulthood of child psychiatric patients: a case register study in Denmark

A register-based study of 485 children (0-15 years of age) admitted to a child psychiatric hospital from January 1, 1970 to December 31, 1972 who were followed up on December 31, 1986 showed higher rates of admission to psychiatric hospital in late adolescence or young adulthood (i.e. greater than or equal to 16 years of age) than found in an age-standardized general population. Patients with the childhood diagnosis neurosis (ICD-8 300 + 308.00) were found to have higher rates of admission with personality disorders (ICD-8 301.09-301.39 + 301.82-301.99) but not of other diagnoses including neurotic disorders. Patients with the childhood diagnosis of conduct disorder (ICD-8 301.09-301.99 + 308.01) had a higher risk of admission in adulthood with the diagnosis of personality disorders and drug or alcohol abuse. Girls with adjustment disorder (ICD-8 307 + 308.02-308.06) had higher risks of admission in young adulthood with diagnosis of personality disorders and psychosis. No connection was found between the age at first referral and the incidence of admission after the age of 15 years.     

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.     

The new revolving-door patients: results from a national cohort of first admissions

A cohort of all first admissions to New Zealand psychiatric hospitals and psychiatric wards of general hospitals in 1980 and 1981 was followed up for 5 years. The cohort consisted of 3875 males and 3965 females aged from 15 to 64 years. Of these subjects, 59.4% had only one admission; 14.6% met our criteria for a revolving-door patient, as they had 4 or more admissions within the 5-year follow-up period. Based on first-admission information, patients who were younger and had a psychotic diagnosis had an increased likelihood of becoming a revolving-door patient. Stepwise logistic regression showed that younger age and psychotic diagnosis independently and in interaction were associated with a high probability of becoming a revolving-door patient. Although patients with a first-admission diagnosis of schizophrenia constitute a large group of the new revolving-door patients for both males and females, for women those with affective disorders and for men those with substance abuse comprise the largest proportion of the new revolving-door patients. This is because affective disorders in women and substance abuse in men are the most common diagnoses on first admission, rather than because the disorders themselves are associated with a high probability of the patients having multiple admissions.     

Prevalence of alcohol related admissions to general medical units

The prevalence of alcohol related admissions to hospitals in Manitoba was examined in an investigation limited to the general medicine units of four representative hospitals within the province. All admissions during one-month periods were closely examined. In order to determine if an admission was related to alcohol, the investigators obtained permission from each patient to ask the attending physician to rate the degree to which they felt the admission was alcohol related, and intensively reviewed all charts. The percentage of alcohol related admissions was found to range from 6.38 percent to 14.93 percent on medical units. The disorders which alcohol related patients presented on admission tended to differ from those in the not-related category. At all hospitals, disorders of the gastrointestinal system were in the majority for the alcohol related group, while the not-related group presented more difficulty in the area of cardiovascular disorders. The cost which is associated with these alcohol related admissions is large, the highest being $61,050.00 for a one-month period in one of the hospitals surveyed. The findings clearly indicate that in Manitoba, health care facilities and health care professionals are very much involved in problems related to alcohol. The findings of this study indicate that the problem is with us and we should make every effort to ensure proper and effective care, and to establish systems for the identification and referral of alcohol related admissions.     

The role of engagement with services in compulsory admission of African/Caribbean patients

Abstract. Background: High rates of compulsory admission of African/Caribbean patients have been reported. Several factors have been associated with this finding. The roles of some factors related to engagement with services have not been empirically evaluated. Aims: The aim of this study was to assess the role of engagement factors in compulsory admission of African/Caribbean patients. Method: A systematic case-note review was made of the admission process of 100 compulsorily and 100 voluntarily admitted patients; each group containing 50 randomly selected African/Caribbean and White British patients. Information about socio-demographic and engagement factors was collected and the findings compared. Results: Compulsorily admitted African/Caribbean patients had more factors indicative of poor engagement with services than patients in the other groups. Prior to admission, they were less likely to keep their appointments, comply with their medication, contact their GPs and were more likely to present late. Furthermore, they had more history of multiple compulsory admissions. The compulsorily admitted patients, irrespective of ethnicity, also engaged poorly with services. Conclusions: Poor engagement with primary care and secondary mental health services of African Caribbean patients appears to be contributing to their high rates of compulsory admission. This aspect of ethnic factors and compulsory admission requires further studies.     

Socio-economic status in early childhood and severe mental illness: an empirical investigation of Danish men born in 1981

Severe mental illnesses are often burdensome, as they have an early onset. This paper examines the relationship between socio-economic status (SES) in early childhood and the probability of developing schizophrenia, affective disorders and personality disorders. We use longitudinal register data on all Danish men born in 1981 and control for family factors one year before their birth. The results show that men born in low-income families are more likely to be hospitalized with affective disorders. Men born into families where the father was not employed at the child's birth are more likely to be hospitalized with schizophrenia or personality disorder than men born into families where the father was a wage earner. The relative differences in the predicted probabilities of developing mental illnesses are large when we compare children who grew up in families with average characteristics to children who grew up in families with low SES.     

Lifetime prevalence of specific mental disorders among people born in Iceland in 1931

The lifetime prevalence rates are presented for mental disorders in a random sample of people born in Iceland in 1931, interviewed at the age of 55-57 years. The diagnoses are made according to DSM-III, on the basis of the National Institute of Mental Health's diagnostic Interview Schedule (NIMH-DIS) used by trained lay interviewers. The most common diagnoses were alcohol abuse and dependence, generalized anxiety disorder, phobic disorders, dysthymic disorder and major depressive episode. Disorders more common in men were antisocial personality, alcohol abuse and alcohol dependence. Disorders more common among women were major depressive episode and generalized anxiety disorder. Alcohol abuse was more prevalent among those living in rural areas, but dependence was more prevalent in the urban area, where panic disorder is also more frequent. Widowed, separated and divorced people had most of the highest prevalences: tobacco-use disorder, alcohol abuse and dependence, dysthymia and generalized anxiety disorder. Except for a very high rate of alcohol abuse and dependence and a low rate of substance abuse disorders, the prevalence rates are similar to those obtained in North American studies using the NIMH-DIS as a survey instrument. The DSM-III criteria for alcohol abuse or dependence may be less applicable to Iceland than to North America, because of differences in what is culturally regarded as acceptable use of alcohol.     

Cigarette Smoking and Psychiatric Disorder in a Community Sample

We examined the lifetime prevalence of psychiatric disorders in cigarette smokers and nonsmokers in a non-patient sample. First-degree relatives of psychiatric patients (n = 697) and normal controls (n = 360) were interviewed with the Diagnostic Interview Schedule and the Structured Interview for DSM-III Personality Disorders. Using these interviews we diagnosed the major mental (Axis I) disorders and personality (Axis II) disorders. A cigarette smoker was defined as someone who smoked daily for a month or more at some time in their lives. We found that smokers more frequently had a lifetime history of major depression, alcohol and drug abuse/dependence, agoraphobia, unstable/acting out and anxious/fearful personality disorders. In a logistic regression analysis, the only significant variables independently associated with smoking status were the alcohol and drug use disorders. Age was an important modifying variable—the smoking-illness relationship was robust in the youngest age cohort and negligible in the oldest cohort. We conclude that cigarette smokers have increased rates of mood, anxiety, substance use, and personality disorders. However, after controlling for the comorbidity among the disorders only alcohol and drug abuse/dependence were independently associated with smoking. Young smokers had particularly high rates of substance use disorders. This age effect may reflect the impact of a quarter century of health education.     

Determinants of unplanned discharge from in-patient drug and alcohol detoxification: a retrospective analysis of 239 admissions

Unplanned and premature discharge from in-patient alcohol or drug detoxification is a common and severe problem in the treatment of substance abuse. So far, most of the relevant studies focused on drug detoxification, whereas only few studies also investigated alcohol detoxification. The aim of the present study was to comparatively identify and analyse determinants of unplanned discharge during in-patient treatment in both diagnostic groups which simultaneously underwent detoxification under the same treatment setting. Subjects were 239 consecutive admissions (alcohol: n = 90; illegal drugs: n = 149) to a specialised qualified detoxification unit at the Psychiatric University Hospital of Heidelberg during the year 2000. Data on sociodemographical and psychosocial variables, medical history, psychopathological findings on admission and presence of psychiatric and/or somatic comorbidity as well as intensity level of withdrawal symptoms were collected retrospectively and analysed with respect to the prediction of planned/unplanned discharge. The high overall rates of unplanned discharge (alcohol: 43.3 % and drugs 62.4 %) confirm the previously reported figures. Treatment success of drug patients was rather affected by sociodemographical and psychosocial factors such as level of education, delinquency, unemployment and hepatitis C diagnosis. Relating to alcohol patients psychopathological findings on admission including orientation, affective state and cognition were most relevant for planned discharge. Furthermore, the results of this study underline the central role of motivation during in-patient treatment as well as the importance of a planned treatment continuation after discharge from the detoxification program.