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1.  Which pathways to psychiatric care lead to earlier treatment and a shorter duration of first-episode psychosis? 
BMC Psychiatry  2014;14:72.
Background
The pathways to care in a first onset psychosis are diverse and may influence the chances of early treatment and therefore the duration of untreated psychosis. We test which pathways to care are associated with a delay in receiving treament and a longer duration of untreated psychosis (DUP).
Methods
In a population based survey, we interviewed 480 people with first episode psychosis aged 18 to 64 years over a 2-year period. Information from structured interview and case files provided DSM-IV diagnostic, clinical, and demographic information. Consecutive contacts in the care pathway were mapped using the World Health Organisation’s Encounter Form. Using information from all sources, DUP was defined as time from symptom onset to first treatment with antipsychotic medication.
Results
The most common first contacts were primary care physicians (35.2%), emergency rooms in general hospital settings (21.3%), and criminal justice agencies (25.4%). In multivariate regression models, compared to DUP for those first in contact with primary care, DUP was shortest for first encounters with psychiatric emergency clinics (RR = 0.4, 95% CI: 0.23-0.71) and longest for first encounters with criminal justice agencies (RR = 1.61, 95% CI: 1–2.58). Older age was associated with a longer DUP (RR = 1.01 per year, 95% CI: 1–1.04). A shorter DUP was associated with a diagnosis of mania and affective psychoses-NOS compared with schizophrenia (RR = 0.22, 95% CI: 0.14-0.35; RR = 0.18, 95% CI: 0.06-0.54, respectively), for Black compared with White ethnicity (RR = 0.52, 95% CI: 0.34-0.82), and for each close person in the social network (RR = 0.9, 95% CI: 0.84-0.96).
Conclusions
To further reduce DUP, better links are needed between primary care, emergency rooms, criminal justice and psychiatric services.
doi:10.1186/1471-244X-14-72
PMCID: PMC3984674  PMID: 24620939
Psychosis; Early treatment; Anti-psychotics; Pathways; Schizophrenia & DSMIV diagnoses
2.  Is Violent Radicalisation Associated with Poverty, Migration, Poor Self-Reported Health and Common Mental Disorders? 
PLoS ONE  2014;9(3):e90718.
Background
Doctors, lawyers and criminal justice agencies need methods to assess vulnerability to violent radicalization. In synergy, public health interventions aim to prevent the emergence of risk behaviours as well as prevent and treat new illness events. This paper describes a new method of assessing vulnerability to violent radicalization, and then investigates the role of previously reported causes, including poor self-reported health, anxiety and depression, adverse life events, poverty, and migration and socio-political factors. The aim is to identify foci for preventive intervention.
Methods
A cross-sectional survey of a representative population sample of men and women aged 18–45, of Muslim heritage and recruited by quota sampling by age, gender, working status, in two English cities. The main outcomes include self-reported health, symptoms of anxiety and depression (common mental disorders), and vulnerability to violent radicalization assessed by sympathies for violent protest and terrorist acts.
Results
2.4% of people showed some sympathy for violent protest and terrorist acts. Sympathy was more likely to be articulated by the under 20s, those in full time education rather than employment, those born in the UK, those speaking English at home, and high earners (>£75,000 a year). People with poor self-reported health were less likely to show sympathies for violent protest and terrorism. Anxiety and depressive symptoms, adverse life events and socio-political attitudes showed no associations.
Conclusions
Sympathies for violent protest and terrorism were uncommon among men and women, aged 18–45, of Muslim heritage living in two English cities. Youth, wealth, and being in education rather than employment were risk factors.
doi:10.1371/journal.pone.0090718
PMCID: PMC3944722  PMID: 24599058
3.  How do adolescents talk about self-harm: a qualitative study of disclosure in an ethnically diverse urban population in England 
BMC Public Health  2013;13:572.
Background
Self-harm is prevalent in adolescence. It is often a behaviour without verbal expression, seeking relief from a distressed state of mind. As most adolescents who self-harm do not seek help, the nature of adolescent self-harm and reasons for not disclosing it are a public health concern. This study aims to increase understanding about how adolescents in the community speak about self-harm; exploring their attitudes towards and experiences of disclosure and help-seeking.
Methods
This study involved 30 qualitative individual interviews with ethnically diverse adolescents aged 15–16 years (24 females, 6 males), investigating their views on coping with stress, self-harm and help-seeking, within their own social context in multicultural East London. Ten participants had never self-harmed, nine had self-harmed on one occasion and 11 had self-harmed repeatedly. Verbatim accounts were transcribed and subjected to content and thematic analysis using a framework approach.
Results
Self-harm was described as a complex and varied behaviour. Most participants who had self-harmed expressed reluctance to talk about it and many had difficulty understanding self-harm in others. Some participants normalised self-harm and did not wish to accept offers of help, particularly if their self-harm had been secretive and ‘discovered’, leading to their referral to more formal help from others. Disclosure was viewed more positively with hindsight by some participants who had received help. If help was sought, adolescents desired respect, and for their problems, feelings and opinions to be noticed and considered alongside receiving treatment for injuries. Mixed responses to disclosure from peers, family and initial sources of help may influence subsequent behaviour and deter presentation to services.
Conclusions
This study provides insight into the subjective experience of self-harm, disclosure and help-seeking from a young, ethnically diverse community sample. Accounts highlighted the value of examining self-harm in the context of each adolescent’s day-to-day life. These accounts emphasised the need for support from others and increasing awareness about appropriate responses to adolescent self-harm and accessible sources of help for adolescents.
doi:10.1186/1471-2458-13-572
PMCID: PMC3685521  PMID: 23758739
Self-harm; Help seeking; Adolescent; Qualitative methods; Self-injury; Ethnicity
4.  THERACOM: a systematic review of the evidence base for interventions to improve Therapeutic Communications between black and minority ethnic populations and staff in specialist mental health services 
Systematic Reviews  2013;2:15.
Background
Black and Minority Ethnic (BME) groups in receipt of specialist mental health care have reported higher rates of detention under the mental health act, less use of psychological therapies, and more dissatisfaction. Although many explanations have been put forward to explain this, a failure of therapeutic communications may explain poorer satisfaction, disengagement from services and ethnic variations in access to less coercive care. Interventions that improve therapeutic communications may offer new approaches to tackle ethnic inequalities in experiences and outcomes.
Methods
The THERACOM project is an HTA-funded evidence synthesis review of interventions to improve therapeutic communications between black and minority ethnic patients in contact with specialist mental health services and staff providing those services. This article sets out the protocol methods for a necessarily broad review topic, including appropriate search strategies, dilemmas for classifying different types of therapeutic communications and expectations of the types of interventions to improve them. The review methods will accommodate unexpected types of study and interventions. The findings will be reported in 2013, including a synthesis of the quantitative and grey literature.
Discussion
A particular methodological challenge is to identify and rate the quality of many different study types, for example, randomised controlled trials, observational quantitative studies, qualitative studies and case studies, which comprise the full range of hierarchies of evidence. We discuss the preliminary methodological challenges and some solutions. (PROSPERO registration number: CRD42011001661).
doi:10.1186/2046-4053-2-15
PMCID: PMC3599664  PMID: 23442299
Interventions; Therapeutic communications; Black and minority ethnic patients; Psychiatric services
5.  Does Guru Granth Sahib describe depression? 
Indian Journal of Psychiatry  2013;55(Suppl 2):S195-S200.
Sikhism is a relatively young religion, with Guru Granth Sahib as its key religious text. This text describes emotions in everyday life, such as happiness, sadness, anger, hatred, and also more serious mental health issues such as depression and psychosis. There are references to the causation of these emotional disturbances and also ways to get out of them. We studied both the Gurumukhi version and the English translation of the Guru Granth Sahib to understand what it had to say about depression, its henomenology, and religious prescriptions for recovery. We discuss these descriptions in this paper and understand its meaning within the context of clinical depression. Such knowledge is important as explicit descriptions about depression and sadness can help encourage culturally appropriate assessment and treatment, as well as promote public health through education.
doi:10.4103/0019-5545.105531
PMCID: PMC3705682  PMID: 23858254
Depression; Guru Granth Sahib; psychiatry; sadness; Sikh; Sikhism
6.  The culture of care within psychiatric services: tackling inequalities and improving clinical and organisational capabilities 
Introduction
Cultural Consultation is a clinical process that emerged from anthropological critiques of mental healthcare. It includes attention to therapeutic communication, research observations and research methods that capture cultural practices and narratives in mental healthcare. This essay describes the work of a Cultural Consultation Service (ToCCS) that improves service user outcomes by offering cultural consultation to mental health practitioners. The setting is a psychiatric service with complex and challenging work located in an ethnically diverse inner city urban area. Following a period of 18 months of cultural consultation, we gather the dominant narratives that emerged during our evaluation of our service.
Results
These narratives highlight how culture is conceptualized and acted upon in the day-to-day practices of individual health and social care professionals, specialist psychiatric teams and in care systems. The findings reveal common narratives and themes about culture, ethnicity, race and their perceived place and meaningfulness in clinical care. These narratives express underlying assumptions and covert rules for managing, and sometimes negating, dilemmas and difficulties when considering “culture” in the presentation and expression of mental distress. The narratives reveal an overall “culture of understanding cultural issues” and specific “cultures of care”. These emerged as necessary foci of intervention to improve service user outcomes.
Conclusion
Understanding the cultures of care showed that clinical and managerial over-structuring of care prioritises organisational proficiency, but it leads to inflexibility. Consequently, the care provided is less personalised and less accommodating of cultural issues, therefore, professionals are unable to see or consider cultural influences in recovery.
doi:10.1186/1747-5341-7-12
PMCID: PMC3509394  PMID: 23020856
Cultural consultation; Cultural formulation; Ethnography; Institutional racism; Culture and mental health
7.  Migration experiences, employment status and psychological distress among Somali immigrants: a mixed-method international study 
BMC Public Health  2012;12:749.
Background
The discourse about mental health problems among migrants and refugees tends to focus on adverse pre-migration experiences; there is less investigation of the environmental conditions in which refugee migrants live, and the contrasts between these situations in different countries. This cross-national study of two samples of Somali refugees living in London (UK) and Minneapolis, Minnesota, (USA) helps to fill a gap in the literature, and is unusual in being able to compare information collected in the same way in two cities in different countries.
Methods
There were two parts to the study, focus groups to gather in-depth qualitative data and a survey of health status and quantifiable demographic and material factors. Three of the focus groups involved nineteen Somali professionals and five groups included twenty-eight lay Somalis who were living in London and Minneapolis. The quantitative survey was done with 189 Somali respondents, also living in London and Minneapolis. We used the MINI International Neuropsychiatric Interview (MINI) to assess ICD-10 and DSM-IV mental disorders.
Results
The overall qualitative and quantitative results suggested that challenges to masculinity, thwarted aspirations, devalued refugee identity, unemployment, legal uncertainties and longer duration of stay in the host country account for poor psychological well-being and psychiatric disorders among this group.
Conclusion
The use of a mixed-methods approach in this international study was essential since the quantitative and qualitative data provide different layers and depth of meaning and complement each other to provide a fuller picture of complex and multi-faceted life situations of refugees and asylum seekers. The comparison between the UK and US suggests that greater flexibility of access to labour markets for this refugee group might help to promote opportunities for better integration and mental well-being.
doi:10.1186/1471-2458-12-749
PMCID: PMC3489604  PMID: 22954304
8.  The Olympic Regeneration in East London (ORiEL) study: protocol for a prospective controlled quasi-experiment to evaluate the impact of urban regeneration on young people and their families 
BMJ Open  2012;2(4):e001840.
Introduction
Recent systematic reviews suggest that there is a dearth of evidence on the effectiveness of large-scale urban regeneration programmes in improving health and well-being and alleviating health inequalities. The development of the Olympic Park in Stratford for the London 2012 Olympic and Paralympic Games provides the opportunity to take advantage of a natural experiment to examine the impact of large-scale urban regeneration on the health and well-being of young people and their families.
Design and methods
A prospective school-based survey of adolescents (11–12 years) with parent data collected through face-to-face interviews at home. Adolescents will be recruited from six randomly selected schools in an area receiving large-scale urban regeneration (London Borough of Newham) and compared with adolescents in 18 schools in three comparison areas with no equivalent regeneration (London Boroughs of Tower Hamlets, Hackney and Barking & Dagenham). Baseline data will be completed prior to the start of the London Olympics (July 2012) with follow-up at 6 and 18 months postintervention. Primary outcomes are: pre–post change in adolescent and parent mental health and well-being, physical activity and parental employment status. Secondary outcomes include: pre–post change in social cohesion, smoking, alcohol use, diet and body mass index. The study will account for individual and environmental contextual effects in evaluating changes to identified outcomes. A nested longitudinal qualitative study will explore families’ experiences of regeneration in order to unpack the process by which regeneration impacts on health and well-being.
Ethics and dissemination
The study has approval from Queen Mary University of London Ethics Committee (QMREC2011/40), the Association of Directors of Children's Services (RGE110927) and the London Boroughs Research Governance Framework (CERGF113). Fieldworkers have had advanced Criminal Records Bureau clearance. Findings will be disseminated through peer-reviewed publications, national and international conferences, through participating schools and the study website (http://www.orielproject.co.uk).
doi:10.1136/bmjopen-2012-001840
PMCID: PMC3432843  PMID: 22936822
9.  Forced residential mobility and social support: impacts on psychiatric disorders among Somali migrants 
Background
Somali migrants fleeing the civil war in their country face punishing journeys, the loss of homes, possessions, and bereavement. On arrival in the host country they encounter poverty, hostility, and residential instability which may also undermine their mental health.
Methods
An in-depth and semi-structured interview was used to gather detailed accommodation histories for a five year period from 142 Somali migrants recruited in community venues and primary care. Post-codes were verified and geo-mapped to calculate characteristics of residential location including deprivation indices, the number of moves and the distances between residential moves. We asked about the reasons for changing accommodation, perceived discrimination, asylum status, traumatic experiences, social support, employment and demographic factors. These factors were assessed alongside characteristics of residential mobility as correlates of ICD-10 psychiatric disorders.
Results
Those who were forced to move homes were more likely to have an ICD-10 psychiatric disorder (OR = 2.64, 1.16-5.98, p = 0.02) compared with those moving through their own choice. A lower risk of psychiatric disorders was found for people with larger friendship networks (0.35, 0.14-0.84, p = 0.02), for those with more confiding emotional support (0.42, 0.18-1.0, p = 0.05), and for those who had not moved during the study period (OR = 0.21, 0.07-0.62, p = 0.01).
Conclusions
Forced residential mobility is a risk factor for psychiatric disorder; social support may contribute to resilience against psychiatric disorders associated with residential mobility.
doi:10.1186/1472-698X-12-4
PMCID: PMC3384470  PMID: 22510245
10.  Does cultural integration explain a mental health advantage for adolescents? 
Background A mental health advantage has been observed among adolescents in urban areas.
This prospective study tests whether cultural integration measured by cross-cultural friendships explains a mental health advantage for adolescents.
Methods A prospective cohort of adolescents was recruited from 51 secondary schools in 10 London boroughs. Cultural identity was assessed by friendship choices within and across ethnic groups. Cultural integration is one of four categories of cultural identity. Using gender-specific linear-mixed models we tested whether cultural integration explained a mental health advantage, and whether gender and age were influential. Demographic and other relevant factors, such as ethnic group, socio-economic status, family structure, parenting styles and perceived racism were also measured and entered into the models. Mental health was measured by the Strengths and Difficulties Questionnaire as a ‘total difficulties score’ and by classification as a ‘probable clinical case’.
Results A total of 6643 pupils in first and second years of secondary school (ages 11–13 years) took part in the baseline survey (2003/04) and 4785 took part in the follow-up survey in 2005–06.
Overall mental health improved with age, more so in male rather than female students. Cultural integration (friendships with own and other ethnic groups) was associated with the lowest levels of mental health problems especially among male students. This effect was sustained irrespective of age, ethnicity and other potential explanatory variables. There was a mental health advantage among specific ethnic groups: Black Caribbean and Black African male students (Nigerian/Ghanaian origin) and female Indian students. This was not fully explained by cultural integration, although cultural integration was independently associated with better mental health.
Conclusions Cultural integration was associated with better mental health, independent of the mental health advantage found among specific ethnic groups: Black Caribbean and some Black African male students and female Indian students.
doi:10.1093/ije/dys007
PMCID: PMC3396315  PMID: 22366123
Adolescents; mental health; advantage; cultural integration
11.  A public health approach to understanding and preventing violent radicalization 
BMC Medicine  2012;10:16.
Background
Very recent acts of terrorism in the UK were perpetrated by 'homegrown', well educated young people, rather than by foreign Islamist groups; consequently, a process of violent radicalization was proposed to explain how ordinary people were recruited and persuaded to sacrifice their lives.
Discussion
Counterterrorism approaches grounded in the criminal justice system have not prevented violent radicalization. Indeed there is some evidence that these approaches may have encouraged membership of radical groups by not recognizing Muslim communities as allies, citizens, victims of terrorism, and victims of discrimination, but only as suspect communities who were then further alienated. Informed by public health research and practice, a new approach is proposed to target populations vulnerable to recruitment, rather than rely only on research of well known terrorist groups and individual perpetrators of terrorist acts.
Conclusions
This paper proposes public health research and practice to guard against violent radicalization.
doi:10.1186/1741-7015-10-16
PMCID: PMC3305506  PMID: 22332998
12.  A Synthesis of the Evidence for Managing Stress at Work: A Review of the Reviews Reporting on Anxiety, Depression, and Absenteeism 
Background. Psychosocial stressors in the workplace are a cause of anxiety and depressive illnesses, suicide and family disruption. Methods. The present review synthesizes the evidence from existing systematic reviews published between 1990 and July 2011. We assessed the effectiveness of individual, organisational and mixed interventions on two outcomes: mental health and absenteeism. Results. In total, 23 systematic reviews included 499 primary studies; there were 11 meta-analyses and 12 narrative reviews. Meta-analytic studies found a greater effect size of individual interventions on individual outcomes. Organisational interventions showed mixed evidence of benefit. Organisational programmes for physical activity showed a reduction in absenteeism. The findings from the meta-analytic reviews were consistent with the findings from the narrative reviews. Specifically, cognitive-behavioural programmes produced larger effects at the individual level compared with other interventions. Some interventions appeared to lead to deterioration in mental health and absenteeism outcomes.Gaps in the literature include studies of organisational outcomes like absenteeism, the influence of specific occupations and size of organisations, and studies of the comparative effectiveness of primary, secondary and tertiary prevention. Conclusions. Individual interventions (like CBT) improve individuals' mental health. Physical activity as an organisational intervention reduces absenteeism. Research needs to target gaps in the evidence.
doi:10.1155/2012/515874
PMCID: PMC3306941  PMID: 22496705
13.  Identifying Depression in South Asian Patients with End-Stage Renal Disease: Considerations for Practice 
Nephron Extra  2011;1(1):262-271.
Depression is a prevalent burden for patients with end-stage renal disease (ESRD) and one that is under-recognized and consequently under-treated. Although several studies have explored the association between depression symptoms, treatment adherence and outcomes in Euro-American patient groups, quantitative and qualitative exploration of these issues in patients from different cultural and ethnic backgrounds has been lacking. This review discusses the methodological issues associated with measuring depression in patients of South Asian origin who have a 3- to 5-fold greater risk of developing ESRD. There is a need to advance research into the development of accurate screening practices for this patient group, with an emphasis on studies utilizing rigorous approaches to evaluating the use of both emic (culture-specific) and etic (universal or culture-general) screening instruments.
doi:10.1159/000331446
PMCID: PMC3290835  PMID: 22470400
Depression; End-stage renal disease; South Asians; Measurement; Screening
14.  Suicide by burning in the South Asian origin population in England and Wales a secondary analysis of a national data set 
BMJ Open  2011;1(2):e000326.
Objectives
A descriptive analysis of suicide by burning in England and Wales in the general population and in people of South Asian origin.
Design
A cross-sectional secondary analysis of a national data set.
Setting
A population study of all those who died by suicide in England and Wales between 1993 and 2003 inclusive.
Participants
All cases of suicide and undetermined intent identified by the Office for National Statistics for England and Wales. A computer algorithm was used to identify people of the South Asian origin from their names. There were 55 140 suicides in the UK between 1993 and 2003. The ratio of male to female suicides was 3:1. There were 1455 South Asian suicides identified by South Asian Name and Group Recognition Algorithm.
Primary and secondary outcome measures
Death by suicide and undetermined intent, as determined by Coroner's Inquest. ICD9 codes E958.1 and E988.1 and ICD10 codes X76 and Y26.
Results
1.77% of suicides in the general population and 8.45% of suicides in the South Asian origin population were by burning. The suicide rate by burning was 0.8/100 000 person-years for England and Wales and 2.9/100 000 person-years for the South Asian origin population. The odds of suicide by burning were increased in the South Asian group as a whole (OR 3.06, 95% CI 2.30 to 4.08). Those born in Asia and Africa were at higher risk than those born in the UK (OR 2.69, 95% CI 2.01 to 3.60 and OR 2.10, 95% CI 1.46 to 3.01, respectively). The increased risk was for those aged 25–64 years.
Conclusion
Suicide by burning remains a significant issue in the South Asian origin working-age population in England and Wales. A prevention strategy could target working-age people of South Asian origin born abroad as they are at the highest risk. More in depth research on the reasons for using this method may help to identify possible prevention strategies.
Article summary
Article focus
A descriptive analysis of suicide by burning in the UK.
A description of suicide by burning in those of South Asian origin in the UK.
Key messages
Suicide by burning is a significant issue in the South Asian population in England and Wales.
The working-age population is at particular risk with those born abroad, especially those born in South Asian countries, having the highest odds.
Though the risk is more elevated in South Asian women when compared with the rest of the population, there are more male suicides using this method overall.
Strengths and limitations of this study
This study used a contemporary national data set.
Using name recognition software rather than place of birth allowed better identification of the South Asian population of the UK.
The data used did not allow for confounders to be taken into account when analysing differences between ethnic groups.
Because administrative data were used, in-depth information on the reasons for choosing this method of suicide were not available.
doi:10.1136/bmjopen-2011-000326
PMCID: PMC3244662  PMID: 22184588
15.  A case study of organisational cultural competence in mental healthcare 
Background
Ensuring Cultural Competence (CC) in health care is a mechanism to deliver culturally appropriate care and optimise recovery. In policies that promote cultural competence, the training of mental health practitioners is a key component of a culturally competent organisation. This study examines staff perceptions of CC and the integration of CC principles in a mental healthcare organisation. The purpose is to show interactions between organisational and individual processes that help or hinder recovery orientated services.
Methods
We carried out a case study of a large mental health provider using a cultural competence needs analysis. We used structured and semi-structured questionnaires to explore the perceptions of healthcare professionals located in one of the most ethnically and culturally diverse areas of England, its capital city London.
Results
There was some evidence that clinical staff were engaged in culturally competent activities. We found a growing awareness of cultural competence amongst staff in general, and many had attended training. However, strategic plans and procedures that promote cultural competence tended to not be well communicated to all frontline staff; whilst there was little understanding at corporate level of culturally competent clinical practices. The provider organisation had commenced a targeted recruitment campaign to recruit staff from under-represented ethnic groups and it developed collaborative working patterns with service users.
Conclusion
There is evidence to show tentative steps towards building cultural competence in the organisation. However, further work is needed to embed cultural competence principles and practices at all levels of the organisation, for example, by introducing monitoring systems that enable organisations to benchmark their performance as a culturally capable organisation.
doi:10.1186/1472-6963-11-218
PMCID: PMC3184058  PMID: 21920044
organisational cultural competence; mental health
16.  Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study 
Objective To examine the rise in the rate of involuntary admissions for mental illness in England that has occurred as community alternatives to hospital admission have been introduced.
Design Ecological analysis.
Setting England, 1988-2008.
Data source Publicly available data on provision of beds for people with mental illness in the National Health Service from Hospital Activity Statistics and involuntary admission rates from the NHS Information Centre.
Main outcome measures Association between annual changes in provision of mental illness beds in the NHS and involuntary admission rates, using cross correlation. Partial correlation coefficients were calculated and regression analysis carried out for the time lag (interval) over which the largest association between these variables was identified.
Results The rate of involuntary admissions per annum in the NHS increased by more than 60%, whereas the provision of mental illness beds decreased by more than 60% over the same period; these changes seemed to be synchronous. The strongest association between these variables was observed when a time lag of one year was introduced, with bed reductions preceding increases in involuntary admissions (cross correlation −0.60, 95% confidence interval −1.06 to −0.15). This association increased in magnitude when analyses were restricted to civil (non-forensic) involuntary admissions and non-secure mental illness beds.
Conclusion The annual reduction in provision of mental illness beds was associated with the rate of involuntary admissions over the short to medium term, with the closure of two mental illness beds leading to one additional involuntary admission in the subsequent year. This study provides a method for predicting rates of involuntary admissions and what may happen in the future if bed closures continue.
doi:10.1136/bmj.d3736
PMCID: PMC3130113  PMID: 21729994
17.  Chronic fatigue syndrome in an ethnically diverse population: the influence of psychosocial adversity and physical inactivity 
BMC Medicine  2011;9:26.
Background
Chronic fatigue syndrome (CFS) is a complex multifactorial disorder. This paper reports the prevalence of chronic fatigue (CF) and CFS in an ethnically diverse population sample and tests whether prevalence varies by social adversity, social support, physical inactivity, anxiety and depression.
Methods
Analysis of survey data linking the Health Survey for England (1998 and 1999) and the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) study undertaken in 2000. The study population comprised a national population sample of 4,281 people ages 16 to 74 years. CF and CFS were operationally defined on the basis of an interview in the EMPIRIC study, alongside questions about psychosocial risk factors. Previous illnesses were reported in the Health Survey for England during 1998 and 1999, as was physical inactivity.
Results
All ethnic minority groups had a higher prevalence of CFS than the White group. The lowest prevalence was 0.8% in the White group, and it was highest at 3.5% in the Pakistani group (odds ratio (OR), 4.1; 95% confidence interval (95% CI), 1.6 to 10.4). Anxiety (OR, 1.8; 95% CI, 1.4 to 2.2), depression (OR, 1.4; 95% CI, 1.1 to 1.8), physical inactivity (OR, 2.0; 95% CI, 1.1 to 3.8), social strain (OR, 1.24; 95% CI, 1.04 to 1.48) and negative aspects of social support (OR, 2.12; 95% CI, 1.4 to 3.3) were independent risk factors for CFS in the overall sample. Together these risk factors explained ethnic differences in the prevalence of CFS, but no single risk factor could explain a higher prevalence in all ethnic groups.
Conclusions
The prevalence of CFS, but not CF, varies by ethnic group. Anxiety, depression, physical inactivity, social strain and negative aspects of social support together accounted for prevalence differences of CFS in the overall sample.
doi:10.1186/1741-7015-9-26
PMCID: PMC3072345  PMID: 21418640
18.  The promotion of children's health and wellbeing: the contributions of England's charity sector 
BMC Research Notes  2010;3:188.
Background
Sports and arts based services for children have positive impacts on their mental and physical health. The charity sector provides such services, often set up in response to local communities expressing a need. The present study maps resilience promoting services provided by children's charities in England. Specifically, the prominence of sports and arts activities, and types of mental health provisions including telephone help-lines, are investigated.
Findings
The study was a cross-sectional web-based survey of chief executives, senior mangers, directors and chairs of charities providing services for children under the age of 16. The aims, objectives and activities of participating children's charities and those providing mental health services were described overall. In total 167 chief executives, senior managers, directors and chairs of charities in England agreed to complete the survey. From our sample of charities, arts activities were the most frequently provided services (58/167, 35%), followed by counselling (55/167, 33%) and sports activities (36/167, 22%). Only 13% (22/167) of charities expected their work to contribute to the health legacy of the 2012 London Olympics. Telephone help lines were provided by 16% of the charities that promote mental health.
Conclusions
Counselling and arts activities were relatively common. Sports activities were limited despite the evidence base that sport and physical activity are effective interventions for well-being and health gain. Few of the charities we surveyed expected a health legacy from the 2012 London Olympics.
doi:10.1186/1756-0500-3-188
PMCID: PMC2914653  PMID: 20626843
19.  Physical activity and depressive symptoms in adolescents: a prospective study 
BMC Medicine  2010;8:32.
Background
The frequency of mental illness amongst adolescents and its potential long-term consequences make it an important topic to research in relation to risk and protective factors. Research on the relationship between physical activity and depressive symptoms in adolescents is limited. There is a particular lack of evidence from longitudinal studies. This study examines the relationship between depression and physical activity using the Research with East London Adolescents: Community Health Survey (RELACHS).
Methods
This was a prospective cohort study. Participants were recruited from three Local Education Authority boroughs in East London in 2001 from year 7 (aged 11-12) and year 9 (aged 13-14) and were followed-up in 2003. All pupils in the 28 schools that took part were eligible for the study. Of the total 3,322 pupils eligible for the survey the overall response rate was 84% (2,789 pupils). A total of 2,093 (75%) pupils were also followed-up in 2003. The sample was multiethnic (73% of respondents were non-white) and deprived. Just under half of the sample was male (49%). Depressive symptoms were measured using the Short Moods and Feelings Questionnaire (SMFQ). Logistic regression analyses were used to examine the association between physical activity and depressive symptoms both cross-sectionally and longitudinally.
Results
After adjustments, there was evidence for a cross-sectional association between physical activity and depressive symptoms for both boys and girls at baseline, with a decrease in the odds of depressive symptoms of about 8% for each additional hour of exercise undertaken per week (boys: odds ratio (OR) = 0.92, 95% CI 0.85 to 0.99; girls: OR = 0.92, 95% CI 0.85 to 1.00). There was no evidence for an association between a change in physical activity from baseline to follow-up and depressive symptoms at follow-up.
Conclusions
This study provides some evidence for an association between level of physical activity and decreased depressive symptoms in adolescents. Further longitudinal research of these associations is required before physical activity can be recommended as an intervention for depression in adolescents.
doi:10.1186/1741-7015-8-32
PMCID: PMC2895574  PMID: 20509868
20.  A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment 
BMC Psychiatry  2010;10:33.
Background
Although psychoses and ethnicity are well researched, the importance of culture, race and ethnicity has been overlooked in Personality Disorders (PD) research. This study aimed to review the published literature on ethnic variations of prevalence, aetiology and treatment of PD.
Method
A systematic review of studies of PD and race, culture and ethnicity including a narrative synthesis of observational data and meta-analyses of prevalence data with tests for heterogeneity.
Results
There were few studies with original data on personality disorder and ethnicity. Studies varied in their classification of ethnic group, and few studies defined a specific type of personality disorder. Overall, meta-analyses revealed significant differences in prevalence between black and white groups (OR 0.476, CIs 0.248 - 0.915, p = 0.026) but no differences between Asian or Hispanic groups compared with white groups. Meta-regression analyses found that heterogeneity was explained by some study characteristics: a lower prevalence of PD was reported among black compared with white patients in UK studies, studies using case-note diagnoses rather than structured diagnostic interviews, studies of borderline PD compared with the other PD, studies in secure and inpatient compared with community settings, and among subjects with co-morbid disorders compared to the rest. The evidence base on aetiology and treatment was small.
Conclusion
There is some evidence of ethnic variations in prevalence of personality disorder but methodological characteristics are likely to account for some of the variation. The findings may indicate neglect of PD diagnosis among ethnic groups, or a true lower prevalence amongst black patients. Further studies are required using more precise cultural and ethnic groups.
doi:10.1186/1471-244X-10-33
PMCID: PMC2882360  PMID: 20459788
21.  Institutional racism in mental health care 
BMJ : British Medical Journal  2007;334(7595):649-650.
Services have some way to go before they meet the challenges of a multicultural society
doi:10.1136/bmj.39163.395972.80
PMCID: PMC1839175  PMID: 17395908
22.  Culture, religion and health care 
PMCID: PMC2834912  PMID: 20228918
23.  Do 'alternative' help-seeking strategies affect primary care service use? A survey of help-seeking for mental distress 
BMC Public Health  2008;8:207.
Background
Epidemiological studies suggest that only some distressed individuals seek help from primary care and that pathways to mental health care appear to be ethnically patterned. However few research studies examine how people with common mental disorder manage their mental distress, which help-seeking strategies they employ and whether these are patterned by ethnicity? This study investigates alternative help-seeking strategies in a multi-ethnic community and examines the relationship with primary care use.
Methods
Participants were recruited from four GP practice registers and 14 community groups in East London. Of 268 participants, 117 had a common mental disorder according to a valid and structured interview schedule (CIS-R). Participants were of Bangladeshi, black Caribbean and White British ethnic background. For those with a common mental disorder, we examined self-reported help-seeking behaviour, perceived helpfulness of care givers, and associations with primary care service use.
Results
We found that alternative help-seeking such as talking to family about distress (OR 15.83, CI 3.9–64.5, P < .001), utilising traditional healers (OR 8.79, CI 1.98–38.93, p = .004), and severity of distress (1.11, CI 1.03–1.20, p = .006) was positively associated with primary care service use for people with a common mental disorder. Ethnic background influenced the choice of help-seeking strategies, but was less important in perceptions of their helpfulness.
Conclusion
Primary care service use was strongly correlated with lay and community help-seeking. Alternative help-seeking was commonly employed in all ethnic groups. A large number of people believed mental distress could not be resolved or they did not know how to resolve it. The implications for health promotion and integrated care pathways are discussed.
doi:10.1186/1471-2458-8-207
PMCID: PMC2443800  PMID: 18547400
24.  Drug Consumption in Conflict Zones in Somalia 
PLoS Medicine  2007;4(12):e354.
The authors discuss the public health implications of a new study on the use of khat and other drugs by Somali combatants.
doi:10.1371/journal.pmed.0040354
PMCID: PMC2121649  PMID: 18076283
25.  Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review 
BMC Public Health  2007;7:336.
Background
Studies suggest that the rates of self harm vary by ethnic group, but the evidence for variation in risk factors has not been synthesised to inform preventive initiatives.
Methods
We undertook a systematic literature review of research about self harm that compared at least two ethnic groups in the United Kingdom.
Results
25 publications from 1765 titles and abstracts met our inclusion criteria. There was higher rate of self harm among South Asian women, compared with South Asian men and White women. In a pooled estimate from two studies, compared to their white counterparts, Asian women were more likely to self harm (Relative Risk 1.4, 95%CI: 1.1 to 1.8, p = 0.005), and Asian men were less likely to self harm (RR 0.5, 95% CI: 0.4 to 0.7, p < 0.001). Some studies concluded that South Asian adults self-harm impulsively in response to life events rather than in association with a psychiatric illness. Studies of adolescents showed similar methods of self harm and interpersonal disputes with parents and friends across ethnic groups. There were few studies of people of Caribbean, African and other minority ethnic groups, few studies took a population based and prospective design and few investigated self harm among prisoners, asylum seekers and refugees.
Conclusion
This review finds some ethnic differences in the nature and presentation of self harm. This argues for ethnic specific preventive actions. However, the literature does not comprehensively cover the UK's diverse ethnic groups.
doi:10.1186/1471-2458-7-336
PMCID: PMC2211312  PMID: 18021438

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