Inequalities exist across many areas of healthcare but are particularly evident in mental health settings, where healthcare professionals can restrict choices to hospital stays and treatments. Racism, as well as socioeconomic inequalities, which more frequently affect patients from certain ethnic groups, are also risk factors for the development of mental health conditions. This article reviews the evidence of how race affects mental health care, including access to services, diagnoses and treatments. It also highlights how black, Asian and minority ethnic (BAME) patients do experience different pathways into services and different treatments, particularly with antipsychotics, when compared with white British patients. Gaps in the evidence are highlighted, particularly in relation to antidepressants, where information on the impact of ethnicity is not well understood. Opportunities for pharmacy staff to support patients to reduce inequalities are also discussed, alongside national initiatives.
Keywords: ethnicity, inequality, mental health
In 2020, a spotlight was thrown onto inclusion, diversity, and inequality — particularly racial inequality. The COVID-19 pandemic highlighted the disparity in outcomes for patients from different ethnic backgrounds, particularly the higher death rates in patients who are black and those from certain Asian populations[1,2]. The Black Lives Matter movement has also facilitated more open conversations about the general inequality and stigma experienced by people purely because of their race.
Mental health care carries its own stigma and inequality, with patients with serious mental illness less likely to be in long-term employment, usually achieving fewer educational milestones and more likely to live in poverty[4–6]. Health outcomes are also significantly poorer, with patients with a serious mental illness living on average 15–20 years less than the general population[7,8]. In the UK, people who identify as black, Asian and minority ethnic (BAME) are more likely to live in poverty, less likely to be employed and earn less when in employment and therefore have greater risk factors for developing a serious mental illness, increasing their risk of poverty and unemployment[9–11].
Racial inequality within mental health services can take many forms and affects the diagnosis, evidence-based treatment and management of mental health conditions[12–15], including the increasing likelihood of being detained under the Mental Health Act 1983 and the increased use of restrictive interventions (e.g. rapid tranquilisation, long acting antipsychotics and community treatment orders)[16–18]. Inequality may also exist where patients are not involved in treatment decisions, cultural or religious factors are not considered or discussed, or accessible information is not provided to enable full consent to medication.
BAME patients may have difficulty in accessing and obtaining support for mental health conditions, particularly where there is disparity in services provided across different areas and long waiting times[19,20]. For people for whom English is not their first language, access to practitioners who speak their language or to translation services can provide further delays and barriers to assessment and treatment. This is of relevance to diagnosis and any psychological therapy, which is based entirely on the ability to communicate effectively[21,22].
Fear around mental health, both in terms of cultural belief and concerns about how you may be treated within mental health services, can also delay access to appropriate treatment. Reviews looking at referral pathways into mental health services found that ethnicity is a factor, which impacts on people seeking help from services, reducing the opportunity for the provision of appropriate treatment and support, and can lead to an increase in compulsory detention and treatment[23,24].
Black men in the UK are significantly more likely than others to be stopped as part of ‘stop and search’, to be arrested, not to be given bail and to serve a longer prison sentence if convicted. Being in prison may increase the development of, and worsen, established mental health conditions owing to the stressful nature of going through the criminal justice system, restrictions on life and isolation, and can limit and delays access to appropriate treatment[25,26]. There is a substantial overrepresentation of patients with mental health conditions in UK prisons, with more than 50% having a symptom or a diagnosis of a mental illness and outcomes are poor, with increased rates of completed suicide and self-harm[25,27] — the overall rate of suicide is around 0.4 per 1,000 of the population per year in England, compared with a rate of 1 per 1,000 people annually in prisons[28,29].
The direct effect that racism and stigma can have on people’s mental health should not be underestimated. Being exposed to racism increases the risk of someone presenting with a mental health condition, and people who experience a racial attack or verbal abuse are up to 3-5 times more likely to develop psychosis or depression[30–32]. It can also support division between healthcare professionals and patients, with patients feeling that the way they are being treated may differ based on their race[33,34].
Comorbidities, such as diabetes and hypertension, are more common in people of certain ethnicities, especially south Asian and African populations — diabetes can occur 3-5 times more frequently compared with the white British population[35–37]. Comorbidity with long-term conditions and depression or anxiety is high and worsens outcomes for both conditions, especially when mental health conditions are not managed. Comorbidity must also be considered when treating mental health conditions. In particular, antipsychotics risk worsening underlying comorbidities and this may play a factor in shortening life expectancy for patients with an serious mental illness[39,40].
Pharmacists should promote mental wellbeing and can help support patients to access services, provide education on mental health and reduce associated stigma attached to seeking support. Pharmacists must understand the risks that ethnicity plays within mental health and ensure that this is considered when supporting the management of mental health conditions. They also need to understand the evidence to ensure treatment optimisation to achieve better patient outcomes. Understanding the hidden effects that race may have is also important to account for the impact of ethnicity on physical and mental health conditions and handling of medication to support patient and prescriber education around appropriate medication choices. Ensuring patients can access appropriate information about medication may help them be more involved in the management of their mental health condition, reducing fear and stigma.
This article provides an overview of the evidence behind racial inequality in the treatments provided for mental health conditions and how this may affect outcomes and experiences. It also outlines how pharmacists can ensure that inequality is challenged and prevented. Literature searches were undertaken to identify all English language articles relating to ethnicity or race and mental health treatment.
Summary of evidence and recommendations for pharmacy practice
Psychosis and antipsychotic prescribing
Most information considering the effects of ethnicity in mental health treatment relates to the management of psychotic illnesses.
A 2019 study that considered two population studies of first episode psychosis in south London 15 years apart (1997–1999, n=266; 2010 and 2012, n=446), demonstrated that black African patients are three times more likely to be admitted under the Mental Health Act than white British patients. In the 15 years between the studies, compulsory admission for black African patients has remained similar. Caribbean and black African patients were significantly more likely to access mental health services via the police than via their GP compared to white British patients[41,42]. A study of 1,115 Mental Health Act assessments in 2016, concluded that the “disproportionality” of BAME detention was as a consequence of higher rates of mental illness and poorer social support as opposed to ethnicity. While there is evidence that psychosis is more prevalent in BAME populations, what is not clear is whether this is caused by genetics, increased poverty, migration, particularly forced migration and broader racial inequality, or a combination of factors[43,44].
Studies from the United States demonstrate that black patients have a higher likelihood of being prescribed older antipsychotics (odds ratios [OR] 1.48–2.50 compared to white patients), particularly depot antipsychotics and high-dose antipsychotics (OR 2.17–2.67 compared to white patients)[45–48]. UK studies have mainly failed to find significant differences between the treatment of patients of different ethnicities, but they are mainly older studies and are often limited to only black and white patients, with other ethnicities excluded.
A one-day census involving 3,576 psychiatric ward inpatients in the UK who had been prescribed antipsychotic medication concluded that there was no significant difference of ethnicity on either polypharmacy or incidence of high-dose prescribing although exact differences were not presented.
A 2007 study by Connolly et al. considered antipsychotic prescribing quality and ethnicity among hospitalised black or white patients in south east London, who had been taking the same antipsychotic medicine for three weeks or longer. Patients were classed as black if both parents were also black (including Africans, African-Americans and Afro-Caribbeans). Patients from other ethnic backgrounds were excluded. The study showed that total antipsychotic daily dose was 82.2% of licensed maximum dose in black patients, and 77.2% in white patients. Antipsychotic polypharmacy (two or more antipsychotics prescribed concurrently) was seen in 23.2% of black patients and 16.9% of white patients. High-dose antipsychotic prescribing was more common in white patients than black patients (15.9% vs. 16.9%). Despite the findings, the study concluded that prescribing quality was similar for black and white patients and that “numerical differences were small and there was no suggestion of clinically important differences in prescribing quality”.
A second study by the same authors also examined the quality of antipsychotic prescribing among 225 (152 white and 103 black) psychiatric ward inpatients in south London. The study had similar conclusions that prescribing quality was broadly similar for black and white patients with no significant difference in mean dose of antipsychotic or high-dose antipsychotic prescribing. However, antipsychotic polypharmacy was more prominent amongst black patients (25.7% for white and 31.1% black, respectively). One centre involved in the study showed an exceptionally high rate of polypharmacy among black patients compared with white patients (74% vs 37%); there were no reasons identified for this.
A third larger multicentre study considered prescribing across the UK, involving black and white inpatients (n=938) across eight mental health trusts, taking one or more regular antipsychotics. The key outcome measures for the study were polypharmacy, high-dose antipsychotics, antipsychotic dose and type of antipsychotic (typical [e.g. haloperidol, flupentixol, zuclopenthixol] or atypical [e.g. risperidone, olanzapine, quetiapine, clozapine]). The study used an extensive range of confounders to try to limit the chance of intended differences between the two groups; however, many of these, such as language and education, seem to lack clear rationale as to their use and it is not clear what impact the individual confounders had on the data. The study concluded that antipsychotic prescribing practice did not differ between white and black patients with no significant differences in any outcome by ethnicity.
The three studies by the same group used percentage of the British National Formulary (BNF) maximum to compare different antipsychotics[50–52]. This fails to account for the differences in licences, particularly of the older antipsychotics, which have higher maximum doses compared with what is considered as their maximum effective dose[53,54]. This is particularly significant because black patients were proportionally more likely to be prescribed older antipsychotics (28.5% vs. 21.7%), therefore the finding that the doses were equivalent could be inequitable. As all the studies showed differences in the doses given to black patients and taking into account the higher levels of older antipsychotics given to these patients, the fact that these are not considered by the authors is a major limitation. Several other methods for calculating equivalent doses have been published, such as defined daily doses and maximum effective doses[54,55]. The use of alternative methods alongside BNF maximums would provide a more robust evaluation of antipsychotic dose differences between ethnic groups.
A small-scale study considered the differences in prescribing practice (dosing and polypharmacy of antipsychotics) for patients according to their ethnicity prescribed clozapine (n=200) and olanzapine (n= 328). The dosage and extent of antipsychotic co-prescription did not significantly differ between ethnic groups prescribed clozapine. However for olanzapine, co-prescription was significantly more prominent among black patients than in white patients (33% vs. 20%). A systematic review has shown that, despite higher levels of psychosis, and evidence of increasing use of antipsychotic combinations, clozapine is underutilised in BAME patients. However, as clozapine is the first-line treatment for treatment resistant schizophrenia and evidence shows that delaying clozapine makes it less effective, this is concerning. Concerns around benign ethnic neutropenia may reduce willingness for initiating clozapine despite evidence of effectiveness in this population[59,60].
Overall, the study evidence described above signals that black patients are more likely to receive polypharmacy, older antipsychotics and combinations of antipsychotics than white patients. It is not currently known what impact this may have on patients’ outcomes. General studies indicate a lack of a clear dose response with some antipsychotics, particularly those that are older or have high affinity for blocking dopamine D2 receptors, therefore higher doses in combinations are likely only to increase dose-related adverse effects. Pharmacists have a responsibility to challenge inappropriate dose escalations and combinations of medication.
In the UK, compliance with long-term monitoring of antipsychotics has been repeatedly shown to be poor[62–64]. Patients from certain BAME populations, such as South Asians, Black Africans and Black Caribbeans, are at greater risk of developing illnesses such as diabetes, cardiovascular disease and hypertension. Also, as antipsychotics are associated with cardiometabolic adverse effects, not carrying out regular monitoring puts these patients at greater risk[35,36,62,65–67]. The increased risk of diabetes, hypertension or other diseases owing to ethnicity should be a major consideration for antipsychotic choice; however, this is not currently routine practice.
Increased prevalence for psychotic illness and difficulty in accessing services may be seen as sufficient reason to justify the differences in prescribing of antipsychotics and other restrictive practice[68,69]. While increased prevalence of psychotic illnesses in black patients may justify an increased need to admit patients into hospital, it should not alter the way in which they are treated[70,71]. Treatment of patients presenting later during their illness can be less effective, however the initial treatments, choices and doses should not be automatically altered and there is little evidence that increasing doses or combining medicines is an effective strategy[72–74]. Patients should be encouraged to access treatment earlier, as this is likely to be the most effective intervention. There is no compelling reason to justify differences in antipsychotic choices across ethnicities; however, it is not possible to account for the reasons as to why BAME patients are more likely to be prescribed older generation antipsychotics at higher doses that increase the risk of significant adverse effects and likely non-compliance[75–77].
Box 1: Best practice for management of patients with psychosis
Pharmacists can support the effective management of patients by:
- Knowing the effective doses and adverse effects of antipsychotic medications and be able to review antipsychotic prescriptions;
- Support patients to be involved in decisions around medication choice and provide information in an appropriate format;
- Understand the use, effectiveness and constraints of using clozapine and be able to signpost patients to specialist mental health services where suitable;
- Signposting patients to appropriate organisations where further information is required, including advocacy services for patients who lack capacity or are treated under the Mental Health Act 1983;
- Signposting patients who may require an assessment of their mental health and encourage patients to seek support when necessary.
Anxiety and depression
There is a lack of recent, UK-based literature considering differences in treatment based on ethnicity and the subsequent long-term outcomes. A 2001 practice-based cross-sectional survey examined the prescribing rates of psychotropic medication (antidepressants and anxiolytics) among 164 general practices in east London. The study demonstrated that practices with a higher proportion of Asian patients had a lower prescribing rate of both antidepressants and anxiolytics. Reasons for this included GP prescribing behaviours, under-representation and difficulty of diagnosis. In addition, ethnic minority groups are less likely to be offered and engage with psychological interventions, such as talking therapies, which are a first-line option in the management of anxiety and depression.
Box 2: Best practice for management of patients with anxiety and depression
Pharmacists can support the effective management of patients by:
- Helping patients access information about common mental health conditions;
- Being aware of the resources available to support patients in culturally appropriate ways, including information in appropriate languages;
- Highlighting gaps in available information that do not meet needs of individual patients or populations.
Older adult mental health and dementia
Despite the prevalence of mental health conditions and increased use of psychotropic medication in older people, there is a lack of good quality data on differences in diagnosis and treatment of older patients of different ethnicities. There is growing evidence that the prevalence of dementia may be greater among BAME people, particularly the black population, yet many of those with dementia in this population remain undiagnosed or are diagnosed too late to benefit from pharmacological and social support[80–82]. The prescribing rate of anticholinesterases and memantine for dementia has been shown to be lower in BAME than white populations; however, antipsychotics, while used for similar proportions of patients, were shown to be used for longer in black and Asian patients, with a study showing an increase in prescribing for up to 27 days per year[81,83,84]. Consequently, BAME populations have a higher overall burden of dementia. Stigma, lack of understanding of dementia, and cultural and language barriers all are thought to contribute to reduced access to dementia services in the UK[81,85].
A 2019 US study examined racial ethnic variations in the use of psychotropic medication in older patients (n=7,616); samples were taken between 2012 and 2015. These patients are at greater risk of adverse effects associated with inappropriate use of medication than other age groups. Overall, 48% of community patients were inappropriately prescribed a psychotropic medication. The study also found that 22% of patients from a Hispanic background had a higher rate of inappropriate medication compared with the white population. No differences were found between white and black patients.
Box 3: Best practice for management of older people with mental health conditions and dementia
Pharmacists can support the effective management of patients by:
- Supporting patients who are showing signs of memory loss to access their GP for a review;
- Identifying patients who are prescribed antipsychotics in dementia and ensure that they are reviewed regularly;
- Being aware of the dementia care services in their areas, as these can differ from mental health services.
Child and adolescent mental health
Racial disparities exist in paediatric mental health among BAME groups, particularly for black children in comparison with white children, and these disparities are independent of socioeconomic status[88–90]. These include reduced access to mental health services for those in need and/or at high risk, reduced uptake and engagement with treatment, and poorer treatment outcomes. These findings mean that, overall, non-white children and adolescents are more likely to receive fewer and poorer quality health services than their white peers[88,90]. Most evidence comes from US studies where the structure of the healthcare system is significantly different and likely a major factor in the differences identified.
These studies have consistently shown that black African-American and Latino/Hispanic children and adolescents are less likely to be prescribed or use psychotropic medications such as antidepressants, antipsychotics and stimulants compared with white children, even adjusting for factors such as age, gender, income, insurance status, need or impairment[88,90]. Studies that involved the treatment of attention deficit hyperactivity disorder (ADHD) showed that prescribing rates are significantly lower — up to half that of white patients — for black and Hispanic children, even where differences in insurance coverage, income, health status or comorbid medical conditions were accounted for[91–93]. Furthermore, children belonging to an ethnic minority have less access to mental health services and are more likely to receive inadequate treatment or to go untreated, and less likely to receive psychotherapy, especially in the outpatient setting[88,90]. This is independent of potential contributing factors such as diagnosis, level of education, household income and insurance status[46,90]. There is a significant lack of information from paediatric mental health services in the UK.
Box 4: Best practice for management of children with mental health conditions
Pharmacists can support the effective management of patients by:
- Understanding the diagnosis of ADHD and how medication can support this;
- Supporting patients to access information on childhood mental health conditions and common medication in appropriate formats.
Very little research has been published about BAME patients who have a learning disability, particularly around medication and treatment. However, there is some evidence to suggest that the use of mental health services across people who have learning disabilities varies between ethnicities.
The 2006 National Census for inpatients in mental health and learning disability services in England and Wales found differences between admission rates among ethnic groups. People who have a learning disability from black Caribbean, mixed white and other black groups were two to three times more likely to be admitted for mental health problems than the average for all patients.
A mapping of services for young people who have a learning disability and mental health in South Asian communities in Bradford showed that they were not accessing mental health services and therefore not receiving specialist treatments. Families often feel services are not culturally and religiously sensitive to the needs of patients who have learning disabilities. Other barriers included a lack of knowledge about the services, communication problems and a lack of appropriate services. Research also shows that there is a higher incidence of schizophrenia and autism in black people who have a learning disability compared with white patients who have a learning disability.
A 2012 study examined the experiences of 32 people who had learning disabilities from different ethnic groups accessing mental health services. Study involvement required reasonably advanced verbal comprehension, therefore only people with mild learning disability were included, excluding the experience of people with severe learning disability. They found that black patients had a less positive experience regarding the level of support and person-centred approach offered (e.g. they felt more likely that medication would be offered instead of non-pharmacological alternatives) compared with white patients.
More research is required to examine the treatment and medication options available to patients who have a learning disability and whether this differs in the BAME population.
Box 5: Best practice for management of patients with learning disability
Pharmacists can support the effective management of patients by:
- Knowing how to access information that meets the needs of patients with a learning disability, including appropriate advice for the indication;
- Ensuring patients with learning disability, their parents and carers have access to appropriate support and can signpost them to appropriate organisations where necessary.
In 2005, the UK Department of Health published an action plan on delivering equality in mental health services, which aimed to tackle the major issues causing racial inequality in mental health treatment. Subsequently, there were several local developments and successes; however, it failed to significantly change the experiences of BAME patients accessing mental health services.
Further publications, including the ‘Patient and Carers Race Equality Framework’ (PCREF), have outlined recommendations to place these experiences at the centre to break the cycle of fear of mental health services, which is thought to prevent BAME patients accessing support and treatment, and looks to promote services focused on recovery and specifically targeted at BAME inclusion[99,100]. Reducing the stigma associated with both mental health diagnosis and mental health services is paramount to support patients to access effective treatment.
While discrimination can occur across healthcare, mental health stands apart in its ability to enforce treatment for patients who are not able to consent but who may also actively dissent to it. Where there are differences in mental health treatments, there is less of a clear strategy to reduce inequality, perhaps owing to the lack of clear robust evidence highlighting the problems and more robust data is also required to support the identification of and effectiveness of interventions to reduce inequity.
What is clear is that mental health care needs to be patient-centred and meet the needs of individuals holistically. Pharmacists should be using the principles of person-centred care and ask appropriate questions about medication choice, monitoring and side effects. Patients must be given support in a format that works for them, and pharmacy should drive the provision of information in ways that meets the needs of underrepresented populations. This should be culturally appropriate information in different languages and should support working with different religions to support and address ways that medication can be used that doesn’t restrict someone’s ability to practice their faith. Information must respond to the questions that local populations have about their management and address fears that compulsory treatments may nurture. How often do pharmacists ask about someone’s religious or cultural beliefs as part of a medication review, do we ensure that their medication fits within their views or highlight where it does not? Where patients are on medication that they do not have capacity to understand, do pharmacists ensure that views are still sought from the individual and carers, best interest decisions are made and that their medication is optimised?
The effective doses of antipsychotics should also be considered as part of medication reviews and where possible alongside easily available side effect rating scales, such as the ‘Liverpool University Neuroleptic Side Effect Rating Scale’ (LUNSERS) or ‘Glasgow Antipsychotic Side-Effect Scale’ (GASS), which help to identify adverse effects that people may not always discuss[102,103]. Discussing options about medication, such as antidepressants or antipsychotics, can be complicated for patients, particularly those with longstanding illness, as they may have already tried many treatments. Pharmacists can still help patients to understand the basic concepts of medication, adverse effects and help identify which questions the patient may want to ask in consultations, so that they can be more informed and better prepared for any discussions about their treatment.
Pharmacists in any setting should have an understanding of the mental health system where they are, so that they are able to discuss concerns with patients who have had negative experiences or who are worried about accessing mental health services. The consequences of untreated mental illness is not dissimilar to some physical conditions, in that untreated illness can decline, cause permanent changes and become more and more resistant to effective treatment. Pharmacists need to be able to have open and frank conversations to support people to make informed decisions about accessing services, the effects of untreated illness and knowing when and how to refer patients in their areas.
Pharmacists are a diverse population and should share examples of interventions and good practice to support the development of our profession and take opportunities to ensure the impact of ethnicity is explored and published.
The evidence of direct inequality in the treatment of mental health conditions for BAME patients is limited by a lack of high quality, up-to-date information. Inequalities exist in patients accessing treatments and may exist in the treatments offered but the evidence is inconclusive. In future research examining the treatment of mental health conditions, specific consideration should be given to also examine the effect of race on mental health outcomes, including quality of life, so that services and interventions can be targeted to support patients where they need it the most. An understanding of why treatment differences occur, particularly around delayed use of clozapine, use of older antipsychotics and use of antipsychotics in dementia, is also needed.
BAME patients often experience fear and stigma surrounding mental health services and removing the related barriers is central to supporting patients achieve the best outcomes. Pharmacists can help patients access the support that they need, understand what their treatment means and empower them to be involved in their treatment decisions. All pharmacists, regardless of sector or setting, should have a good understanding of mental health conditions and knowledge of medicines is an important component to achieving this goal.
The link between race and social inequality is likely to play a big part in the overall inequality seen in mental health services. Strategies must look at supporting society to reduce poverty which disproportionately affects BAME populations. Without that, any interventions in mental health services alone will not be able to completely distinguish inequality.
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