Race

The MHAC, not for the first time, noted the over-representation of black patients in psychiatric detention. As the report notes in paragraph 1.37:

This finding is consistent with previous epidemiological data (see later discussion). The report goes on to complain that, despite previous recommendations, the Department of Health had taken no steps to produce translated information leaflets in services and that BME (black and minority ethnic) patients continued to complain about regular racist abuse (MHAC, 2009:14).

Age

According to the consensus in psychiatric epidemiology, the life-span distribution of mental health problems is a u-shaped curve (see later discussion) (Rogers and Pilgrim, Reference Rogers and Pilgrim2003). That is, most recorded mental health problems occur in the very young and the very old. Maybe counter-intuitively, on average our positive mental health peaks in late middle-age. Despite this, the age distribution of psychiatric detention is a variation on the bell-shaped curve, as Figure 4, taken from the MHAC report, shows by different levels of security.

Figure 4.

Age range of detained patients by gender and security level, England and Wales, 31 March 2008

Source: Reproduced from Mental Health Act Commission (2009).

The divergence in later life (with an upward trend of female admissions compared to men) probably reflects the greater longevity of women and so their prevalence of mental disorder deemed to require control in statutory services (depression and dementia). This bucks the trend in younger groups where men, not women, are disproportionately processed in the statutory mental health system – as we see in the next section.

Gender

Turning to the MHAC data on gendered psychiatric detention, this mirrors that of prison populations. The more secure the mental health service, the more that it will include men rather than women. Indeed, in the case of maximum security (as will be discussed later) women are even less visible now than in prison populations. Men are represented at over four times the rate of women in medium secure psychiatric care and over twelve times the rate in high security. This pattern relates to one sub-group of those with a diagnosed mental disorder (mentally disordered offenders) shown in Figure 5, reproduced from the MHAC report.

Figure 5.

Male and female detained patients by security level, resident in hospital on 31 March 2008

Source: Reproduced from Mental Health Act Commission (2009).

We can also look at those on ‘civil’ sections of the Mental Health Act admitted to local acute psychiatric units, which are typically in District General Hospitals. The pattern relevant to our discussion here about acute admissions is demonstrated in Figure 6.

Figure 6.

Male and female patients admitted to hospital under Part 2 of the Mental Health Act, England, 1997/98–2007/08

Source: Reproduced from Mental Health Act Commission (2009).

Note that, over time, there is no clear discernable pattern of sex bias at the point of admission (men and women have been admitted at roughly equal rates in recent years). In the 1990s, there was a slight preponderance of women and more recently that trend reversed. However, the data on residence (rather than admission) show that men are much more likely to be inpatients, as is shown in Figure 7, which is reproduced from the report.

Figure 7.

Resident detained population, NHS and private sector by gender, England, 1999–2008

Source: Reproduced from Mental Health Act Commission (2009).

The two figures above show that the incidence of risky action warranting admission under civil sections (i.e. those responding to non-criminal risk) of the Mental Health Acts of 2003 and then 2007 has been about equal for men and women, but the latter remain in hospital for shorter periods. This leads to a point prevalence of residence in which men are present at around twice the rate of women. This in turn mirrors risky action which is gendered more generally in society.

Men are dangerous to others more often than women and they are more likely to abuse substances (which increases the probability of anti-social action). As with the control of mentally disordered offenders, this indicates that the mental health system is normative in character and it is an extension of an apparatus of coercive social control (largely and typically associated with the criminal justice system). What makes debates about the coercive social control role peculiar in mental health policy is that the legal arrangements for the ‘management’ of mental disorder are not consistent with those linked to criminal justice. This point begins our discussion section.

The questionable basis of legalism-plus-safeguards

One resolution to this challenge of dealing with accusations of human rights violations is to extend State paternalism to include safeguards against the adverse impact of the State's own delegated lawful powers of coercive social control. For example, the World Health Organization (WHO) (2005) recommends a policy to national jurisdictions that enshrines both coercive powers and measures to mitigate their consequences: legalism-plus-safeguards. For example, the WHO spells out the appropriate ‘components [to be] included in legislation on mental health’:

1. 1. Access to mental health care including access to the least restrictive care

2. 2. Rights of mental health service consumers, family members, and other care givers

3. 3. Competency, capacity, and guardianship issues for people with mental illness

4. 4. Voluntary and involuntary treatment

5. 5. Accreditation of professionals and facilities

6. 6. Law enforcement and other judicial system issues for people with mental illness

7. 7. Mechanisms to oversee involuntary admission and treatment practices

8. 8. Mechanisms to implement the provisions of mental health legislation.

   (WHO, 2005:16, emphasis added)

The measures currently evident in the UK and most other developed countries are consistent with this list, which is pregnant with practical contradictions arising from the ‘components’ italicised. The MHAC provided the ‘mechanisms to oversee involuntary admission and treatment practices’. Implied here by the WHO is the legitimate devolution of coercive State powers, on a daily basis, to clinicians, with some protection of rights in the lay arena. The WHO position, and the same adopted by receptive countries accepting its advice, means that medical discretion to operate coercively is retained, while attempts are also made to protect the human rights of patients and their significant others. These rights are sometimes incommensurable.

The WHO formula might obscure the substantive (not aberrant) role of psychiatry as an extension of a coercive apparatus of social control. It might also have the effect of obscuring the role of social inequalities in relation to that apparatus by emphasising that the problem being addressed simply relates to the aggregate effects of individual pathology; the social dimension is mystified by a focus on the symptoms of patients always self-evidently warranting professional action. This creates a discourse of ‘mental health needs’ and the doctor's ‘right to treat’ and their ‘duty of care’. Thus, we can observe a self-fulfilling pattern of the individualisation of mental health problems and the inevitability of current service characteristics.

The view that ‘access to services’ should be defined by professional assessments and impositions, when judged appropriate, is not neutral and interest free. It is dominated by the interests of the psychiatric profession, within WHO deliberations and reflected in their policy advice noted above, and indirectly the pharmaceutical industry, which funds psychiatric campaigns about detection, treatment and management policies (Pilgrim and Rogers, Reference Pilgrim and Rogers2005). For example, apart from the legislative focus, there is also an emphasis from the WHO on the mass screening of children to detect and treat mental disorder and the increasing availability to populations of psychotropic medication.

Tensions about this matter can be found in the WHO's own policies. For example, in its wider deliberations it is highly sensitive to the impact of human rights violations on health in general (WHO, 2002). However, State-sanctioned psychiatric paternalism is seen as part of the solution not part of the problem in this regard. In the light of psychiatry's internal and external critics noted above, the relationship between human rights and ‘mental health services’ continues to be a recurrent point of both presumption (from conservative legalists and radical libertarians), and therefore contention, globally.

Does the ‘inverse care law’ apply to ‘mental health services’?

A strong indication that our understanding of social inequalities takes on a new meaning in the context of mental healthcare utilisation can be considered in relation to the ‘inverse care law’. The latter phenomenon was highlighted by Tudor-Hart (Reference Tudor-Hart1971) when he demonstrated that, in the case of physical health problems, those with the greatest need, the poor, had the poorest access to healthcare. This point even applied to ‘socialised’ healthcare, such as the British NHS. However, quite dramatically, the reverse is the case with psychiatric problems. Although a class gradient is evident in the prevalence of all health problems, whether designated as physical or mental (the poorest are the most ill), the presence of the poor in mental healthcare is greater not lesser than richer citizens. Thus, ‘access’ to mental healthcare seemingly contradicts the ‘inverse care law’.

Since the run down of the old large Victorian asylums and the reliance on smaller numbers of beds in acute units and medium secure units, the threshold of risk to warrant admission has now changed, with increasing numbers being admitted involuntarily and, even when notionally voluntary, they are still placed on locked wards. These features were noted earlier from the MHAC data, as was the conclusion that these units are now not ‘treatment centres’ but sites of risk management, which create new risks to patients as well as managing risks from patients.

A further indication that Tudor-Hart's arguments about the inverse care law need to be applied cautiously in relation to mental healthcare is the pattern of MHAC findings on race, age and gender. As we saw earlier from the MHAC report, Black African and Black African-Caribbean patients are over-represented in compulsorily detained parts of the mental healthcare system and we also know that they are under-represented in primary mental healthcare, with its ethos of voluntarism (Nazroo, Reference Nazroo2003; Commander et al., Reference Commander, Odell, Surlees and Sashidharan2003).

This ‘imposed access’ pattern is gendered as well as racialised. Women are over-represented overall in terms of diagnosed mental disorder, and they are admitted as frequently as men to inpatient care, but male patients remain longer in the system (see MHAC findings earlier). For both men and women, psychiatric admission typically reflects a point of social transition or family crisis (Barnes et al., Reference Barnes, Bowl and Fisher1990) and all psychiatric crises are social crises (Bean, Reference Bean1980).

Thus, the incidence (first cases) of serious mental health problems is about the same in men and women, because both men and women are prey to social crises, but the point prevalence detained in services (cumulative cases) is not. This suggests greater caution in discharging men, who are more often assumed to be riskier than women. Also men under-report problems voluntarily in primary healthcare compared to women (Rogers and Pilgrim, Reference Rogers and Pilgrim2010). Most of the difference in prevalence of recorded mental disorder between the sexes is accounted for by the diagnosis of depression and anxiety disorders in primary care (i.e. the very settings in which coercion is absent, along with the absence therefore of the jurisdiction of bodies like the MHAC).

As was clear from the MHAC data, men, not women, are disproportionately regulated by involuntary psychiatric provision. Indeed, now at the harshest end of psychiatric control (high secure provision) female patients have virtually disappeared, following successful campaigning by professional and lay advocates. The other consideration about women (in both acute and secure detention) relates to greater risk taking by services to permit them to return to gendered roles (such as child rearing). This gendered risk-taking takes an actuarial trend (women on average are less dangerous in society than men) and turns it into a stereotype (all women are less dangerous than all men). Again this reflects a normative process: male risk is sequestrated and the latter is justified more often than female risk. Moreover, those differences in risky action are replayed in acute units themselves, where women are at greater risk than men of sexual harassment and assaults (Johnson et al., Reference Johnson, Bingham, Billings, Pilling, Morant, Bebbington, McNicholas, Dalton and 2004).

Thus, with these complex processes, related to risk assessment and management, being shaped by societal norms in ‘mental health services’, the principle of ‘patient-centredness’ is then rendered problematic. ‘Patient-centredness’, now at the top of the health policy agenda more widely, inherently focuses on voluntarism and mutually negotiated decision making between patients and professionals. Such an emphasis is on ‘expressed need’, whereas psychiatric decision making, backed up by legislative powers and expectations, requires an emphasis on ‘defined need’; it is an explicitly legitimised form of parens patriae. Logically and pragmatically, it is not, and cannot, be a negotiation between equal citizens. Accordingly, when a person becomes a psychiatric patient ‘expressed need’ is displaced by ‘defined need’, identified first in the lay arena and then rubber-stamped by professionals (Coulter, Reference Coulter1973). Psychiatric decision making and action are inherently normative and psychiatrists are inevitably (even if not knowingly) rule enforcers (Bean, Reference Bean1986).

The distribution displayed earlier about the age profile of those psychiatrically detained exemplifies this point. Note that epidemiological studies suggest that the greatest prevalence of mental health problems is in the very young and the very old (Rogers and Pilgrim, Reference Rogers and Pilgrim2003). And yet, when we look at the age distribution of those detained from the MHAC findings, we find that the most prevalent group are those of child-rearing and working age. Detention is roughly a bell-shaped curve in the MHAC data, but social epidemiology suggests that the prevalence of problems is a roughly a u-shaped life span distribution; apparently opposite trends. This picture about the age profile of detained inpatients suggests that the concerns of psychiatric professionals and legislators is about the exercise of power to regulate rule transgressions and role failure in an age cohort actuarially with fewer, not more, mental health problems overall (judged by life span prevalence data).

If ‘mental health services’ accurately and proportionately responded to the prevalence of problems across the life span, then we would expect resources to be devoted overwhelmingly to treating the very young and the very old. Instead, most of the cost of mental healthcare is absorbed by the containment and treatment of those exhibiting risky behaviour in young and middle adulthood (Knapp, Reference Knapp, Thornicroft and Szmukler2001). For example, statutory child and adolescent mental health services have been significantly under-resourced even though the community prevalence of mental health problems in childhood is estimated to be 50 per cent and the incidence of mental health problems, in this life phase presenting in primary care, is around 10 per cent (Ford et al., Reference Ford, Goodman and Meltzer2003; Meltzer et al., Reference Meltzer, Gatward, Goodman and Ford2003).

These socio-political patterns revealed by the MHAC report in relation to race, age and gender may, at least in part, obscure, but also hint at, a deeper social structural point. As noted already, in relation to Tudor-Hart's overall thesis and confirmed subsequently by 40 years of medical sociology, health status is strongly correlated with social class: the poorest in society are the sickest (Link and Phelan, Reference Link and Phelan1995). This is true for mental disorder as well as for physical illness.

Not surprisingly then, we find chronic psychiatric patients also dying younger both from both physical causes and suicide. For example, smoking rates are higher in psychiatric patients and they have poor general healthcare when living outside of hospital. They also have regular access to prescribed powerful psychotropic drugs (which can be dangerous in overdose) and they live in neighbourhoods with high crime rates and ready access to illicit drugs. This combination exposes poor patients living in poor community settings to high health risks and this leads to an increased rate of relapse compared to those in richer and less socially disorganised neighbourhoods (Silver et al., Reference Silver, Mulvey and Monahan1999; Soyka, Reference Soyka2000; Stockdale et al., Reference Stockdale, Wells, Tang, Belin, Zhang and Sherbourne2007; Padgett et al., Reference Padgett, Henwood, Abrams and Drake2008).

This underlying pattern of material deprivation associated with chronic mental health problems, might go some way to explain the racialised profile revealed by the MHAC data. As the latter confirm, people of African and African-Caribbean origin remain over-represented in compulsory care and under-represented in voluntary outpatient settings. This might suggest that lay and/or professional decision-making is racially biased. It could, alternatively suggest that these groups are actually more mentally disordered because of the pressures of racism. However, many other groups, such as those of South Asian origin, are also exposed to the chronic pressure of racism but they tend to be under-represented in inpatients settings or the findings on incidence and prevalence have been contradictory. Thus the data on BME communities is confusing, with neither hypothesis fully explaining the data on racially skewed psychiatric detention (Rogers and Pilgrim, Reference Rogers and Pilgrim2010).

Moreover, in the recent past a white group (Irish people) has also been over-represented in this regard in Great Britain. Their white skin might signal an interpretive problem with a direct thesis of the stress from racism, based on colour, and might suggest, instead, shifting socio-economic factors (Abbotts et al., Reference Abbotts, Williams and Ford2001; Leavey et al., Reference Leavey, Rozmovits, Ryan and King2007). This mixed picture about racialised patterns found in descriptive epidemiology remains, but most of it can be accounted for by underlying material inequalities (because, on average, BME communities are poorer and suffer greater social exclusion) (Nazroo and Williams, Reference Nazroo, Williams, Marmot and Wilkinson2005). As we noted above, people with severe and enduring mental health problems are disproportionately unemployed and live in poor and stressful neighbourhoods, with high rates of crime and substance misuse and low levels of social capital (Rosenfeld and Wenzel, Reference Rosenfeld and Wenzel1997; Pescosolido and Wright, Reference Pescosolido and Wright2004; Berry, Reference Berry2008).

In the case of BME patients, they relapse less often if they live in localities with higher rates of those from a similar origin (Velling et al., Reference Velling, Susser, van Os, Mackenbach, Selten and Hoek2008; Boydell et al., Reference Boydell, van Os, McKenzie, Allardyce, Goel, McCreadie and Murray2001). This important finding is more than a point about race, it also points up the protective functions of social bonds, which are not equally distributed in society. Thus, those in richer areas and ones with greater ‘ethnic density’ for the identified patient, the less likely they are to relapse and so be exposed to coercion and iatrogenic treatments. Those living in poor areas and/or who are ethnically isolated are more exposed to ‘ambient hazards’ (raised rates of crime and illicit drug use, poor social capital, dirt, noise, traffic dangers, etc.) when out of hospital and to coercion and iatrogenesis at admission, in the wake of the resulting raised risk of relapse, noted earlier (Hiday, Reference Hiday1995). This implies a vicious circle of the poor getting poorer and being disproportionately exposed to health risks both inside and outside of hospital; a cue for the next section.

‘Mental health services’ as a risk to wellbeing

Apart from this broad confirmation from the MHAC that some social groups are disproportionately controlled coercively by psychiatric professionals, there are other important implications of its final report. Such social patterning and the over-representation of some social groups and not others is not inherently a problem. Indeed, if psychiatric treatment was always benign, effective and given to all those requesting it voluntarily, then those expressing the need for help and support would get it. However it is not – hence the public and political concern since Victorian times about ‘unfair detention’.

Psychiatric care is certainly effective at controlling unwanted behaviour (using locks and tranquillisation), but is of debatable value in creating mental health gain for identified patients (Pilgrim and Vassilev, Reference Pilgrim and Vassilev2007). Much of this lack of effectiveness and progress about treatment is because of extensive iatrogenic effects offsetting symptom reduction. Iatrogenic effects are often misleadingly dubbed ‘side-effects’, implying their triviality when they are actually adverse or unwanted effects which may not be trivial in their consequences for patients. (The term iatrogenesis or ‘doctor made illness’ can be discussed in a wider social and cultural context of dependency on medical ministrations (Illich, Reference Illich1978). Here though the term is limited to the adverse clinical impact of treatment.)

Psychiatric treatments are life diminishing and occasionally life threatening, whether received voluntarily or under compulsion (Breggin, Reference Breggin1993; Fisher and Greenberg, Reference Fisher and Greenberg1997). Thus, if some social groups are subjected to disproportionate compulsion, then they are also being subjected disproportionately to enforced treatments that may actually do them harm or even kill them in entrapped conditions (Brown and Funk, Reference Brown and Funk1986; Kellam, Reference Kellam1987). It is little surprising then that sudden deaths in secure provision have disproportionately contained black men, given the cumulative findings reported by the MHAC about this group of patients and noted earlier.