Dear Editor,
News:-
Strengthen mental health bill to tackle “inexcusable” failures on racial inequality, says scrutiny committee
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p150 (Published 19 January 2023)
Cite this as: BMJ 2023;380:p150
The joint committee on the draft mental health bill will need to take evidence from clinicians currently working in this area, using the existing MHA, and struggling with severe mental illness in populations including ethnic minorities. Often, what is needed goes against common sense.
For example, it is not psychiatrists who are racist, but the whole of our society that remains so. The enduring finding of a six times higher finding of schizophrenia in Afro-Caribbean populations has been repeatedly replicated. This is partly due to the influence of being brought up in the competitive environment of cities, but also due to repeated micro-aggressions of racial abuse throughout life.
Minorities are more likely to live in poor areas, and to be more exposed to exploitative drug dealers. The King’s College study (1) of the influence of skunk (cannabis plants specially bred for a high content of tetrahydrocannabinol, some with less of the calming cannabidiol (CBD) of older herbal cannabis), reveals both a higher incidence and prevalence of schizophrenia in daily users. For many, this is not a series of brief drug-induced psychoses, but the initiation of a life-long schizophrenic illness. In the US, substance use disorders are called ‘the diseases of despair’.
Current substance use, a comorbid personality disorder, and failure to attend for follow-up, as well as recent discharge from services, are predictive of non-compliance with medication, ending in serious breakdown, with possible violence to others. However, we must remember that people suffering from schizophrenia are more likely to be the victims of violence.
Assertive outreach teams should be active in every district, and be prepared to care for patients at high risk of recurrence over a timescale of years, not just discharging them to the care of over-burdened GP’s. Such teams need to be aware of cultural inflences affecting minorities, and preferably have minority members.
People suffering from schizophrenia tend to suffer repeated illnesses, with a risk of further cognitive deterioration, not to mention alienation from their families, and society as a whole.
Such people die 10-20 years younger than the general population, much more than a 10 year loss from smoking. A recent review (2) has shown that anti-psychotic medications (‘remain a cornerstone in treatment guidelines worldwide’) reduce premature deaths (including suicide) by a factor of more than two, especially in younger patients. Which leads on to Community Treatment Orders, which allow prolonged community treatment and supervision, subject to recall to hospital, before serious deterioration has taken place. Early recall preserves patients’ dignity, as the Police are less likely to be called to assist the patients into hospital. Both the Percy Commission of 1956, and the subsequent MHA 1959, tried to make compulsory detention a medical matter, not a criminal one.
These Orders are a humane way of dealing with patients who do not regain sufficient insight as to be able to comply with medication and other treatments, including psychological and psychosocial ones.
If the Committee feels these are of little effect, they should be reminded that all detained patients are encouraged to appeal to a Mental Health Review Tribunal, headed by a lawyer, which has to be convinced that sufficient risks exist to justify continuation. If CTO’S are ineffective, then most appeals should be successful, something that would be shown by a perusal of hospital records.
As doctors, our primary duty is to save lives, and anything that improves continuing treatment, including medication, is likely to do just that.
1. Marta D. Forti, et al, Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis:
a case-control study. The Lancet Psychiatry VOLUME 2, ISSUE 3, P233-238, MARCH 2015
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00117-5/fulltext
DOI:https://doi.org/10.1016/S2215-0366(14)00117-5
2. Maria F Stromme, et al. Mortality and non-use of antipsychotic drugs after acute admission in schizophrenia: A prospective total-cohort study. Schizophrenia Research Volume 235, September 2021, Pages 29-35
https://www.sciencedirect.com/science/article/pii/S0920996421002620#bb0185
DOI:https://doi.org/10.1016/j.schres.2021.07.009
Yours sincerely,
Gareth Jones, MRCP, FRCPsych, retired psychiatrist.
Bryn Capel, Rudry, CAERFFILI CF83 3DF.
07950 366 876, 02920 883847. gareth.jones1k@doctors,org.uk
Re: Strengthen mental health bill to tackle “inexcusable” failures on racial inequality, says scrutiny committee