This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
In the UK, people from diverse ethnic minority groups have poorer access to, experiences with, and outcomes from mental healthcare services, compared to White British people. A large review of the evidence explored how these ethnic inequalities are created and sustained in mental healthcare.
The authors call for culturally informed approaches to mental health assessment and treatment. Approaches need to recognise and respond to the everyday realities of people from diverse ethnic minority groups, including racism.
The review included 66 studies on ethnic minority groups’ and mental health professionals’ perceptions and experiences of mental health services. The studies explored barriers to accessing services, as well as experiences and outcomes. The researchers assessed how ethnic inequalities in mental healthcare are created and sustained, and how they could be overcome.
The review found that mental healthcare services often did not consider how racism, migration stress, and complex trauma affect mental health. Mental health professionals described barriers to providing person-centred care such as a lack of time, discomfort when talking about race and spirituality, and fear of calling out racist practice when it was witnessed. The researchers call for more personalised care, and consideration of the complex interplay between social and economic circumstances, and systemic racism.
More than half of the studies analysed were published before 2013. Mental healthcare services may have become more aware of these issues since then. However, existing research indicates that there has been little progress in tackling ethnic inequalities over the past 50 years. This may be because of systemic racism and an overly ‘medical’ culture that prioritises diagnosis and drug treatments.
More information about mental health services is available on the NHS website.
The issue: why is there ethnic inequality in mental healthcare?
In the UK, people from ethnic minority groups have worse mental health, and poorer access to mental healthcare, than White British people. People from ethnic minority groups are more likely to have undiagnosed mental health difficulties and follow involuntary pathways into care. This could be through the criminal justice system, or in crisis situations. Overall, outcomes of mental health care are worse for people from ethnic minority groups.
These inequalities have been known for more than 50 years. Progress in addressing this issue has been slow, despite many policy initiatives. The perspectives of service users, carers, and mental health professionals, among others, are needed to inform new and effective approaches.
This study explored why more people from ethnic minority groups come into services through crisis pathways and present less often to primary care, compared to the white British ethnic group. The researchers explored how ethnic inequalities in mental healthcare are created and sustained, and how these issues could be overcome.
What’s new?
The review included 66 studies of the perceptions and experiences of people from a diverse range of ethnic minority groups in relation to mental healthcare services. An ethnically diverse advisory group of people with lived experience of providing and receiving mental healthcare provided input on research questions, data analysis, and the dissemination of findings.
The review found that people from ethnic minority groups:
- experienced services as predominantly white and structurally racist (for example, in terms of leadership and knowledge systems)
- wanted care that was less ‘medical’ (focused only on diagnosis and prescription of medicines, for instance)
- wanted a ‘whole person’ approach to assessment and treatment that takes into account relevant social, psychological, spiritual, and economic factors (including racism, trauma and migration stress); people felt these issues were too often ignored.
It found that mental health services:
- often did not recognise how experiences of racism create social and economic disadvantage and how these factors combine to make people’s mental health worse
- were sometimes unwilling to engage with people’s spiritual needs to help resolve their mental health issues; some feared that attention to religion would be seen as ‘unscientific’ by their peers and others said they lacked the time to explore these issues during assessments
- confused people’s racial, cultural and spiritual presentation with illness, leading to misdiagnosis and more severe treatment (including coercive treatment).
Generally, people’s experiences of racism and exclusion in society and within mental health services led them to distrust services. The lack of a person-centred approach and the lack of progress in tackling racism increased mistrust for some. Many people did not seek help because they did not perceive any benefit, or thought that any benefits would be outweighed by the risks. They thought that poor person-centered care and racist discrimination could lead to misdiagnosis and make their mental health worse.
Why is this important?
The lived experiences of people from ethnic minority groups need to be taken into account to deliver safe and person-centred care that is equal for all. This includes considering how personal experiences of racism and migration affect mental health during assessment and treatment; current approaches may re-enact people’s experiences of racism and exclusion. This review found that meaningful change will require radical shifts in the way medical training and services are designed and delivered.
Strategies to tackle ethnic inequalities in mental healthcare should be informed by people from ethnic minority groups. Strategies need more emphasis on personalised care, and the complex racial, social and economic factors that influence mental health. The researchers recommend exploration of institutional barriers to equitable care.
More than half of the studies analysed were published before 2013. Mental health services may have become more sensitive to these issues since the publication dates, but research suggests that there has been little progress over the past 50 years.
What’s next?
The researchers are working with the Bristol Integrated Care Board and the Southwest London & St George’s Mental Health NHS Trust to improve services for people from ethnic minority groups.
They recommend that mental health services:
- overcome practical barriers to access by creating non-stigmatising wellbeing centres, staffed by local people; increase availability of interpreters in all settings to cover the range of languages spoken
- address fears and concerns by addressing institutional racism and running community and workplace initiatives to tackle racism and empower people from ethnic minority groups; build and support authentic and effective partnerships with existing culturally-sensitive community mental health organisations
- improve people’s experiences through quicker access to culturally-appropriate services including talking therapies and wellbeing activities (yoga, for example), access to quality green spaces, creative activities and art therapy; reduce coercion and increase consensual care
- increase the numbers of ethnic minority staff in leadership and senior management roles
- train clinicians and trainees on providing person-centred care for people from diverse ethnic groups, and on how to detect, report and tackle racist practice.
You may be interested to read
This Alerts is based on: Bansal N, and others. Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography. PLOS Medicine 2022; 19: e1004139.
Guidance for GPs about improving mental healthcare for people of colour published in British Journal of General Practice Life.
Information on mental health for people from ethnic minority groups from the Mental Health Foundation.
Funding: The study was funded by the NIHR Research for Patient Benefit Programme.
Conflicts of Interest: The authors had no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
