Mental health problems are incredibly common, can affect anyone and have a profound impact; not just on individuals and their families, but on wider society as well.

Mental health difficulties begin early in life, with three-quarters of disorders being established by the age of 24 (Kessler et al., 2005). Early intervention is crucial as it predicts better prognosis, and the earlier young people receive the treatment, the better their outcomes.

However, alarmingly, only one in five young individuals with a diagnosable difficulty access mental health services in the United Kingdom (Green et al., 2005) and a recent study by Edbrooke-Childs and Patalay (2019) has suggested that there could be ethnic differences in how young people access and get referred to those services.

Methods

The authors analysed national, routinely collected data from 14,588 young individuals accessing mental health services in the United Kingdom. The data was provided by 74 representative services covering 60% of the population of young people in England. Young individuals aged below 25 with complete case characteristics were included in the analysis given they had no missing data on key demographic characteristics, such as age, sex and ethnicity. The final sample was 54% female, 64% White British, with a mean age 12.28 (SD = 3.75).

Ethnic differences in youth mental health referral routes were explored with multilevel multinomial logistic regressions. Researchers accounted for the fact that data are nested within services, as well as controlled for age, sex, problem type, and contextual factors. Additionally, a sensitivity analysis was conducted to explore whether ethnic differences in referral route were attenuated when adjusting for area-level socioeconomic deprivation.

Results

Multilevel multinomial regression analyses suggested that ethnicity is strongly associated with routes of referral:

• Compared to White British peers, White non-British young individuals were more likely to be referred through social care/youth justice than through primary care (OR = 1.61, 95% CI: 1.06 to 2.46).
• In comparison to White British, young individuals with Black (OR = 2.90, 95% CI: 2.07 to 4.06) or mixed (OR = 2.66, 95% CI: 1.91 to 3.72) heritage were more than twice as likely to be referred through social care/youth justice relative to primary care.
• Similarly, young individuals of Asian descent were also more likely to be referred through social care/youth justice than through primary care (OR = 1.85, 95% CI: 1.34 to 2.54).
• Individuals from other or unstated ethnic minorities were less likely to be referred through education, child health, mental health services, social care/youth justice and by themselves relative to primary care, in comparison to their White British peers.

However, after accounting for the service area of deprivation in further sensitivity analysis, the authors found that the effect of being from the non-British White background on social care/youth justice became non-significant, while effects of minority ethnic backgrounds on the same referral route became smaller. Similarly, associations between being of Black heritage and mental health, and being Black or from an unstated ethnic background and other referral routes, were no longer significant.

Conclusion

Consistent with the literature, there are ethnic differences in mental health service utilisation. This study found that compared to White British peers, young people from ethnic minorities are less likely to enter the mental health system through referral by primary care. This difference is important, as while primary care referral implies voluntary help-seeking, social care or youth justice represents a more compulsory admission. Additionally, attenuation of some effects by the inclusion of socioeconomic deprivation measure in their analysis suggested that socioeconomic status may play an important role in the association between ethnicity and referral routes to mental health services.

Strengths and limitations

• This study was the first to examine ethnic differences in youth mental health referral routes while accounting for service-level variation and controlling for multiple factors known to be related to the type of mental health problem, help-seeking behaviour and service provision: deprivation, age, sex, type of problem, and contextual factors
• However, the data were collected from one country only and thus, the findings may not be generalisable to other countries, especially with a different system of referral in mental healthcare
• Also, even though the authors have accounted for area-level socioeconomic deprivation, the individual-level indicators of socioeconomic disadvantage (e.g. family income, child eligibility for free school meals and state aid, etc.) were unavailable for the study. Therefore, the less precise measure of socioeconomic status might have inflated some of the ethnicity effects
• Even though the data came from representative services, the services from the most deprived areas were likely to be underrepresented: no services included were classified in the highest band of deprivation

Implications for practice

In consideration that 60% of the population in England is made up of young people aged 25 years or less, their well-being should be of high priority to the national health services. However, the current study revealed that only 20% of those were referred to in the first place, whereas the remaining 80% were not.

Despite the need for further research to replicate findings from the current research, this study might imply the need for revision of policy regarding access to care to mental health services. This might be directed national health services and/or government policymakers, where more focus should be placed on services in socio-economically deprived areas. Before discovering the exact causes of such ethnic differences in youth referral routes, the current study might also be an alarming pointer for schools. More resources should be implemented into schools to inform youths of the importance of seeking help early, routes available, as well as early detection of high-risk individuals.

Contributors

Thanks to the UCL Mental Health MSc students who wrote this blog: Aleksandra Paksina (@a_paksina) Alice O’Mahony, Franca Onyeama, Hin Ching Koey Tin, Maitri Khurana, Natalia Chemas Lopez, Nora Bahhar, Sedigheh Zabihi, Tabs Craston (@CrastonTabs) and Terry Lau.

Conflicts of interest

None.

UCL MSc in Mental Health Studies

This blog has been written by a group of students on the Clinical Mental Health Sciences MSc at University College London. A full list of blogs by UCL MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.

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Links

Primary paper

Edbrooke-Childs J, Patalay P. (2019) Ethnic Differences in Referral Routes to Youth Mental Health Services. Journal of the American Academy of Child & Adolescent Psychiatry, 58(3), 368-375. [PubMed abstract]

Other references

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.

McGinnity, Á., Meltzer, H., Ford, T., & Goodman, R. (2005). Mental Health of Children and Young People in Great Britain, 2004. H. Green (Ed.). Basingstoke: Palgrave Macmillan.

Photo credits

• Photo by Naassom Azevedo on Unsplash
• Photo by Huy Phan from Pexels
• Photo by Markus Spiske on Unsplash
• Photo by The Human Rights Campaign