Response

Fonseca Freitas et al's^{Reference Fonseca Freitas, Walker, Nyikavaranda, Downs, Patel and Khondoker1} study of care before first admission is of major importance and undermines the proposed new Mental Health Act. South London and Maudsley (SLAM) can be congratulated on its data collection, which all trusts should provide. However, there is lack of contextual information and unlikely interpretations.

The population is highly unusual, experiencing probable area × ethnicity syndemic effects.^{Reference Coid, Gonzalez Rodriguez, Kallis, Zhang, Bhui and De Stavola2} The giveaway is remarkably high involuntary admission rates for Asian Chinese people. National Health Service (NHS) Digital statistics consistently show they have lowest rates nationally, lower than for White people. London boroughs of Lambeth (SLAM) and Hackney (East London) similarly have the highest concentrations of people of African and Caribbean heritage in the UK. These catchment areas have shown the highest incidence rates of psychosis ever recorded in the literature. But perhaps the major contextual issue is that SLAM has among the highest rates of compulsory admissions of any UK NHS trust.³

Why might this be?

Black patients with psychosis have the worst long-term outcomes in terms of social disadvantage and isolation, more hospital admissions, with more compulsory admissions and admissions involving the police.^{Reference Morgan, Fearon, Lappin, Heslin, Donoghue and Lomas4} They need much better treatment than they are currently getting. Perhaps they already get the best available nationally in SLAM. Or perhaps they simply get more treatments that do not work – as strongly suggested by this paper – leading to more admissions. Paradoxically, the more frequently patients received home treatment and early intervention, the more likely they were compulsorily admitted.^{Reference Fonseca Freitas, Walker, Nyikavaranda, Downs, Patel and Khondoker1} Could this mean SLAM community and early intervention services substantially fail in their purpose to prevent admissions?

As for the authors’ recommendations for more talking treatments, all clinicians know these do not work until the patient first gets better on medication and becomes well enough to cooperate.

The rationale behind the new Act includes making it more difficult to compulsorily admit patients in crisis (especially Black patients). Will all their symptoms somehow go away after the Act so they no longer warrant detention? The Act seems an attempt to legislate against psychosis through a raft of endless bureaucratic procedures, including advocates matched according to patient ethnicity, which challenge and delay mental health professionals’ decision-making in emergencies.

One cited possible reason for the new Act is that compulsory admissions have risen because of racism. However, if SLAM sections more Black patients than most other UK trusts, this does not mean it is more racist, simply that it is struggling with a catchment area population with more risk factors for severe mental illness.

An alternative possibility, not considered by the authors, is that the study describes a service doing the best it can with a highly atypical UK population, showing multi-morbidity, syndemics,^{Reference Coid, Gonzalez Rodriguez, Kallis, Zhang, Bhui and De Stavola2} with unusually high rates of psychosis, corresponding to high levels of inner-urban deprivation. The study is important in re-evaluating service effectiveness. Sadly, it also suggests SLAM could have insufficient beds for its population. This needs urgent investigation. It may also be adhering to overly community-orientated models, unable to prevent deterioration despite numerous community consultations. If so, this corresponds to the national tsunami of compulsory admissions across other trusts, occurring long after the point when a voluntary admission might have been helpful to the patient.