Ethnic inequalities in recovery from severe mental illness - a mixed methods study

"Background Severe Mental Illness (SMI), such as schizophrenia and bipolar disorder, affects around 1% of the population but has a disproportionate impact in terms of overall disease burden.

SMI also has a disproportional effect on ethnic minorities with reviews showing up to 3 times increased incidence overall and for some groups, such as UK Black Caribbean and Black African populations, 4-6 times higher rates (1).

Historically SMI has been described as following a chronic deteriorating course; a view largely discounted in recent decades with studies promoting recovery as a viable outcome for many.

The original proponents of a "recovery model" emphasised the importance of social factors, moving away from the prevailing biomedical model.

Despite this, while there has been a wealth of research into social factors and illness onset, most of the literature is "strangely silent" (2) about socio-structural inequalities in recovery.

This shortfall is particularly noticeable in ethnicity studies with ethnic inequalities in SMI aetiology having received considerable research attention (1) but rarely addressed in terms of recovery (2) .

Research points to specific factors implicated in ethnic inequalities in incidence, including: substance use, the experience of migration, acculturation, limited social support and social isolation, neighbourhood ethnic density, social adversity and discrimination (1); which may also be implicated in recovery.

Other relevant factors may be higher rates of coercive treatment, associated with poor recovery (3) and reduced access to talking treatments.

Aims This mixed methods study therefore has two aims: firstly, to compare recovery rates for different ethnic minority groups and how these relate to the above factors using information available in routinely collected data; secondly, to investigate in detail how ethnicity shapes the experience of recovery through in-depth interviews with relevant stakeholders.

Methods A mixed methods approach is proposed because of the complex social factors involved and because recovery is a contested term and cannot be easily encapsulated using quantitative data alone.

The CASE partner for this project, Rethink Mental Illness, are a large mental health charity (currently 22,660 clients) with a strong commitment to tackling ethnic inequalities in SMI.

They currently have an interest in developing measures to assess recovery for their clients and plan to role these out over the next year.

The project will work with Rethink in two ways: firstly, Rethink will provide detailed data on clients' recovery status using these measures alongside information collected about clients' social circumstances.

Secondly, Rethink will draw on their client base to help recruit ethnic minority service users with SMI for semi-structured interviews.

Alongside this will be interviews with Rethink staff, with ethnically diverse caseloads, investigating their views on the relation between ethnicity and recovery.

To complement the quantitative analysis the study will also include an analysis of the Clinical Record Interactive Search (CRIS) case register - providing de-identified electronic health records for all patients using secondary mental health services in South London.

This will look at ethnic differences in discharge from services alongside routinely collected recovery related measures.

QUANTITATIVE COMPONENT The study will begin with an analysis of CRIS data (comprising >300,000 de-identified electronic health records) covering all patients using secondary mental healthcare in the South London and Maudsley (SLaM) NHS Trust.

A cohort will be created of a range of ethnic groups with SMI followed from first diagnosis until discharge, death or move out of the borough - also incorporating recovery related outcomes such as Health of the Nation Outcome Scale (HoNOS) scores. Additional measures such as deprivation, age, sex, marital status, migration and housing status, and treatment