From the Editor
Discrimination. Microaggression. Stigma. Patients in ethnic groups often face greater challenges and stresses than others. Do suicide rates differ? What are the implications for interventions?
These are good and important questions, yet the literature is thin. In a new paper for The Lancet Psychiatry, Isabelle M. Hunt (of the University of Manchester) and her co-authors consider suicide rates by ethnic group in the UK, focused on those who have had contact with mental health care. Drawing on a large database, they find lower rates of suicide completions compared to White patients, but significant variation among the different groups. The authors see potential clinical implications: “Clinicians and the services in which they work should be aware of the common and distinct social and clinical needs of minority ethnic patients with mental illness.”
The Death of Socrates – and, yes, White patients died by suicide more
In the second selection, Dr. Anees Bahji (of the University of Calgary) and his co-authors consider cannabis use disorder in a patient who presents with cannabis hyperemesis syndrome. Their JAMA Internal Medicine paper is very practical; they suggest: “a multidisciplinary approach that incorporates psychotherapy, withdrawal symptom management, and close follow-up in the primary care setting is recommended for treatment of cannabis-related harms.”
Selection 1: “Suicide rates by ethnic group among patients in contact with mental health services: an observational cohort study in England and Wales”
Isabelle M. Hunt, Nicola Richards, Kamaldeep Bhui, et al.
The Lancet Psychiatry, December 2021
In the UK, there has been a recent rise in deaths by suicide and the rate recorded in 2018 was 11.2 deaths per 100 000 population. Suicide prevention remains a top priority for the UK, reflected by national commitment to make suicide prevention a priority over the next decade, supported by a minimum additional spend on mental health of £2.3 billion annually in the coming years…
According to the 2011 census, the minority ethnic population in England and Wales was 14% in 20113 and is estimated to rise to 28% by 2031. UK studies have shown higher rates of psychosis among Black people and depressive illness among South Asian populations. However, there is considerable evidence that health inequalities exist for minority ethnic people in relation to mental health care, not only in accessing services but also in higher rates of coercive psychiatric treatment…
With regard to suicide, there are few large-scale studies on ethnicity to inform policy and practice; furthermore, ethnicity is not routinely recorded on national death registrations in England and Wales. However, accounting for ethnicity in suicide to ensure prevention is tailored to individual needs is important. Studies done on psychiatric populations have found lower suicide mortality ratios in Black Caribbean people with severe mental illness than in White British people. By contrast, a previous study showed higher suicide rates among young male psychiatric patients of Black Caribbean and Black African origin, and among South Asian, Black African, and Black Caribbean women aged 25–39 years than in White patients. Despite higher suicide rates in certain groups, Bhui and colleagues found common clinical suicide risk indicators such as suicide ideation and depressive symptoms, and clinician’s perceptions of suicide risk, were less evident among minority ethnic psychiatric in-patients who died by suicide than in White in-patients. However, risk factors for suicide such as unemployment, previous violence, and non-adherence with medication were more prevalent among minority ethnic patients who die by suicide than in White patients…
In this study, we examined suicide rates in a clinical sample of minority ethnic individuals and, for the first time, used both general population and mental health service use denominators to begin to investigate the effects of differential help-seeking. Our additional aims were to investigate trends in suicide and to describe clinical characteristics of patients who died by suicide with a particular emphasis on the management they received.
So begins a paper by Hunt et al.
Here’s what they did:
- “We did a retrospective observational cohort study on a national case-series of patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2007 and 2018.”
- Data was drawn from the National Confidential Inquiry into Suicide and Safety in Mental Health.
- They considered suicide rates and calculated the standardized mortality ratios (SMRs) for South Asian (Indian, Pakistani, and Bangladeshi), Black African, Black Caribbean, Chinese, and White patients.
- Statistical analyses were done.
Here’s what they found:
- 698 patients were from four minority groups.
- Demographics. Patients tended to be male (69%) and, on average, 41 years of age.
- “Rates and SMRs for suicide among minority ethnic patients were lower than for White patients (2.73 deaths…) per 100 000 population.” See figure below.
- “Differences were found between ethnic groups with higher suicide rates in Black Caribbean patients (1.89 deaths… per 100 000 population) and lower rates in South Asian patients (1.49 deaths… per 100 000 population).” (!!)
- Rates. There was an increase for White patients (years 2007 to 2012), followed by a decline. In contrast, ethnic groups were unchanged in rates.
- Methods. “Among minority ethnic patients overall, hanging or strangulation (43%) and jumping from a height or in front of a moving vehicle (24%) were the most common methods of suicide.” However, violent methods were less common among White patients.
- Diagnoses. “Schizophrenia was more common among Black African patients (54%) and Black Caribbean patients (44%), while affective disorder was more common among South Asian patients (41%).”
- Socioeconomics. “Fewer minority ethnic patients lived alone but more lived in unstable housing (eg, local authority accommodation) or in areas with the highest deprivation score than did White patients…”
“We found that overall suicide rates using both general population and service-contact denominators were lower for minority ethnic patients than for White patients. However, there was variation within the minority ethnic patient groups, with comparatively higher rates seen in Black Caribbean patients and lower rates in South Asian patients.”
A few thoughts:
- This is a good paper.
- The study is also quite unique – so little work has been done in this area.
- A quick summary: rates varied widely.
- Are there practical implications? The authors argue that there are:
“The important social and clinical differences we found between minority ethnic groups highlights that the one size fits all approach by mental health services might not be fit for purpose. Care needs to be better tailored to meet the needs of individual minority ethnic patients and approaches to prevention should not treat minority ethnic patients as homogenous groups. Ensuring substance misuse services are available, culturally competent, and integrated with wider mental health services could also improve outcomes.”
- Like all papers, there are limitations. The authors note several problems around the quality of data itself. For example, in the UK, ethnicity isn’t recorded by coroners; data is drawn from hospital records.
- In an editorial, “The role of racial and ethnic disparities in understanding risks of suicide,” Phoebe Barnett (of the University College London) writes:
“This variation between ethnic groups demonstrates that patients from different cultural backgrounds might experience different stressors or levels of support such that the effect of the cultural context on mental health problems or the experience of care can vary considerably. Lower suicide rates in South Asian patients, as the authors suggest, could in part stem from the increased rates of schizophrenia reported among the Black Caribbean and Black African patients. However, understanding how factors such as social adversity might interact with such potential risk factors to influence the experience of mental health conditions is important. For example, although the prevalence of schizophrenia is frequently reported as higher among Black African and Black Caribbean groups, considering this as a singular driver of outcomes such as death by suicide or compulsory detention ignores the complexity of social factors associated with minority group membership, which can contribute to the onset of mental health conditions as well as negative experiences within and external to mental health services. Hunt and colleagues’ study is strengthened by the exploration of some of these factors – the authors report that minority ethnic groups are characterised by more markers of social adversity such as deprivation and unemployment than are White people. A smaller percentage of South Asians were in the most deprived quintile than were Black African or Black Caribbean patients, which provides one possible explanation for the lower rates of suicide reported in this group.”
The full Lancet Psychiatry paper can be found here:
Selection 2: “Considering Cannabis Use in Differential Diagnosis: A Teachable Moment”
Anees Bahji, Thomas D. Brothers, Marlon Danilewitz
JAMA Internal Medicine, 29 November 2021 Online First
A young adult presented to the emergency department (ED) for the fourth time in 6 months with intermittent abdominal pain, nausea, and vomiting. During previous visits, cannabis use history was not obtained, and after undergoing a basic medical examination and receiving supportive treatment, the patient had been discharged without a diagnosis.
During the fourth ED presentation, the patient reported daily cannabis use, smoking approximately 8 to 10 joints per day, in addition to 1 to 2 alcoholic drinks per week; other substances use was denied. During the past month, the patient had begun taking hot showers of 40 minutes or longer duration to relieve abdominal symptoms. The patient’s medical and psychiatric histories were otherwise unremarkable. A physical examination revealed tachycardia, elevated blood pressure, and diffuse abdominal tenderness. Results of a noncontrast computed tomography scan of the abdomen were normal. Results of a urine drug screening were positive only for cannabis metabolites. The patient received intravenous fluids, diclofenac, and ondansetron in the ED.
Following admission to the internal medicine ward, the patient received a working diagnosis of cannabis hyperemesis syndrome. The internal medicine team consulted with the psychiatry service regarding the cannabis use.
So begins a paper by Bahji et al.
They make a few points about cannabis and cannabis withdrawal:
- “The number of cannabis-related ED presentations has been increasing since 2015.”
- “Cannabis withdrawal syndrome involves 3 of the following symptoms within 7 days of reducing cannabis use: aggression, anxiety, sleep or appetite disturbance, depression, headache, sweating, nausea, and vomiting.”
- “Approximately 47% of people with cannabis use disorders experience withdrawal symptoms when reducing cannabis use.”
The authors note the patient’s history of cannabis use: increasing use over three years, and frequent withdrawal symptoms when not using. Unfortunately, the patient turned to “progressively more cannabis, which became associated with worsening abdominal pain, nausea, and vomiting.”
In terms of treatment for cannabis hyperemesis: “Hot showers and as-needed medications provide only symptomatic relief for cannabis hyperemesis and withdrawal symptoms… Pharmacotherapy may alleviate the symptoms of cannabis withdrawal, which can last for months. For example, withdrawal symptoms such as anxiety, depression, and insomnia may be managed with targeted pharmacotherapy (eg, selective serotonin reuptake inhibitors) or short-term use of mild anxiolytics (eg, hydroxyzine).”
The authors write: “Patient education is essential, especially emphasizing that withdrawal symptoms may persist for several days to weeks and can be managed in an outpatient setting. When clinicians identify a patient with cannabis hyperemesis or withdrawal or cannabis use disorder, they should first explain to the patient that their symptoms are related to cannabis use and then elicit the patient’s motivation for cutting down on or abstaining from cannabis use.” They also note the role of motivational interviewing.
A few thoughts:
- This is a concise and highly readable paper.
- With increased substance use over the pandemic, this paper is very timely.
- Besides taking a history, is there a way of better understanding cannabis use – and possible use disorder? The authors suggest using the Cannabis Use Disorders Identification Test, noting that the scale is “an 8-item self-reported tool with 91% sensitivity and 90% specificity.”
- Motivational interviewing is helpful for such patients, of course. A past Reading considered a podcast with Dr. Leslie Buckley (of the University of Toronto) on the topic: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-better-ptsd-symptom-control-less-diabetes-jama-psych-also-buckley-on-cannabis-quick-takes-and-the-life-of-kajender-globe/
- For those who like this paper, JAMA Internal Medicine regularly publishes “teachable moment” papers. “Addressing Biased Patient Behavior” was thoughtful: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2784798
The full JAMA Internal Medicine paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.