Individuals from different cultures have different patterns of mental illness. ^{Reference Littlewood1–Reference Littlewood and Lipsedge2} Several studies have reported a higher prevalence of severe mental illness, especially schizophrenia, among Black Caribbean people in Britain compared with the White population. ^{Reference Erbington, Hurry, Pennant, Sturt and Wing3–Reference Audini and Lelliot7} Other studies reported disproportionate rates for compulsory admissions under both civil and forensic sections of the Mental Health Act 1983 (England and Wales) for Black Caribbean individuals, particularly young men. ^{Reference Harrison, Owens, Halton, Milson and Bhud8–Reference Szmukler, Bird and Button10} Black Caribbean individuals seem more likely to have contact with the police and forensic services, ^{Reference Moodley and Thornicroft11} to be treated in locked facilities ^{Reference McGovern and Cope12} and to have had a criminal conviction if they are young and male. ^{Reference Wessely, Castle, Douglas and Taylor13} Traumatic feelings arising from detention and coercion experienced by service users and carers may be exacerbated by these inequalities and probably cause mistrust and resistance to intervention, with delayed help-seeking and the necessity for further coercion. ^{Reference Singh and Burns14–Reference Singh, Greenwood, White and Churchill16}

One of the most significant changes brought forward in the Mental Health Act 1983 was enhancing individuals’ civil rights. For example, appeal against detention was encouraged. There are two types of appeal, the mental health review tribunal (MHRT) and the (hospital) managers appeal (HMA). The MHRT is run by a department of the Lord Chancellors Office. The panel consists of a medical member, a legal member who chairs the panel and a lay member. The HMA is a hearing that includes non-executive members of the trust board who have received appropriate training. Hospital managers are not obliged to hold a hearing each time an appeal is received. As a matter of good practice, individuals should receive application forms for the two different types of appeal along with their ‘section papers’ and rights (admission pack). There are restrictions on the number of MHRT appeals that can be made during any one period of detention.

A previous study showed the rate of discharge from section after appeal to be 15%. ^{Reference Crimlisk and Phelan17} In another study, O’Dwyer & Neville looked at a series of 400 people detained under section 2. They found an appeal rate of 9% of eligible individuals; 16% of appellants were successful. ^{Reference O'Dwyer and Neville18} In this study we explored the association between ethnicity and rates and outcome of appeal against detention under the Mental Health Act 1983.

Method

This study had the approval of the local research ethics committee. We conducted a retrospective survey of all people detained under civil or forensic sections in a large mental health unit (110 beds) in north-west London over a 1-year period. We included all people who where detained in hospital or had their sections renewed during this period. We excluded people who were admitted under sections that had no right of appeal.

We used the computerised patient administration system to search for all admissions to the unit under the Mental Health Act 1983 during the study period, and also we requested a list of individuals who appealed against section and the outcome of their appeals from the Mental Health Act coordinator. People's self-defined ethnicity (as classified by the UK census) was recorded. Data were analysed by using Statistical Package for Social Sciences (SPSS) version 15 for Windows.

For the purposes of analysis we condensed ethnicity data by combining Asians (Indian, Pakistani, Bangladeshi, Asian other and Arab) together and adding all other groups including mixed ethnicity together as ‘others’.

Results

During the study period, 462 individuals were admitted under civil and forensic sections (270 male, 192 female): 191 under section 2 (28-day order); 220 under section 3 (6-month order; 30 of these were renewed for 6 months or 1 year); and 51 were under various forensic sections.

Two hundred and thirty-two (50.2%) of these people appealed against their section (147 (54.4%) male, 85 (44.2%) female). For those detained under section 2, 51 appealed to the MHRT and 4 to the hospital managers; for those under section 3, 117 appealed to the MHRT and 43 to hospital managers. Sixteen appealed against forensic sections.

Only 4 (2%) people were successful in their appeals (1 White British, 1 Asian, 1 other ethnic group and 1 White other). Further data are shown in Table 1. Compared with White British individuals there were significantly more appeals from Black Caribbean people (Yates’ corrected χ² = 11.9, d.f. = 1, P = 0.0001) and White Irish people (Yates’ corrected χ² = 7.6, d.f. = 1, P = 0.01). No significant differences emerged comparing White British with Black African or Asian people.

Table 1. Number (%) of appeals against detention in different ethnic groups (total n = 462)

	n (%)
	Black British Caribbean	Black British African	White British	White Irish	White others	Asian	Others
Detained	112	63	92	31	15	81	68
Appealed	71 (63)	22 (35)	36 (39)	21 (68)	1 (7)	42 (52)	39 (57)
Not discharged	31 (44)	5 (23)	11 (31)	8 (38)	0 (0)	19 (45)	11 (28)
Section discharged before appeal	24 (34)	15 (68)	16 (44)	12 (57)	1 (100)	14 (33)	13 (33)
Other outcomea	16 (22)	2 (9)	9 (25)	1 (5)	0 (0)	9 (22)	15 (39)

Discussion

Our study found that overall, 50% of individuals appealed against detention with 29% appealing against section 2. The success rate of appeal was 2%. This contrasts with the findings of O’Dwyer & Neville who reported that 9% appealed against section 2, of whom 17% were successful. ^{Reference O'Dwyer and Neville18} The increase in appeals found in our study may reflect changing attitudes to appeals by individuals and clinicians, greater understanding of the appeals process or awareness of rights by individuals, carers and advocates. Most people appealed only to the MHRT – we were struck by the relative paucity of appeals to hospital managers, especially for those detained under section 2.

Although the rates of appeal have increased, the success rate appears to have fallen. This may be as a result of a less liberal approach by both the MHRT and HMA tribunals, but another explanation is that many people are appealing (or being encouraged to appeal) when the chance of a successful appeal is unrealistic. We have observed solicitors and advocates canvassing individuals to submit an appeal which raises questions about the balance between a person's rights to treatment and rights to freedom. Where coercion may operate (for example in encouraging an appeal) this balance is distorted – not in itself a problem if no harm results. However, given that appeals are expensive and often confrontational and counter-therapeutic (patient and consultant are pitched against each other in an adversarial and legalistic milieu neither feels comfortable with) perhaps it is time to overhaul the appeals process. The new Mental Health Act 2007 has not substantially changed the appeals system.

We found substantial differences in the appeal rates between different ethnic groups, with White British and Black African groups appealing less frequently than other major ethnic groups. Several explanations are possible here. It may be because of different attitudes to detention by individuals or carers in different cultures, or a greater desire to encourage appeals in certain ethnic groups by clinicians or advocates. Additionally, it may reflect differences in understanding the appeals process across ethnicities or differences in the appropriateness of original detention (although if this latter point were true one should hopefully expect differences in success rates which were not observed).

This study does have some limitations. It was based in only one unit, albeit in a large one serving an ethnically diverse population. All administrative data may have errors; however, we believe the data are sufficiently robust to draw some conclusions.

Despite much research into ethnic differences in detention rates, we believe there has been insufficient scrutiny of ethnic differences in rates and success of appeals against detention. Further research into how and why people from different backgrounds come to appeal is warranted.

Declaration of interest

P.S., L.W. and G.D. are employees of St Andrew's Healthcare.