Likelihood and predictors of detention in patients with personality disorder compared

with other mental disorders: A retrospective, quantitative study of Mental Health Act

assessments

KIKE OLAJIDE, PETER TYRER, SWARAN P. SINGH, TOM BURNS, JORUN RUGKÅSA,

LAVANYA THANA, MOLI PAUL, ZOEBIA ISLAM, MIKE J. CRAWFORD

ABSTRACT

Background

The UK guidelines on the treatment of personality disorder recommend avoiding compulsory treat- ment except

in extreme situations. Little is known about how often patients with personality disorder are detained or

how this compares with the treatment of other mental disorders.

Objectives

Our aim is to test the hypothesis that people with personality disorder are infrequently detained under the

Mental Health Act (MHA) and that risk factors associated with detention are the same as those for

people with other mental disorders.

Method

We used a retrospective, quantitative study of MHA assessments.

Results

Of the 2087 assessments undertaken, 204 (9.8%) patients had a diagnosis of personality disorder;

40.7% of assessments in the personality disorder group resulted in detention, as did 69.7% of patients with

other mental disorders. A higher proportion of people with personality disorder received no intervention

following assessment compared with those with other mental disorders (20.6% vs. 4.7%, p < 0.001).

Study centre and a history of admission were risk factors for detention in both groups. Risk was a predictor

of detention in those with other mental disorders.

Conclusions

Detention rates in patients with personality disorder are lower than those for other disorders but are still

substantial. Risk factors for detention in patients with personality disorder differ from those with other

mental disorders.

Introduction

Most countries have enacted mental health legis- lation for treating people with mental disorders against their will (Freeman et al., 2005). In England and Wales, the Mental Health Act (MHA) 1983 gives health professionals the power to detain, assess and treat people with mental dis- orders. If two doctors agree that a patient is suffer- ing from a mental disorder, and that it is of a nature or to a degree that the patient should be detained in the interest of their health, safety or for the protection of others, they can make a recommendation for detention under Section 2 or 3 of the MHA. Under Section 2 of the MHA, patients can be detained for up to 28 days for assessment; under Section 3, they may be detained for up to 6 months for assessment and treatment. The legislation also provides police officers with the authority to remove individuals who appear to be suffering from a mental illness from any pub- lic place to a designated ‘place of safety’ for appro- priate assessment under Section 136 of the MHA. In 2014/2015, 58 400 people were detained under the Act (The Health and Social Care Information Centre, 2015).

Internationally, personality disorders are rela- tively common, with a prevalence of 6% (Huang et al., 2009). Prevalence studies suggest that 10– 13% of the adult population in England and Wales have a personality disorder (National Insti- tute for Mental Health in England, 2003). When considering psychiatric populations, estimates rise to 40% (Newton-Howes et al., 2010). Patients with personality disorder may make frequent con- tact with health and judicial services during crises (National Institute for Mental Health in England, 2003). The use of compulsory treatment among people with personality disorder is controversial. Studies have shown the key role that autonomy plays in the recovery process for patients with per- sonality disorder—so much so that it is viewed as fundamental to the management of these patients (NICE, 2009a,2009b; Bateman, Gunderson, & Mulder, 2015). This, coupled with the lack of

evidence supporting the effectiveness of compul- sory detention, has divided professional opinion on the use of compulsory treatment in personality disorder (Crawford et al., 2008). National Institute for Health and Care Excellence (NICE) advises that compulsory treatment should only be considered in extreme circumstances (NICE, 2009a,b).

There are insufficient data to establish the extent to which people with personality disorder are treated against their will, or which factors are associated with the decision to detain these pa- tients. The AMEND study explored determinants of detention in patients undergoing an MHA assessment in England. We proposed several risk factors for detention—including low social sup- port, a history of previous detention, the presence of risk and female gender (Singh et al., 2012). The AMEND study captured data on diagnosis, clini- cal background and outcome of MHA assessment; these data provided an opportunity to examine the proportion of patients with a primary diagnosis of personality disorder detained following MHA assessment and factors associated with their deten- tion. We conducted a secondary analysis of the AMEND data to establish if detention rates and risk factors for patients with personality disorder were similar to those with other mental disorders. We hypothesized that people with personality disorder are less likely to be detained under the MHA than those with other mental health disor- ders and that risk factors associated with detention would be the same.

Methods

The AMEND study was a retrospective examination of clinical and social care records of patients referred to services for an MHA assessment in three centres: London, Birmingham and Oxfordshire. An MHA assessment was defined as a clinical encounter where an ‘approved social worker’ or an ‘approved mental health professional’ (AMHP) was involved or in- vited, or where at least one medical recommendation was completed. For this analysis, we examined data on patients with a recorded diagnosis of personality

Table 1: Demographic and clinical characteristics of people with personality disorder, those with other mental disorders and the total sample

Variable

Personality disorder

n, %

Other mental disorder

n, %

Total

n, %Test

statistic* p value

Study centre, N = 2 087 Birmingham 36, 17.6% 527, 28.0% 563, 27.0%

26.106 <0.001

Oxford 85, 41.7% 482, 25.6% 567, 27.2%

London 83, 40.7% 874, 46.4% 957, 45.9%

Mean age (SD), N = 1 961 37.67 (14.65) 43.59 (15.32) 42.98 (15.35) 5.194 <0.001Gender, N = 2

084 Female 120, 58.8% 801, 42.6% 921, 44.2%19.624 <0.001

Male 84, 41.2% 1 079, 57.4% 1 163, 55.8%

Ethnicity, N = 2 036 White 165, 81.7% 1 050, 57.3% 1 215, 59.7%

54.244 <0.001

Black 14, 6.9% 394, 21.5% 408, 20.0%

Asian 4, 2.0% 222, 12.1% 226, 11.1%

Other 19, 9.4% 168, 9.2% 187, 9.2%

Risk to self, N = 2 087 150,73.5% 1 269, 67.4% 1 419, 68.0% 3.185 0.740

Risk to others, N = 2 087 69, 33.8% 876, 46.5% 945, 45.3% 11.978 <0.001Assessment venue, N = 1

789 A&E/general hospital 24, 13.0% 211, 13.1% 235, 13.1%140.171 <0.001

Police station 71, 38.6% 358, 22.3% 429, 24.0%

Community 43, 23.4% 948, 59.1% 991, 55.4%

Other 46, 25.0% 88, 5.5% 134, 7.5%

Section 136, N = 1 750 Yes 75, 41.9% 261, 16.6% 336, 19.2%

66.277 <0.001

No 104, 58.1% 1 310, 83.4% 1 414, 80.8%

Year of MHA, N = 2 082 7.107 0.0692008 40, 19.7% 471, 25.1% 511, 24.5%

2009 55, 27.1% 466, 24.8% 521, 25.0%

2010 73, 36.0% 542, 28.8% 615, 29.5%

(Continues)

Table 1: (continued)

Personality disorder Other mental disorder TotalTest

Variable n, % n, % n, % statistic* p value

2011 35, 17.2% 400, 21.3% 435, 20.9%

Previous admission, N = 1 703 No 108, 62.4% 601, 39.3% 709, 41.6%

34.269 <0.001

Yes 65, 37.6% 929, 60.7% 994, 58.4%

Living status, N = 1 722 5.965 0.113Friend/family 52, 29.9% 537, 34.7% 589, 34.2%

NFA 17, 9.8% 108, 7.0% 125, 7.3%

Alone 101, 58.0% 824, 53.2% 925, 53.7%

Supported 4, 2.3% 79, 5.1% 83, 4.8%

*The p values are derived from significance tests for the association between each variable and diagnostic group, using indepen- dent sample T-test for age and χ2/Fisher’s exact for the rest of the variables.

SD, standard deviation; A&E, accident and emergency; MHA, Mental Health Act; NFA, No fixed Abode.

disorder compared with those with other mental disorders of psychosis, affective disorder or anxiety disorder.

Data were collected on all MHA assessments conducted at the three study sites between July and October (2008–2011 inclusive). The research team made weekly contact with clinical teams to identify all MHA assessments conducted in the previous week. Details of the MHA assessment were then collected from the information recorded by the AMHPs from routine records. These records included information on the clinical characteris- tics—such as a risk assessment, the details of previ- ous admission, the circumstances surrounding assessment, a record of the interview with the ser- vice user and their social situation, information about the location of assessment, the legal status at the time of the MHA assessment and the out- come of the assessment. The format of the forms and the level of detail varied depending on the site

of collection and the AMHP recording the infor- mation. To ensure consistent and reliable data collection, information on these forms was then cross-checked against electronic patient records and the dataset of MHA assessments held by social services. The information was collated and encoded at each site using PASW STATISTICS (version 18, IBM) and SPSS (version 19 Armonk, NY: IBM); the data were subsequently combined to create a single database.

Data were presented under the following headings.

Setting of the assessment. Which individuals were present (including discipline and role), whether or not a carer/family member was present and where and when the assessment was conducted (venue, day and time) were recorded. The venue setting was recorded as ‘police station’, ‘community’ or ‘general hospital’. Assessments that occurred in

the community included assessments that occurred in the patient/carer’s home, at the general practitioner’s surgery and at the commu- nity psychiatric team’s office. Assessments that occurred in the general hospital included assess- ments that occurred in the accident and emer- gency department and the medical wards.

Patient characteristics. Socio-demographic vari- ables such as age, gender, self-ascribed ethnicity, res- idential status, level of community and social support and clinical variables including diagnosis, type and presence of risk were recorded.

Risk was considered present if any of the fol- lowing six risks were noted in the MHA: risk of self-harm, risk of self-neglect, risk of deteriora- tion, risk of harm to other people, risk of harm to property and risk of harm to the vulnerable. For the purpose of data analysis, the first three risks were combined into the larger category of

‘risk to self’ and the second three as ‘risk to others’.

Service characteristics. Details pertaining to local bed availability and availability of alternatives to detention were recorded.

Factors determining outcome. The factors deter- mining outcome recorded included risk, home treatment team availability and diagnosis. ICD- 10 diagnosis following MHA assessment was ex- tracted from clinical records. These were then grouped into personality disorders (codes F60– F69) and other mental disorders (all other codes).

Outcome of the assessment. The outcome of the MHA assessment and the follow-up care was taken from clinical records. Patients were admit- ted to the hospital (voluntarily or compulsorily

Table 2: Outcome of MHA assessment by diagnosis

Outcome

Personality disorder Axis I disorders Total

n, % n, % n, % Test

statistic p value

Voluntary admission 22, 10.8% 149, 7.9% 171, 8.2% 129.123 <0.001

Compulsory admission (under MHA) 83, 40.7% 1 313, 69.7% 1 396, 66.9%

Total admitted 105, 51.7% 1 462, 79.3% 1 567, 76.5%

Voluntary community treatment 39, 19.1% 171, 9.1% 210, 10.1%

Compulsory community treatment (under MHA) 0, 0.0% 47, 2.5% 47, 2.3%

Total treated in the community 39, 19.2% 218, 11.8% 257, 12.6%

No intervention 42, 20.6% 88, 4.7% 130, 6.2%

Unspecified 18, 8.8% 115, 6.1% 133, 6.4%

Total 204, 100.0% 1 883, 100.0% 2 087, 100.0%

MHA, Mental Health Act.

Table 3: Outcome of MHA assessment by assessment venue

Police

General hospital (including

Outcome

station

n, %

A&E)

n, %

Community

n, %

Unknown

n, %

TotalTest

n, % statistic p value

Voluntary admission 31, 7.2% 24, 9.9% 82, 8.3% 34, 8% 171, 8.2% 114.956 <0.001

Compulsory admission (under MHA)

Total admitted

252, 58.7%

283, 65.9%

182, 75.2%

206, 85.1%

690, 69.6%

772, 77.9%

272, 64%

306, 72%

1 396, 66.9%

1 567, 75.1%

Voluntary community treatment 62, 14.5% 16, 6.6% 102, 10.3% 30, 7.1% 210, 10.1%

Compulsory community treatment 2, 0.5% 0, 0.0% 38, 3.8% 7, 1.6% 47, 2.3%(under MHA)

Total treated in the community 64, 15% 16, 6.6% 140, 14.1% 37, 8.7% 257, 12.3%

No intervention 53, 12.4% 7, 2.9% 37, 3.7% 33, 7.8% 130, 6.2%

Unspecified 29, 6.8% 13, 5.4% 42, 4.2% 49, 11.5% 133, 6.4%

Total 429, 100.0% 242, 100.0% 991, 100.0% 425, 100.0% 2 087, 100.0%

MHA, Mental Health Act; A&E, accident and emergency.

detained under the MHA), treated in the commu- nity or received no intervention following MHA.

Statistical analysis

Information from the assessment documentation was coded and entered using statistical analysis software (SPSS version 19). All analyses were con- ducted in SPSS version 23. Descriptive analyses and Pearson’s χ2 tests were used to describe and explore baseline differences in socio-demographic and clinical characteristics between the two diagnostic groups. Frequency and percentage were used for categorical variables, while mean and standard deviation (SD) were used for continuous variables.

Cases with missing entries in any variable un- der consideration were excluded from that analysis (complete case analysis) with the exception of the

‘risk to self’ and ‘risk to others’ variables. In keep- ing with the method used in the main analysis (Singh et al., 2012), if all six risks were missing (refer to the preceding discussion), the case was excluded as missing; if the risk assessment was par- tially completed, the missing risks were assumed to be ‘risk not present’.

Detailed data on ethnicity were collected. However, for the purposes of the multivariate analyses reported in this paper, service users were categorized as either Black and Minority ethnic (BME) or White. Although neither of these are homogenous groups, the Black and Asian service users in the personality disorder group were represented in numbers too small to provide sufficient statistical power and were therefore combined into a larger BME group.

For the clinically important parameter of assessment venue, comparisons of basic socio-

demographic and clinical characteristics were made between those patients with missing data (n = 298) and those with data available (n = 1 789). There were no statistically significant differences with regard to age, gender, diagnostic cat- egory or ethnicity when the data were missing vs. not missing for assessment venue (all p values > 0.05). Table1 lists the rates of missing data per variable.

Binary logistic regression was used to identify variables correlated with compulsory detention in the two diagnostic groups. The factors assessed were study centre, age, gender, ethnicity, risk to self, risk to others, assessment venue, year of MHA assessment, social support (living status) and history of previous admission. All variables were used in a categorical format, and the ‘enter’ method was used to create the model. Odds ratios, 95% confidence intervals (CIs) and p values werecalculated. The analysis was conducted separately

Socio-demographic and clinical characteristics by diagnostic group

Demographic and clinical characteristics of the two groups are presented in Table 1. There were a higher proportion of women in the personality disorder group (58.8%) compared with the ‘other mental disorders’ group (42.6%). The former group also had a higher proportion of White patients (81.7%) and a lower proportion of Black patients (6.9%) compared with the ‘other mental disorders’ group (57.3% and 21.5% respectively).

While both groups had similar proportions of those deemed a risk to themselves, the greatest proportion of those deemed a risk to others was found in the ‘other mental disorders’ group (46.5%). A greater proportion of assessments of people with personality disorder took place in police stations (38.6%), compared with the ‘other2

for people with a primary diagnosis of personality mental disorders’ group (22.3%) (χ = 140.17,

disorder and those with other mental disorders to allow comparison of the factors associated with likelihood of detention in these two groups of patients.

Ethics

Ethical approval for the study was obtained from the West Midlands Research Ethics Committee (WMREC Ref 08/H1208/44) and Birmingham City Council Ethics Committee prior to the start of data collection.

Results

Overall, 2 087 patients were included in the anal- ysis; 204 (9.8%) patients had a diagnosis of personality disorder, and 1 883 (90.2%) patients had other mental disorders. The personality disor- der group was composed of 84 (41.2%) men, and the mean age was 38 years (SD 14.65). The ‘other mental disorders’ group was composed of 1 079 (57.4%) men, and the mean age was 44 years (SD 15.32).

p < 0.001). In addition, significantly higher rates of detention under Section 136 MHA were ob- served among patients with personality disorder (41.9%) than those with other mental disorders (16.6%) (χ2 = 66.28, p < 0.001).

Outcome of MHA assessments

In total, 1 396 (66.9%) service users were compul- sorily detained. Rates of detention based on diag- nostic group and assessment venue are included in Tables 2 and 3 respectively. The diagnostic group showing the highest rate of detention was the ‘other mental disorders’ group (69.7%). Over half the personality disorder group were admitted (51.7%); the majority of these were compulsory detentions (40.7%). People with other mental dis- orders had similar rates of voluntary admission to the personality disorder group (10.8% and 7.9% respectively). However, a significantly higher percentage of people with personality disorder re- ceived no

intervention than those with other mental disorders (20.6% vs. 4.7%, χ2 = 129.12, p < 0.001), and they had higher rates of no inter- vention than treatment in the community.

Most MHA assessments took place in the com- munity (n = 991, 55.3% of assessments in which the venue was recorded), followed by the police station (n = 429, 24% of assessments in which the venue was recorded). Assessments that occurred in the police station resulted in an increased proportion of patients who received no intervention following MHA assessment (12.4%) compared with those in the community (3.7%) or the general hospital (2.9%)—the differences were statistically significant. In addition, those assessed in the police station had lower proportions of service users detained following MHA assessment (58.8%), compared with those assessed in the community (69.6%) or the general hospital (75.2%).

Factors associated with the decision to detain a person

Tables 4 and 5 show the associations between the socio-demographic and clinical characteris- tics and the decision to detain for the person- ality disorder group and the ‘other mental disorders’ group. The odds of being detained did not significantly differ with age or ethnicity for either group. Study centre and a history of previous admis- sion were predictors of detention in both groups: assessments that occurred in Birmingham and Oxfordshire had lower odds of detention than those that occurred in London, and those with a history of previous admission had higher odds of detention, with both differences being statistically significant (p < 0.05).

There was a significant difference in compulsory detention rates among patients with personality disorder whose assessment occurred in the police station—the overall odds of detention were five times lower than those whose assessment occurred in the community or the general hospital. In con- trast, the venue of the MHA assessment was not a significant determinant of detention in the ‘other mental disorders’ group.

In those with other mental disorders, assessments for service users who presented a risk to themselves were over twice as likely to end in detention. Simi- larly, in those who presented a risk to others,

assessments were just under twice as likely to end in detention. Both differences were highly significant (p < 0.01). This association was not statistically significant in patients with personality disorder.

The likelihood of compulsory detention among service users with other mental disorders who lived with friends and family was far lower than among those who lived in supported accommoda- tion (odds ratio 0.47, CI 0.23–0.96, p < 0.05). A comparable association was seen in those service users with personality disorder. However, the dif- ference was not statistically significant.

Within the ‘other mental disorders’ group, men were found to have reduced odds of detention compared with women (0.72, CI 0.54–0.95, p < 0.05). In contrast, the men in the personality disorder group showed higher odds than their female counterparts. However, the differences did not reach statistical significance (p = 0.09).

Discussion

There are a number of important ways in which this study moves beyond previous research. It is the largest UK study assessing the frequency of compulsory detention among patients with per- sonality disorder. It is also the first study to suggest predictors of detention in patients with personal- ity disorder.

In keeping with our original hypothesis, we found patients with personality disorder had lower deten- tion rates than those with other mental disorders. However, their detention was not a rare occurrence (41% of all those with personality disorder assessed under the MHA), and, although their risk factors for detention shared some similarities (study centre and history of previous admission), there were clear differences between the two diagnostic groups. The study findings raise several questions—the question of not only why assessment venue matters in person- ality disorder and not in other mental disorders but also why risk increases detention in other mental disorders but not

in personality disorder. This discus- sion will seek to address those questions.

Table 4: Single logistic regression

Personality disorders Other mental disorders

95% CI for odds ratio

95% CI for odds ratio

Oddsratio Lower Upper Significance

Odds ratio Lower Upper Significance

Study centre London 1 1Birmingham 0.371 0.164 0.838 0.017 0.362 0.282 0.463 <0.001Oxford 0.169 0.085 0.334 <0.001 0.367 0.285 0.472 <0.001

Gender Female 1 1Male 1.459 0.825 2.578 0.194 0.775 0.631 0.952 0.015

Ethnicity White 1 1BME 1.748 0.824 3.708 0.146 1.172 0.951 1.445 0.137

Risk to self No 1 1Yes 1.296 0.678 2.478 0.433 1.846 0.680 1.054 0.136

Risk to No 1 1others Yes 1.328 0.737 2.392 0.345 1.293 1.056 1.583 0.013

Venue Police 1 1A&E/ 2.947 1.175 7.394 0.021 1.856 1.259 2.737 0.002

hospitalCommunity 5.109 2.254 11.578 <0.001 1.223 0.945 1.584 0.127Other 0.626 0.247 1.586 0.323 0.650 0.401 1.052 0.080

Year of MHA 2011 1 1assessment 2010 0.815 0.314 2.113 0.674 1.067 0.803 1.417 0.655

2009 2.031 0.853 4.833 0.109 1.598 1.175 2.172 0.0032008 0.957 0.414 2.210 0.917 0.874 0.657 1.163 0.355

Age 30 years and 1 1older

Under 0.832 0.458 1.511 0.545 1.306 1.021 1.671 0.03330 years

Living status Supported 1 1 0.001Friends/ 0.162 0.016 1.674 0.127 0.347 0.189 0.634 0.122

familyNFA 0.182 0.015 2.154 0.177 0.569 0.278 1.163 0.025Alone 0.210 0.021 2.088 0.183 0.506 0.278 0.919

BME, Black and Minority ethnic; MHA, Mental Health Act; A&E, accident and emergency; CI, confidence interval; NFA, No fixed Abode.Significant result are in bold (p<0.05).

Detention rates for patients with a diagnosis of personality disorder were substantial. These differ- ences may be explained by the fact that any patient for whom an MHA assessment is scheduled (i.e. all of the patients studied) is, by definition, likely to represent an extreme circumstance. When the outcome of MHA assessment was evaluated, the

results did share some similarities with previous studies (Chang, Lee, Lee, Yang, & Wen, 2001) and NICE guidelines (NICE, 2009a,2009b): pa- tients with a diagnosis of personality disorder were found to have higher rates of informal admission, which may indicate that their autonomy in the decision-making process was considered.

Table 5: Multiple logistic regression

Personality disorders Other mental disorders

Odds ratio

95% CI for odds ratio

Lower Upper SignificanceOdds ratio

95% CI for odds ratio

Lower Upper Significance

Study centre London 1 1Birmingham 0.045 0.008 0.266 0.001 0.226 0.154 0.333 <0.001Oxford 0.089 0.018 0.433 0.002 0.349 0.234 0.521 <0.001

Gender Female 1 1Male 2.481 0.871 7.068 0.089 0.716 0.542 0.946 0.019

Ethnicity White 1 1 0.392BME 0.559 0.106 2.948 0.493 1.142 0.843 1.546

Risk to self No 1 1Yes 5.414 0.993 29.522 0.042 2.562 1.742 3.768 <0.001

Risk to others No 1 1Yes 1.508 0.558 4.075 0.418 1.885 1.425 2.494 <0.001

Venue Police 1 1A&E/hospital 5.582 1.171 26.614 0.031 1.537 0.924 2.556 0.098Community 5.296 1.325 21.167 0.018 1.113 0.791 1.566 0.538Other 0.503 0.126 2.005 0.330 0.705 0.399 1.247 0.230

Year of MHA 2011 1 1assessment 2010 6.626 1.197 36.662 0.030 1.157 0.787 1.700 0.458

2009 4.137 0.722 23.702 0.111 1.618 1.054 2.482 0.0282008 2.121 0.352 12.796 0.412 0.888 0.601 1.312 0.550

Age 30 years and 1 1older

Under 0.689 0.251 1.888 0.468 1.351 0.963 1.896 0.08230 years

Living status Supported 1 1Friends/family 0.270 0.012 6.005 0.408 0.474 0.234 0.961 0.038NFA 0.801 0.027 23.480 0.898 0.768 0.305 1.932 0.575Alone 0.184 0.008 4.053 0.283 0.571 0.283 1.153 0.118

Previous No 1 1admission Yes 4.873 1.705 13.921 0.003 1.843 1.387 2.449 <0.001

BME, Black and Minority ethnic; MHA, Mental Health Act; A&E, accident and emergency; CI, confidence interval; NFA, Nifixed Abode.Significant result (p<0.05) are in bold.

A substantially greater proportion of people with personality disorder received no intervention following MHA assessment than those with other mental disorders (20.6% vs. 4.7%). Much has been written about the exclusion of patients with personality disorder from services (Kealy & Ogrodniczuk, 2010)—so much so that national at- tempts have been made to reduce it (National

Institute for Mental Health in England, 2003). However, this study showed that patients with

personality disorder are possibly still being excluded, as they were less likely to be followed

up than patients with other psychiatric diagnoses. Black patients were under-represented within the

personality disorder group. This is in keeping with previous study findings, which have reported a

lower

prevalence of personality disorder among people from BME communities who are in contact with mental health services (McGilloway, Hall, Lee, & Bhui, 2010). Given that in the UK personality disor- der is estimated to be at least as prevalent among Black and other minority ethnic groups as it is Caucasian populations (Crawford et al., 2011), these findings may indicate a neglect of personality diagno- sis among BMEs.

The presence of risk is a legal prerequisite for de- tention under the MHA. The original AMEND study indicated that risk is a determinant of deten- tion (Singh et al., 2012); it was, therefore, unsurpris- ing that risk to self and others was a determinant of detention in other mental disorders. However, it was an unexpected, but important, finding that patients with personality disorder who proved a risk to themselves or others were not at greater risk of de- tention. In a group of patients who may consistently report multiple risk factors, clinicians conducting the assessment may begin to give less weight to the risk—with more emphasis placed on the nature and degree of the disorder (which may be judged by prox- ies such as a history of previous admission).

In keeping with the original AMEND study and previous study findings (Singh et al., 2012; van der Post, Peen, & Dekker, 2014), a history of previous admission was found to be a risk factor for detention in both diagnostic groups. Patients who have been admitted previously may represent a more chronic and severe subgroup and, might, therefore, be more likely to be detained. Equally, clinicians may be more confident in recommending detention in those with a history of admission, as this speaks to the nature and degree of their disorder.

Patients with personality disorder had more than double the rate of detention under Section136 and a significantly higher proportion of MHA assessments conducted in a police station, yet they had a similar risk to self and a reduced risk to others when compared with service users with other mental disorders. Furthermore, there were significantly decreased rates in detention observed in personality disorder patients who were assessed at the police station, in

whom the odds of

detention were five times less than those assessed in the community. Overall, those assessed in the police station had over three times the proportion of people who received no intervention following MHA assessment than those assessed in the community or the general hospital—raising the question of the appropriateness of these assess- ments. These findings echo previous studies in which patients with personality disorder were over-represented in those detained under Section 136 (Borschmann, Gillard, Turner, Chambers, & O’Brien, 2010), and patients brought by police to a place of safety were less likely to be detained (Al-Khafaji, Loy, & Kelly, 2014). It may be that in such settings, clinicians are more willing to accept a forensic reason for patients’ behaviours rather than attributing their behaviours to a mental disorder, thus reducing the likelihood of detention. However, this does not explain why, in the personality disorder group, there was a significantly higher proportion of assessments that occurred at the police station than those with other mental disorders, when the former group had a similar rate of risk to self and a lower rate of risk to others than the latter. It is possible that a police officer with limited clinical training in mental health disorders may find it difficult to accurately as- sess the patient’s risk and therefore detain patients unnecessarily.

Implications for clinical services, policy and fu- ture research

The NICE guidelines recommend that detention should be used only in extreme circumstances (NICE, 2009a,2009b)—yet, in this study, 40% of patients with a diagnosis of personality disorder were detained. Promisingly, personality disorder patients were found to have higher rates of informal admis- sion, which is in line with the autonomy promoted in NICE guidelines (NICE, 2009a,2009b). Further research should be undertaken to explore the out- comes of contact with mental health services for patients with personality disorder at times of crisis.

A large proportion of those with personality disor- der had an MHA assessment at a police

station

compared with those with other mental disorders. The Care and Quality Commission highlighted the issue of high numbers of mentally ill patients being detained in police custody (CQC et al., 2013). In Britain, both the Crisis Care Concordat (Her Majesty’s Government, 2014) and the 2015 MHA code of practice (Department of Health 2015) aim to reduce this number, with both guidelines suggest- ing that a police station should not be used as a place of safety except in ‘exceptional circumstances’. Our study findings support this drive for MHA assess- ments to be conducted in clinical settings—particu- larly for those patients with personality disorder, for whom an assessment in a police station was less likely to result in subsequent detention (and, therefore, less likely to be appropriate). Further training may be beneficial to assist police officers in identifying those with mental health disorders in general, and person- ality disorder in particular, who require an MHA as- sessment. A brief assessment tool to assist police in measuring the severity of personality disorder may also be useful. A more collaborative approach to ser- vice provision between police and mental health ser- vices is required. Police officers may be less likely to detain patients under Section 136 if a structured pathway for referral to mental health services for an emergency appointment exists.

The low prevalence of personality disorder in BMEs may reflect a neglect of personality disorder di- agnosis in this group. Greater efforts need to be made to ensure that BME service users with personality dis- order have access to suitable services. Well-designed research into the needs of ethnic minorities with personality disorder is important in order to better understand the factors influencing their help-seeking behaviours. Adapted psychological approaches to patients that acknowledge their ethnic origin has been shown to improve outcomes in other mental disorders (Rathod et al., 2013). Future work could explore how personality disorder services engage BME service users, thus equipping us better to develop therapies and services to target these communities.

National attempts have been made to reduce exclusion of patients with personality disorder

from

services (National Institute for Mental Health in England, 2003). However, this study demonstrates that these patients continue to be excluded. In- depth, qualitative research is required to better un- derstand the attitudes of health-care staff to those with personality disorders—enabling targeted educa- tion and training programmes to reduce their exclu- sion from services.

Limitations

Missing data for certain variables were the most notable limitation. As a result, we were unable to explore the impact of home treatment teams or other potential protective factors, such as a ded- icated personality disorder service, in reducing de- tention rates. Data were collected from AMHP records. As such, it was not possible to ascertain the diagnostic criteria for each assessment, and it is likely that most diagnoses were made on the ba- sis of clinical judgement rather than objective measurement tools. Similarly, diagnoses of personal- ity disorder did not elaborate on the type or severity of the disorder. This study has highlighted some of the fundamental difficulties in retrospective data col- lection from routine records: data capture may have been enhanced by the presence of researchers at the MHA assessment—although the logistics of this would have proven problematic and, therefore, sig- nificantly reduced the number of patients recruited to the study.

Detailed data on ethnicity were collected. How- ever, for the purposes of the multivariate analyses reported in this paper, service users were categorized as either BME or White. As Black and Asian service users in the personality disorder group were repre- sented in numbers too small to provide sufficient statistical power, they had to be combined into a larger BME group.

Finally, the issue of generalizability is important. This study looks solely at a subgroup of patients in whom an MHA assessment was scheduled; this denominator may not necessarily be representative of all those who present in an acute setting for psychiatric assessment.

Conclusions

This study has demonstrated not only lower rates of compulsory detention in patients with personality disorder compared with other mental disorders but also lower rates of follow-up in the community. Al- though both groups shared risk factors for detention (study centre and history of previous admission), there were marked differences. In patients with per- sonality disorder, risk did not alter the likelihood of detention, but assessment in a police venue did.

There is a need for more comprehensive research in order to better understand the contact of patients with personality disorder with the mental health services and the police force. Understanding the role of these professionals in assessing and detaining those with personality disorder may act as a catalyst to re- duce unnecessary detention and also exclusion from services.

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Address correspondence to: Dr Kike Olajide, Centre for Mental Health, Imperial College London, The Commonwealth Building, The Hammersmith Hospital, Du Cane Road, London W12 0NN, UK. Email: Kikeolajide@doctors.org. uk