Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study

Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study View ORCID Profile R. Hildersley , View ORCID Profile T.K. Oswald , View ORCID Profile I Bakolis , L Becares , A. Dregan , J Dyer , M. Hotopf , View ORCID Profile J. Ocloo , R Stewart , J. Das-Munshi doi: https://doi.org/10.1101/2025.05.02.25326888 R. Hildersley 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 3 ESRC Centre for Society and Mental Health, King’s College London Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for R. Hildersley T.K. Oswald 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 2 Population Health Improvement UK (PHIUK) , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for T.K. Oswald I Bakolis 5 Centre for Mental Health and Policy Evaluation (CMHPE), Department of Health Service and Population Research Department (HSPR), Institute of Psychiatry, Psychology & and Neuroscience, King’s College London , London, UK 6 Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for I Bakolis L Becares 8 King’s College London, Department of Global Health and Social Medicine, Faculty of Social Science and Public Policy , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site A. Dregan 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 2 Population Health Improvement UK (PHIUK) , UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site J Dyer 9 NHS England (NHS-E), Black Thrive Global Find this author on Google Scholar Find this author on PubMed Search for this author on this site M. Hotopf 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 2 Population Health Improvement UK (PHIUK) , UK 4 South London and Maudsley NHS Foundation Trust , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site J. Ocloo 5 Centre for Mental Health and Policy Evaluation (CMHPE), Department of Health Service and Population Research Department (HSPR), Institute of Psychiatry, Psychology & and Neuroscience, King’s College London , London, UK 7 National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South London, Institute of Psychiatry, Psychology & Neuroscience, King’s College London , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for J. Ocloo R Stewart 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 4 South London and Maudsley NHS Foundation Trust , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site J. Das-Munshi 1 King’s College London, Institute of Psychiatry, Psychology and Neurosciences, Department of Psychological Medicine , London, UK 2 Population Health Improvement UK (PHIUK) , UK 3 ESRC Centre for Society and Mental Health, King’s College London 4 South London and Maudsley NHS Foundation Trust , London, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: jayati.das-munshi{at}kcl.ac.uk Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Background Ethnic inequalities in compulsory psychiatric hospital detentions are well-documented in the UK and internationally. It is unknown how UK COVID-19 ‘lockdown measures’, which led to restrictions in public movement, gatherings, in-person health service delivery, and changes to police powers, further impacted inequalities. Aims In this study, we assessed whether national ‘lockdown’ measures impacted ethnic inequalities in voluntary and compulsory psychiatric hospital admissions, during the COVID-19 pandemic. Methods Daily counts of admissions and detentions to psychiatric hospitals were extracted from a large population-level sample of secondary mental health service users in southeast London. Changes during two COVID-19 lockdown periods, over 2020-2021, were compared with pre-pandemic periods (2016-2019) with the use of a regression discontinuity in time design to assess ethnic inequalities in voluntary/ compulsory mental health admissions. Results Compared to the pre-pandemic reference (2016-2019), after adjusting for seasonal and weekly trends, overall admissions to mental health units dropped during the first COVID-19 lockdown (Incidence Rate Ratio (IRR) 0.87 (95% CI: 0.75-1.00) but with more compulsory detentions (1.25 (1.05-1.54)). This was mostly due to higher compulsory detentions in the Black Caribbean group (1.54 (1.08-2.19)). During the second COVID-19 lockdown, whereas total daily admissions remained similar to the pre-pandemic reference (1.03 (0.92-1.15)), total new daily detentions was elevated (1.28 (1.11-1.49)), specifically in Black Caribbean (1.53 (1.14, 2.06)) and Black African (1.57 (1.06-2.34)) groups. Conclusions COVID-19 lockdown measures exacerbated pre-existing ethnic inequalities in compulsory psychiatric detention, particularly for those from Black Caribbean and Black African backgrounds. There is a need to address ethnic inequalities in compulsory psychiatric detentions and attend to exacerbations of pre-existing inequalities during health emergencies like the COVID-19 pandemic. This cannot be achieved without addressing systemic racism within criminal justice and healthcare systems and tackling inequalities in wider social and economic determinants of mental health. Funding Health Foundation, NIHR, UKRI. Introduction The acute phases of the Coronavirus Disease 2019 (COVID-19) pandemic altered most aspects of daily life, impacting the physical and mental health of populations. Attempts to slow the spread of COVID-19 through “lockdown” measures caused disruptions to employment, education, and health service use. Notably, a study of 10 UK mental health service sites reported reduced daily referrals, inpatient admissions, and caseloads during the first UK lockdown period in Spring 2020, compared with a pre-lockdown period, and this observation was also found elsewhere( 1 , 2 ) Similarly in the U.S., mental health-related emergency department visits declined from March 2020 relative to a pre-pandemic period, and some evidence suggests there was no significant change in psychiatric admissions.( 3 , 4 ) In the UK, Black and other racially minoritised groups are more likely to come into mental health services through compulsory pathways, frequently involving contact with police and criminal justice,( 5 , 6 ) despite no consistent evidence of greater violence or substance misuse.( 7 ) This has also been observed in other countries.( 8 ) During the early stages of the COVID-19 pandemic, police in the UK were given greater powers to enforce pandemic mitigation measures, such as social distancing.( 9 ) It has become evident that there was significant racialised inequality in the way these measures were used.( 9 ) Further, access to mental health care was not equally distributed during the pandemic, with ethnic inequalities reported in some countries. For example, in the US, compared to White Americans, Black, Hispanic, and Asian Americans were significantly less likely to receive mental healthcare services or telemedicine appointments during the pandemic.( 10 , 11 ) Even prior to the pandemic, ethnic inequalities in mental health access and outcomes were known to be a major concern in the UK and internationally.( 12 ) Although pre-existing ethnic inequalities in compulsory psychiatric hospital detentions are well-documented, a review of the literature (see supplementary material 1) suggests no previous studies have yet investigated how COVID19 lockdowns affected pre-existing ethnic inequalities in mental health-related admissions and detentions. Therefore, using a large population-level sample of people in contact with secondary mental health services in southeast London, the aim of the current study was to investigate (a) how the first and second COVID-19 lockdowns, which occurred in 2020, affected overall mental health hospital admissions (both voluntary and compulsory combined, referred to as “admissions” from this point) and compulsory psychiatric hospital detentions (referred to as “compulsory detentions” from this point), and (b) whether this varied between racialised minority groups, compared to White British mental health service users. The present analysis forms part of a larger mixed methods study which investigated the impact of the COVID19 pandemic on health and service use in racially minoritised people( 13 ) Methods Participants and setting Patient-level demographic and hospital admissions data in this study were extracted from mental health medical records from one of Europe’s largest secondary mental healthcare providers, the South London and Maudsley NHS Foundation Trust (SLaM) using its Clinical Record Interactive Search (CRIS) platform.( 14 ) The construction of the dataset is detailed in Figure 1 . In the UK, healthcare is free at the point of contact, and, within this context, SLaM is near sole provider of secondary mental health services for 1.3 million residents in a defined geographic area in southeast London. Like other urban areas in the UK, the catchment area for this study is characterised by high ethnicity and socioeconomic diversity (see supplementary materials 1, Table 1 for further details). Download figure Open in new tab Figure 1: Flow diagram showing construction of dataset for analysis View this table: View inline View popup Download powerpoint Table 1: Descriptive characteristics (median and interquartile range (IQR)) of the sample, with average number of daily new admissions and detentions by ethnicity Measures Hospital admissions data was used to provide daily counts of admissions and all classifications of compulsory detentions under the Mental Health Act (1983) (MHA), subdivided by ethnicity. The outcomes of interest were any admission to inpatient psychiatric services over the observation period, either as voluntary patients or as compulsory detentions. The units for analysis used were: (a) the number of new admissions/detentions per day (incidence, that is, the number of patients added to the patient load on any given day) and (b) the total number of inpatients detained/ all inpatients within in-patient services per day (prevalence, that is, the total patient load compulsorily detained on each given day). Demographic data, specifically ethnicity, were linked to the full list of admissions to SLaM from 1 st January 2016 to 8 th October 2021 using pseudonymised unique patient identifiers. Ethnicity was initially mapped on to Census 2011 ethnicity criteria and grouped as: White British, Irish, White Other, Black Caribbean, Black African, Indian, Pakistani, and Bangladeshi, Chinese, Other Ethnicity, Mixed Ethnicity. Due to small sample sizes a decision was taken to aggregate groups, resulting in: White British, White Other (including Irish), Black Caribbean, Black African, South Asian (a combined category including Indian, Pakistani and Bangladeshi groups) and Other Ethnicity (including other mixed ethnicities, Chinese ethnicity and all other Asian ethnicity). Participants of mixed ethnicity were grouped with individuals with their minority ethnic identity, for example, participants who are mixed Black Caribbean and White British were included in the Black Caribbean category. Time periods for analysis England first introduced “lockdown” regulations on 23 rd March 2020, which involved closing all “non-essential” businesses, recommending that people work from home if possible, and only allowing people to leave their home for essential purposes (including seeking medical care). These regulations started to be lifted from 13 th May 2020, with most national restrictions lifted on 4 th July 2020 and replaced with regional regulations. A modified national “lockdown” policy was reintroduced on 5 th November 2020 and, while this was replaced by regional regulations on 2 nd December 2020, the London regulations remained strict (i.e., limited contact between households, recommendations for people to work from home if possible and closure of “non-essential” businesses). Shortly after this, on 6 th January 2021, a third national “lockdown”. was introduced, with a phased exit from lockdown starting on 8 th March 2021 and ending on 18 th July 2021.( 15 ) These measures were supported by expansions to policing powers, as described above. For the purpose of this study, we therefore chose to treat the UK lockdown measures as two distinct periods, as the regional restrictions placed on London between the second and third national lockdowns were of the highest level, and similar to those introduced during the national lockdown periods. A detailed timeline of the UK coronavirus mitigation measures can be found here: https://www.instituteforgovernment.org.uk/data-visualisation/timeline-coronavirus-lockdowns . For the purpose of this analysis, the first UK lockdown was defined from 23 rd March 2020 to 13 th May 2020 and the second from 2 nd November 2020 to 8 th March 2021. The cut points used for the lockdown periods in the analysis and control periods from 1 st January 2016 to 8 th October 2017, and 1 st January 2018 to 8 th October 2019, are illustrated in Figure 2 . Download figure Open in new tab Figure 2: Timelines of the study with cut points and comparison periods. Lockdown periods are sections of time that include regulations relating to the closure of businesses and limited household mixing. Statistical methods First, we calculated the median and interquartile range (IQR) of the number of new and total admissions and detentions for each study period. Next, we used a fuzzy Regression Discontinuity in Time with a Difference in Differences strategy to determine the effect of the four intervention cut points (i.e., the start and lift of the two described “lockdown” periods).( 1 , 16 , 17 ) We included two parallel pre-pandemic comparison periods in the models (1 st January 2016 to 8 th October 2017 and 1 st January 2018 to 8 th October 2019) to account for any changes associated with the intervention time points that were not due to the COVID-19 “lockdown” policies, shown in figure 2 . We used Poisson regression models with robust standard errors, to assess the change associated with the cut points, accounting for trends associated with the month and day of the week. Where needed, we ran zero inflated Poisson models to account for the high frequency of zero counts in the models analysing the daily rate of new admissions and compulsory detentions. Diagnostic tests including checking for goodness of fit, autocorrelation, normality of the residuals, and robustness of the linear predictions in the model to ensure assumptions were not breached. First, we assessed the overall change in in the total and newly admitted or detained cases per day associated with the cut points, then we assessed the changes associated with the UK lockdown for the ethnicity subgroups. Further details of the statistical methods, including assumptions, can be found in Supplementary Material 2. Post-hoc Analysis We conducted further post-hoc analyses to assess if observed changes in admissions were due to new admissions of people coming into secondary mental health services during the COVID-19 period for the first time. This post hoc analysis assessed whether potential lower levels of early/ preventative access to community care during the COVID19 pandemic was associated with higher levels of inpatient admissions. To assess this, we re-ran the analyses restricted to people making contact for the first time during the pandemic, i.e., ‘flagged’ as first admissions only, in the clinical data. Sensitivity analysis We ran the following pre-planned sensitivity analyses, as per Bakolis et al (2021):( 1 ) To account for anticipatory effects of both lockdown periods potentially impacting people’s behaviours, and UK social distancing measures which were introduced earlier, on 16 th March 2020, we re-ran the analysis with the start-of-lockdown dates set to one week before the actual introduction of the policies (i.e., start of lockdown 1 on 16 th March 2020 and lockdown 2 on 26 th October 2020). To assess the sensitivity of changes associated with the start of the lockdown lifts, we re-ran the analysis with the lockdown ‘lift’ indicators coded as the time periods that had the start of the least restrictive ‘lockdown’ measures (i.e., lift of lockdown 1 set as 4 th July 2020 and lockdown 2 as 18 th July 2021). To check that the findings were not an artefact of the pre-lockdown time periods, we altered the time window for the lockdown periods to include the period from 30 th January to 23 rd March 2020 and 28 th June 2020 to 2 nd November 2020 (i.e., the same number of days as the lockdown period but different specific dates). Patient and Public Involvement Members of our core team had lived experience of the issues under investigation; Dyer has lived experience of caring for siblings with severe mental health issues. The study was part of the COVID-19 Ethnic Inequalities in Mental health and Multimorbidities (COVE-IMM) project which involved an ethnically diverse steering group that included university researchers and people with lived experience of severe mental health problems.( 13 ) Results Daily distributions (medians and IQRs) for the number of new admissions and compulsory detentions for the full sample, grouped by ethnicity, are shown in table 1 . The distributions for total number of inpatients and compulsory detentions are displayed in supplementary table 3.1. The median number of admissions per day was 10, with 6 new compulsory detentions per day The median number of inpatients was 697 per day, with 503 compulsorily detained. Overall, total psychiatric admissions and compulsory detentions dropped during the first lockdown period and remained lower than the pre-lockdown period throughout the study period. In contrast, the daily rate of new admissions detained increased over lockdowns compared to the pre-lockdown period and remained higher throughout the study period. During the first lockdown (23 March 2020 – 12 May 2020), the total number of inpatients admitted, and compulsory detentions fell compared to pre-lockdown trends, illustrated in figure 3a . This trend was consistent for all racially minoritised groups, illustrated in figure 4a . As displayed in Table 2 , in adjusted models, the overall number of new admissions reduced slightly (IRR 0.87 (0.75-1.00)) during the first lockdown period and returned to the same rate following the lift of the first lockdown. However, the number of new compulsory detentions rose during the first lockdown (IRR 1.25 (1.02-1.54)). This trend was not noted across all racially minoritised groups, and in fact, was mostly driven by the Black Caribbean group, who experienced a significant rise in daily new detentions compared to the pre-lockdown period (IRR 1.54 (1.08-2.20)) despite not showing a corresponding increase in total new admissions (i.e. comprising both voluntary admissions and compulsorily detentions, IRR 1.17 (0.86-1.58)) Further, there was a consistent decrease in the total number of Black Caribbean patients who were inpatients (IRR 0.81 (0.80-0.28), Supplementary Table 3.2) and total number of Black Caribbean inpatients who were detained (IRR 0.78 (0.77-0.80), suggesting that Black Caribbean patients were being detained more frequently, however were not being kept as inpatients for as long as they had previously. Download figure Open in new tab Figure 3: Line graph showing the unadjusted changes in the total number of inpatients and number of inpatients detained within mental health services during (a) the first lockdown period from 23 rd March 2020 to 13 th May 2020 and (b) the second lockdown period from 2 nd November 2020 to 8 th March 2021. Dashed lines show the trends during the 2016/2017 and 2018/2019 control periods. Download figure Open in new tab Figure 4: Line graph showing the unadjusted changes in the total number of inpatients and number of inpatients detained, by ethnicity, within SLaM services. Dashed lines show the trends during the 2016/2017 and 2018/2019 control periods. View this table: View inline View popup Download powerpoint Table 2: Incidence Rate Ratios (IRR) indicating changes in daily admissions (informal admissions + compulsory detentions) and compulsory detentions associated with lockdown compared to the pre-lockdown periods, stratified by ethnicity, adjusted for seasonal and weekly trends. Results obtained using zero inflated Poisson regression models accounting for lower admission rates on different days of the week and robust standard errors. There were fewer changes associated with the second lockdown (2 November 2020 - 8 March 2021), as shown in figure 3b and figure 4b . After adjusting for seasonal and weekly trends, accounting for the control period, there was a slight drop in the total inpatients (IRR 0.87 (0.86-0.27), Supplementary Table 3.2) and compulsory detentions (IRR 0.92 (0.91-0.93), Supplementary Table 3.2) during lockdown 2, and this continued past the lift of the lockdown on 8 March 2021. However, this trend was not universally observed in all racially minoritised groups: the total number of inpatients and compulsory detentions rose for both the White Other and Black African groups in lockdown 2 (supplementary table 3.2). Table 2 shows no overall change in the total number of daily new admissions associated with the second lockdown period, however, there was an increase in the Black Caribbean group (IRR 1.31 (1.02-1.67). Further, there was an increase in the number of new daily compulsory detentions associated with the second lockdown (IRR 1.28 (1.11-1.49)). This appeared to be mainly driven by an increase in new compulsory detentions in the Black Caribbean group (IRR 1.53 (1.14-2.06)) and the Black African group (IRR 1.57 (1.06-2.34)). In post hoc analyses, we restricted the sample to those who were admitted for the first time to psychiatric units during the pandemic. The restriction was undertaken to assess the possibility that potential changes to community mental health service provision at the time of the pandemic (i.e. reduced access and/ or transition to remote provision over face-to-face contacts), had impacted associations. Despite the sample restriction, which resulted in a smaller overall sample size (initial sample n=15,869 reduced to n=11,033 with restrictions), we found a higher effect size for detentions at all times points in the total sample, but with no changes to estimates for daily new admissions overall. In addition, rates of compulsory admissions were higher in the Black Caribbean group during the second lockdown (IRR 2.07 (95% CI: 1.11, 3.84) in the sample restricted to first contacts vs. IRR: 1.53 (95% CI: 1.14, 2.06) in the unrestricted sample) (supplementary table 5). In sensitivity analyses we observed evidence of an anticipatory effect in the week leading up to the first UK lockdown, with similar effect sizes to those observed in the main analyses but not as large (see Supplementary Materials 4 Table 4.1). Our findings were robust to further sensitivity analyses which assessed the sensitivity of changes associated with the start of the lockdown lifts (see supplementary table 4.) and sensitivity analyses to check that the findings were not an artefact of pre-lockdown time periods (see supplementary table 4.2). Discussion There have been longstanding concerns that individuals from ethnic minority groups in the UK and across international settings experience inequalities in higher levels of compulsory psychiatric detentions;( 8 ) however, it was unknown how lockdown measures implemented during the COVID-19 pandemic affected this. In line with mental health service trends reported during the early acute stages of the pandemic,( 1 , 3 ) we found that admissions to mental health units dropped significantly during lockdown periods for mental health service users within our sample, irrespective of ethnicity. In contrast, there were more detentions across the study sample during lockdown periods, which were driven by higher rates of detentions in Black Caribbean and Black African people relative to pre-lockdown reference periods. This study is the first to highlight how COVID-19 lockdown measures exacerbated pre-existing ethnic inequalities in compulsory psychiatric detentions. The findings may be attributed to pre-existing social, economic, and health inequalities which were amplified in the pandemic context, alongside concerns that structurally-mediated racism was potentially magnified during the pandemic.( 9 ) People from some ethnic minority backgrounds in Western countries experience disadvantage relating to social and economic determinants of mental health( 18 ) and policies and laws enacted during the pandemic reinforced and widened these inequalities, having a disproportionate impact on the health and wellbeing of racialised groups.( 9 , 19 ) For example, research in the U.S. demonstrated that individuals from ethnic minority groups were more likely to be laid-off or lose employment income during the pandemic,( 19 , 20 ) experience housing instability( 21 ) and food insecurity due to financial difficulties.( 19 , 22 ) Individuals from ethnic minority groups were also more likely to reside in crowded housing, rely on public transportation, and be working in low-wage essential jobs which lacked paid sick leave, ability to work remotely, and increased regular contact with strangers, directly and indirectly increasing the risk of COVID-19 infection, as well as possible stress and anxiety associated with this.( 23 ) Similar inequalities have been reported in the UK( 24 , 25 ). During lockdown periods, restrictions made it difficult for families to cope with COVID-19-related losses, as they could not be involved in the normal processes of death (e.g., saying goodbye or holding a funeral) and access to usual social support systems were reduced.( 26 , 27 ) Outside of the pandemic context, studies from both the UK and US have argued that ethnic minority groups often fear seeking treatment for early symptoms of mental illness due to experiences of racism and discrimination, stigma associated with religious/spiritual practices, mistrust of services, lack of knowledge, fears of confidentiality, and language and cultural barriers.( 6 , 12 , 28 – 30 ) This underrepresentation in primary mental health care can lead to more chronic episodes of mental illness, greater functional limitations, and overrepresentation in crisis pathways. During the pandemic, there were challenges in reaching some ethnic minority groups in the UK following closure of community organisations and the transition to remote service delivery for usual check-ups and providing resources.( 27 ) Community service closures during lock-downs may have made people who were already isolated more vulnerable.( 27 ) The provision of remote healthcare would have further disadvantaged those due to the ‘digital divide’ (the gap between those who have access to digital technologies and those who do not).( 30 ). A previous qualitative study of racially minoritised service users from the same catchment of this study, specifically highlighted the adverse impacts of the abrupt withdrawal and/ or rapid transition to telephone and video contacts for the delivery of mental healthcare, hospital appointments, social service and community/ voluntary organisation contacts on the mental health of people living with severe mental health conditions and on their carers ( 27 ). Participants in this study reported how the withdrawal of support adversely impacted their health and ability to access care, with resultant detrimental impacts on pathways into care, which were then delayed or disrupted ( 27 ). The findings in the study highlighted at least one account of police intervention, which was attributed to disruptions in access to home treatment teams during the pandemic ( 27 ). In addition, our post-hoc analyses suggested that when the sample was restricted to first admissions (i.e. excluding those not previously known to mental health services) rates of compulsory detentions were even higher for the total sample. In addition, rates of compulsory detentions were higher for Black Caribbean service users during the second lockdown, in the sample restricted to first contacts. This could imply that changes to UK community health service provision during the pandemic were potentially implicated in higher compulsory admissions as early/ timely access may have been disrupted, however this latter observation will need further exploration. Some adults from Black ethnic backgrounds in England have described mental health services as disempowering,( 31 ) and detention as a racist and racialised experience, inseparable from a wider context of systemic racism, inequality, and stigma within families and communities.( 32 ) The numbers of people compulsorily detained for treatment in the UK has doubled since 1983 when the most recent legislation governing compulsory admissions to inpatient mental health care was introduced, despite the prevalence of psychosis remaining broadly stable over the same time period.( 33 ) Our observation that there may have been similar, or even elevated rates of compulsory admission in people who had not previously been admitted to mental health services during the pandemic further highlights the potential increase in use of compulsory admissions. In recognition of this increase in detentions, and the persisting ethnic inequalities, there are current moves to reform UK legislation regarding compulsory detention of people suffering from mental health disorders.( 34 , 35 ) The review included the development of a Patient and Carers Race Equality Framework that aims to improve mental health services for people who belong to racialised minority groups.( 36 ) While these developments are important in addressing the overrepresentation of ethnic minority individuals in mental health crisis pathways, the present study has shown that we need to ensure that systems are also responsive and effective during times of crisis, in which inequalities across a range of wider determinants of mental health are synergistically exacerbated for individuals from marginalised and ethnic minority groups.( 23 ). In addition, our findings suggest a need to directly tackle systemic racism in criminal justice and healthcare systems. The methods to address this at systems-level may vary across international contexts. An example of an approach includes the rollout across England of the Patient and Carer Race Equality Framework (PCREF), following the 2018 Mental Health Act Review which highlighted high rates of coercive admissions in racialised minority groups ( 27 ). PCREF in England aims to embed anti-racism within mental health service provision, through partnership working with racialised communities leading to coproduced services, through interventions to tackle racism and implicit biases in the workforce, and through improving data collection, leading to better monitoring and delivery of equitable mental healthcare for racialised communities. Although this is an important initiative which will potentially improve secondary mental health care in England, previous research has indicated that experiences of racism and racial discrimination are pervasive and persistent across domains, and throughout the life course( 37 ). As such, anti-racism initiatives that target single systems are not sufficient to address structural racism; what is needed are multisector, equity-oriented initiatives and policy reform.( 38 ) This study’s strength lies in the utilisation of routine data from a large healthcare provider that covers an ethnically diverse population within southeast London. In the UK, most care is provided freely under the National Health Service (NHS), with the mental health Trust in the present study being the sole NHS secondary mental healthcare provider in this area. Therefore, we can be confident that the analyses would have captured most mental health hospital admissions within the catchment, although a few private providers do also operate in the area of the study. Additionally, the study was conducted over a 5-year period spanning a pre-pandemic period which enabled robust comparisons with a prior reference period, and we adjusted for seasonal and weekly trends across models. Some limitations should be considered. First, the study reports the effect of UK lockdowns on one healthcare provider in one region of the UK. The trends observed in this study may differ from other regions in the UK, however are likely to generalise to other similar urban, and ethnically diverse catchment areas elsewhere. There were also limitations in sample size, particularly for some minority ethnic groups, which may have led to some analyses being underpowered. We had to combine ethnicity groups due to smaller sample sizes, (eg. ‘South Asian’ group included Indian, Pakistani, Bangladeshi people), which would have masked heterogeneity. Further, due to the study design, we assumed other characteristics, such as area deprivation, remained constant between the different comparison periods and cut points, and we were unable to account for the potential confounding effect of these and other factors within our analysis. Our study only followed the sample during the initial lockdown phases of the pandemic, and so should not be extrapolated out of this context. In conclusion, there is a need to address ethnic inequalities in compulsory psychiatric detentions and attend to the exacerbation of pre-existing social and economic inequalities during health emergencies like the COVID-19 pandemic, in the UK and internationally. This cannot be achieved without first ensuring primary mental health care is culturally safe and appropriate, reaching ethnic minority groups early. In England, Mental Health Act reform will play a role in potentially preventing these evident ethnic inequalities within inpatient mental health services. Importantly, there is a need to address systemic racism within criminal justice and healthcare systems to reduce the overrepresentation of ethnic minority individuals in crisis pathways. Funding This paper represents independent research funded by The Health Foundation’s COVID-19 research priorities programme-award reference 2238180, which part supported JO and RH. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. JDM is part supported by the ESRC Centre for Society and Mental Health at KCL (ESRC Reference: ES/S012567/1). JO is part supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. MH, RS, JDM and AD are part supported by the National Institute for Health and Care Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust. LB is supported by the Nuffield Foundation (WEL/43881), the ESRC (ES/V013475/1; ES/W000849/1), and the Health Foundation (AIMS 1874695). RH is currently funded by a doctoral studentship granted by the ESRC managed by King’s College London (ESRC KCL LISS-DTP). JD has additionally received funding from the Health Foundation working together with the Academy of Medical Sciences, for a Clinician Scientist Fellowship. JD and TO are additionally funded by UK Research and Innovation funding for the Population Mental Health Consortium (Grant no MR/Y030788/1) which is part of Population Health Improvement UK (PHI-UK), a national research network which works to transform health and reduce inequalities through change at the population level. RS is additionally part-funded by: i) the National Institute for Health and Care Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust; ii) UKRI – Medical Research Council through the DATAMIND HDR UK Mental Health Data Hub (MRC reference: MR/W014386); iii) the UK Prevention Research Partnership (Violence, Health and Society; MR-VO49879/1), an initiative funded by UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities. The views expressed are those of the author[s] and not necessarily those of UKRI, NIHR or King’s College London. Conflict of interest RS declares research support received within the last 3 years from GSK and Takeda. All other authors declare no conflicts of interest Contributorship JDM, IB, RH conceived and designed the study. JDM led acquisition of the data for analysis. Analysis of the data was led by RH, supported by JDM and IB. All authors-RH, TO, IB, LB, AD, JD, MH, JO, RS, JDM contributed to interpretation of data analyses. Drafting of the work was led by RH and TO, supported by JDM. All authors (RH, TO, IB, LB, AD, JD, MH, JO, RS, JDM) reviewed the work critically for important intellectual content. All authors (RH, TO, IB, LB, AD, JD, MH, JO, RS, JDM) have approved the final version for it to be published. All authors agree to be accountable for the work done. Data Availability The data are not publicly available. Data are owned by a 3rd party SLaM BRC CRIS tool which provides access to anonymised data derived from SLaM electronic medical records. These data can only be accessed by permitted individuals from within a secure firewall (i.e. remote access is not possible and the data cannot be sent elsewhere) in the same manner as the authors, following relevant project approvals. Analytic code may be available by contacting the lead author (RH) or corresponding author (JDM). Footnotes ↵ * Joint first author References 1. ↵ Bakolis I , Stewart R , Baldwin D , Beenstock J , Bibby P , Broadbent M , et al. Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 ‘lockdown’policy in 10 UK sites: a regression discontinuity in time design . BMJ open . 2021 ; 11 ( 5 ): e049721 . OpenUrl Abstract / FREE Full Text 2. ↵ Chen S , Jones PB , Underwood BR , Moore A , Bullmore ET , Banerjee S , et al. The early impact of COVID-19 on mental health and community physical health services and their patients’ mortality in Cambridgeshire and Peterborough, UK . Journal of psychiatric research . 2020 ; 131 : 244 – 54 . OpenUrl CrossRef PubMed 3. ↵ Anderson KN , Radhakrishnan L , Lane RI , Sheppard M , DeVies J , Azondekon R , et al. Changes and Inequities in Adult Mental Health–Related Emergency Department Visits During the COVID-19 Pandemic in the US . JAMA Psychiatry . 2022 ; 79 ( 5 ): 475 – 85 . OpenUrl PubMed 4. ↵ Kim J , Rao N , Collins A , Eboh T , Chugh J , Sheladia S , et al. Retrospective Study of Psychiatric Hospitalizations in a West Texas Mental Health Treatment Facility during the COVID-19 Pandemic . Southern medical journal . 2023 ; 116 ( 2 ): 170 . OpenUrl PubMed 5. ↵ Halvorsrud K , Nazroo J , Otis M , Brown Hajdukova E , Bhui K . Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis . BMC Medicine . 2018 ; 16 ( 1 ): 223 . OpenUrl PubMed 6. ↵ Devonport TJ , Ward G , Morrissey H , Burt C , Harris J , Burt S , et al. A Systematic Review of Inequalities in the Mental Health Experiences of Black African, Black Caribbean and Black-mixed UK Populations: Implications for Action . Journal of Racial and Ethnic Health Disparities . 2023 ; 10 ( 4 ): 1669 – 81 . OpenUrl 7. ↵ Bhui K , Ullrich S , Kallis C , Coid JW . Criminal justice pathways to psychiatric care for psychosis . The British Journal of Psychiatry . 2015 ; 207 ( 6 ): 523 – 9 . OpenUrl Abstract / FREE Full Text 8. ↵ Barnett P , Mackay E , Matthews H , Gate R , Greenwood H , Ariyo K , et al. Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data . The Lancet Psychiatry . 2019 ; 6 ( 4 ): 305 – 17 . OpenUrl PubMed 9. ↵ Harris S , Joseph-Salisbury R , Williams P , White L . Notes on policing, racism and the Covid-19 pandemic in the UK . Race & Class . 2022 ; 63 ( 3 ): 92 – 102 . OpenUrl 10. ↵ Lee , Singh . Monthly Trends in Access to Care and Mental Health Services by Household Income Level During the COVID-19 Pandemic, United States, April: December 2020 . Health Equity . 2021 ; 5 ( 1 ): 770 – 9 . OpenUrl PubMed 11. ↵ Adepoju OE , Chae M , Ojinnaka CO , Shetty S , Angelocci T . Utilization Gaps During the COVID-19 Pandemic: Racial and Ethnic Disparities in Telemedicine Uptake in Federally Qualified Health Center Clinics . Journal of General Internal Medicine . 2022 ; 37 ( 5 ): 1191 – 7 . OpenUrl CrossRef PubMed 12. ↵ Bansal N , Karlsen S , Sashidharan SP , Cohen R , Chew-Graham CA , Malpass A . Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography . PLOS Medicine . 2022 ; 19 ( 12 ): e1004139 . OpenUrl 13. ↵ Impara E , Bakolis I , Bécares L , Dasch H , Dregan A , Dyer J , et al. COVID-19 ethnic inequalities in mental health and multimorbidities: protocol for the COVEIMM study . Social Psychiatry and Psychiatric Epidemiology . 2022 ; 57 ( 12 ): 2511 – 21 . OpenUrl PubMed 14. ↵ Perera G , Broadbent M , Callard F , Chang C-K , Downs J , Dutta R , et al. Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) case register: current status and recent enhancement of an electronic mental health record-derived data resource . BMJ open . 2016 ; 6 ( 3 ): e008721 . OpenUrl Abstract / FREE Full Text 15. ↵ Brown J , Kirk-Wade E , Baker C , S. B. Coronavirus: A history of English lockdown laws . 2021 . https://researchbriefings.files.parliament.uk/documents/CBP-9068/CBP-9068.pdf . 16. ↵ Hausman C , Rapson DS . Regression discontinuity in time: Considerations for empirical applications . Annual Review of Resource Economics . 2018 ; 10 ( 1 ): 533 – 52 . OpenUrl 17. ↵ Hildersley R , Easter A , Bakolis I , Carson L , Howard LM . Changes in the identification and management of mental health and domestic abuse among pregnant women during the COVID-19 lockdown: regression discontinuity study . BJPsych open . 2022 ; 8 ( 4 ): e96 . OpenUrl PubMed 18. ↵ Mude W , Oguoma VM , Nyanhanda T , Mwanri L , Njue C . Racial disparities in COVID-19 pandemic cases, hospitalisations, and deaths: A systematic review and meta-analysis . J Glob Health . 2021 ; 11 : 05015 . OpenUrl PubMed 19. ↵ Perry BL , Aronson B , Pescosolido BA . Pandemic precarity: COVID-19 is exposing and exacerbating inequalities in the American heartland . Proceedings of the National Academy of Sciences . 2021 ; 118 ( 8 ): e2020685118 . OpenUrl Abstract / FREE Full Text 20. ↵ Park J . Who is hardest hit by a pandemic? Racial disparities in COVID-19 hardship in the U.S . International Journal of Urban Sciences . 2021 ; 25 ( 2 ): 149 – 77 . OpenUrl CrossRef 21. ↵ Chun Y , Roll S , Miller S , Lee H , Larimore S , Grinstein-Weiss M . Racial and Ethnic Disparities in Housing Instability During the COVID-19 Pandemic: the Role of Assets and Income Shocks. Journal of Economics , Race, and Policy . 2023 ; 6 ( 2 ): 63 – 81 . OpenUrl 22. ↵ Morales DX , Morales SA , Beltran TF . Racial/Ethnic Disparities in Household Food Insecurity During the COVID-19 Pandemic: a Nationally Representative Study . Journal of Racial and Ethnic Health Disparities . 2021 ; 8 ( 5 ): 1300 – 14 . OpenUrl 23. ↵ Khazanchi R , Evans CT , Marcelin JR. Racism , Not Race , Drives Inequity Across the COVID-19 Continuum . JAMA Network Open . 2020 ; 3 ( 9 ): e2019933 -e. OpenUrl 24. ↵ Finney N , Nazroo J , Bécares L , Kapadia D , Shlomo N . Racism and Ethnic Inequality in a Time of Crisis: Findings from the Evidence for Equality National Survey . Policy Press , 2023 . 25. ↵ Ellingworth D , Bécares L , Šťastná M , Nazroo J. Racism and racial discrimination . In: Racism and ethnic inequality in a time of crisis : 54 – 77 . Policy Press , 2023 . 26. ↵ Torrens-Burton A , Goss S , Sutton E , Barawi K , Longo M , Seddon K , et al. ‘It was brutal. It still is’: a qualitative analysis of the challenges of bereavement during the COVID-19 pandemic reported in two national surveys . Palliative Care and Social Practice . 2022 ; 16 : 26323524221092456 . OpenUrl 27. ↵ Ocloo J , Stuart R , Dasch HK , Dyer J , Choudhury D , McAnuff L , et al. Living less safely through the pandemic in England for people with serious mental and physical health conditions: qualitative interviews with service users and carers of Black African, Caribbean, and South-Asian descent . BMC Public Health . 2024 ; 24 ( 1 ): 2718 . OpenUrl PubMed 28. ↵ Bruce M , Smith J . Length of stay among multi-ethnic psychiatric inpatients in the United Kingdom . Comprehensive Psychiatry . 2020 ; 102 : 152201 . OpenUrl CrossRef PubMed 29. Ahmad G , Cooper C , Das-Munshi J , Hatch SL , McManus S . Prevalence of common mental disorders and treatment receipt for people from ethnic minority backgrounds in England: repeated cross-sectional surveys of the general population in 2007 and 2014 . The British Journal of Psychiatry . 2022 ; 221 ( 3 ): 520 – 7 . OpenUrl PubMed 30. ↵ Winsper C , Bhattacharya R , Bhui K , Currie G , Edge D , Ellard D , et al. The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives . The British Journal of Psychiatry . 2024 ; 224 ( 5 ): 150 – 6 . OpenUrl PubMed 31. ↵ Lawrence V , McCombie C , Nikolakopoulos G , Morgan C . Ethnicity and power in the mental health system: experiences of white British and black Caribbean people with psychosis . Epidemiology and Psychiatric Sciences . 2021 ; 30 : e12 . OpenUrl 32. ↵ Solanki J , Wood L , McPherson S . Experiences of adults from a Black ethnic background detained as inpatients under the Mental Health Act (1983) . Psychiatric Rehabilitation Journal . 2023 ; 46 ( 1 ): 14 – 20 . OpenUrl CrossRef PubMed 33. ↵ Hawkes N . Mental Health Act must be updated to give patients power over care, says review . BMJ . 2018 ; 363 : k5189 . OpenUrl FREE Full Text 34. ↵ Dyer C . Reforms to Mental Health Act aim to tackle poor care and racial inequalities . BMJ . 2021 ; 372 : n103 . OpenUrl FREE Full Text 35. ↵ UK Government . Independent Review of the Mental Health Act . UK. https://www.gov.uk/government/groups/independent-review-of-the-mental-health-act#:~:text=The%20review%20was%20set%20up,groups%20detained%20under%20the%20Act . 36. ↵ NHS England . Advancing mental health equalities . 2020 . https://www.england.nhs.uk/mental-health/advancing-mental-health-equalities/ . 37. ↵ Bécares L , Taylor H , Nazroo J , Kapadia D , Finney N , Begum N , et al. The persistence and pervasiveness of racial discrimination in Great Britain: capturing experienced racial discrimination over time and life domains . Ethnic and Racial Studies . 2024 : 1 – 22 . 38. ↵ Bailey ZD , Krieger N , Agenor M , Graves J , Linos N , Bassett MT . Structural racism and health inequities in the USA: evidence and interventions . Lancet . 2017 ; 389 ( 10077 ): 1453 – 63 . OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted May 06, 2025. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study R. Hildersley , T.K. Oswald , I Bakolis , L Becares , A. Dregan , J Dyer , M. Hotopf , J. Ocloo , R Stewart , J. Das-Munshi medRxiv 2025.05.02.25326888; doi: https://doi.org/10.1101/2025.05.02.25326888 Share This Article: Copy Citation Tools Ethnic inequalities in compulsory psychiatric hospital detentions during UK COVID-19 ‘lockdowns’: A Regression Discontinuity Design in time study R. Hildersley , T.K. Oswald , I Bakolis , L Becares , A. Dregan , J Dyer , M. Hotopf , J. Ocloo , R Stewart , J. Das-Munshi medRxiv 2025.05.02.25326888; doi: https://doi.org/10.1101/2025.05.02.25326888 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Psychiatry and Clinical Psychology Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4436) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6600) Geriatric Medicine (668) Health Economics (997) Health Informatics (4538) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (542) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3333) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9232) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a00f81706be74807',t:'MTc3OTY1OTMxNw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();