Higher ‘Chemical Restraint’ Rates in Black Psych Patients in the ED

Black patients presenting with psychiatric disorders to hospital emergency departments (EDs) across the US have significantly higher rates of chemical restraint than their white counterparts, new research shows.

Results of a national study showed Black patients presenting to the ED were 63% more likely to receive chemical sedation than white patients. The investigators also found White patients were more likely to receive chemical sedation at hospitals with a higher proportion of Black patients — a finding that suggests hospital demographics influence practice patterns and that structural racism may be a root cause.

“There is a large disparity in the rates at which patients who presented to EDs nationally in the US are restrained by race. You are 63% more likely, for the same set of chief complaints, to be chemically sedated if you are Black vs if you’re White,” senior investigator Ari Friedman, MD, PhD, an assistant professor of Emergency Medicine, and Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, told Medscape Medical News.

“The major mediator of that difference is the institution you are at — hospitals that primarily serve Black patients are more likely to chemically sedate their patients for these chief complaints — including White patients. So, it’s mediated by the practice pattern and environment,” Friedman added.

The study was published in the May issue of Annals of Epidemiology.

First Large-Scale Study

Chemical sedation, also known as chemical restraint, is used to calm and help protect patients from harming themselves or others. Previous research on racial differences in the care of ED psychiatric patients with agitation suggests that there may be treatment disparities.

“Previous research from single institutions have shown that Black patients are more likely than White patients to be physically restrained, and this has been shown to be true among adult patients and pediatric patients,” lead author Utsha Khatri, MD, assistant professor of Emergency Medicine at the Icahn School of Medicine in New York, told Medscape Medical News.

Specifically, two single-institution studies within the last year revealed similar disparities, with higher rates of physical restraint for Black and Hispanic psychiatric patients in the ED. Another recent study showed an association with race, ethnicity, and pharmacological restraint use among pediatric patients presenting to the ED for mental health concerns.

“There has been work in psychiatry on disparities in this context, although there is less work in emergency departments,” said Friedman. “We looked across all US EDs as opposed to within a single health system. The major trade-offs for us were that we weren’t able to observe restraint orders, which don’t find their way into national datasets, so we had to make some inferences based on the type of medications given.”

For the study the investigators analyzed data from 2008-2018 through the National Hospital Ambulatory Medical Survey (NHAMCS) database. They examined the association of race and the administration of chemical sedation, with either an antipsychotic or ketamine, in ED visits for psychiatric disorders. These were any visit where the reason for the visit was “symptoms referable to psychological and mental disorders.”

Of the 76.2 million total ED visits evaluated, the researchers found that Black patients presenting with a psychiatric disorder were significantly more likely to receive chemical sedation with antipsychotics or ketamine than White patients presenting with the same conditions (5.3% vs 3.0%; P < .01). This difference remained significant when accounting for admission or transfer to psychiatric facilities.

Combatting the Forces of Racism

When researchers accounted for the percent of hospital population that was Black, they found that patient race no longer affected the likelihood of chemical restraint.

“We found the key source of this racial disparity in use of chemical sedation is accounted for by the fact that hospitals that treat a higher proportion of Black patients tend to use more sedation,” said Khatri.

“Our findings suggest that patients who present to hospitals that serve a patient population that is 60% Black would have [a] Roughly 1.8 times the likelihood of getting chemically sedated compared with a hospital that serves a population that is 10% Black,” she added.

“When a hospital has fewer resources, they often don’t have the staff or time to de-escalate a patient in distress, and can have to resort to chemical sedation more quickly than a hospital with ample staff and resources,” said Friedman in a release.

Khatri added that the study highlights the need to combat the forces of racism by focusing not just on the provider bias but by addressing the “underlying structural issues that lead to Black patients getting worse care based on where they live.”

“Hospitals have unequal distribution of resources and quality, largely patterned on the racial makeup of their patients. Dedicated training and funding for de-escalation techniques as well as sufficient staffing and availability of outpatient mental healthcare may help keep both patients and staff safe by reducing the use of physical restraint and chemical sedation in appropriate circumstances,” said Khatri.

Friedman noted that there will always be a need for restraint use to facilitate rapid medical evaluation and stabilization of patients but “we want to make it as humane, thoughtful, and rare as possible, and to have a large armamentarium of alternative strategies that can be equitably applied across emergency departments.”

Need for Widespread, Systemic Change

Commenting on the findings for Medscape Medical NewsRegina James, MD, the American Psychiatric Association’s chief of Diversity and Health Equity and deputy medical director, said the large-scale study confirms the widespread existence of racial and ethnic disparities in patients with psychiatric disorders.

“This study and previous studies, not only in psychiatry but in other areas of medicine, all bring to light that there continues to be evidence of racial and ethnic disparities in healthcare, and this is consistent across a range of illnesses and healthcare services,” said James.

“It’s important that as we think about the solution we also think about the etiology of the problem and the layers that have contributed to it — understanding, embracing, and recognizing that these differences didn’t just come up de novo. It’s policies, practices , and behaviors that got us to this point, and it’s going to be policies, practices, and behaviors that are going to move us away from this point,” James noted.

She added that future research should focus on further understanding which factors exacerbate agitation among patients and what resources directed at the hospital level, including de-escalation training, nursing staff, and waiting room crowding may be effective at reducing the use of chemical sedation when clinically appropriate.

The authors and James report no relevant financial conflicts of interest.

Annals of Epidemiology. Published May 2022: 69;9-16. Abstract.

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