Journal Article Annotations
2022, 3rd Quarter

Diversity, Equity, and Inclusion

Annotations by Arslaan Arshed, MD MS MHA
October, 2022

Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation.
Association of Everyday Discrimination With Depressive Symptoms and Suicidal Ideation During the COVID-19 Pandemic in the All of Us Research Program.
The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes.

PUBLICATION #1 — Diversity, Equity, and Inclusion

Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation.

Colin M Smith, Nicholas A Turner, Nathan M Thielman, Damon S Tweedy, Joseph Egger, Jane P Gagliardi

Abstract: Psychiatr Serv. 2022 Jul;73(7):730-736. doi: 10.1176/appi.ps.202100474. Epub 2021 Dec 21.

Objective:
Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their White counterparts.

Methods:
This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood alcohol concentration, and diagnosis of a bipolar or psychotic disorder.

Results:
A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07-1.72) and chemically (AOR=1.33; 95% CI=1.15-1.55) restrained than White patients.

Conclusions:
After analyses were adjusted for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with White patients, which is consistent with the growing body of evidence revealing racial disparities in psychiatric care.

Annotation

The finding:
The study examined 12,977 patient encounters between 2014-2020 in a large academic center in Durham, North Carolina and found that Black patients undergoing emergent psychiatric evaluation had higher odds of being subject to physical or chemical restraints compared to white patients.

Strength and weaknesses:
This is one of few articles addressing restraints in psychiatric settings and how their use is associated with Race/Ethnicity. Limitations include generalizability of findings owing the research population and study setting from an academic institution in North Carolina.

Relevance:
C-L psychiatrists frequently respond to and manage behavioral emergencies. C-L psychiatrists must consider the historical and racial implications of restraining Black patients and be cognizant of how biases may affect these significant patient care decisions.

PUBLICATION #2 — Diversity, Equity, and Inclusion

Association of Everyday Discrimination With Depressive Symptoms and Suicidal Ideation During the COVID-19 Pandemic in the All of Us Research Program.

Younga H Lee, Zhaowen Liu, Daniel Fatori, Joshua R Bauermeister, Rebecca A Luh, Cheryl R Clark, Sarah Bauermeister, André R Brunoni, Jordan W Smoller

Abstract: JAMA Psychiatry. 2022 Sep 1;79(9):898-906. doi: 10.1001/jamapsychiatry.2022.1973.

Importance:
The COVID-19 pandemic has coincided with an increase in depressive symptoms as well as a growing awareness of health inequities and structural racism in the United States.

Objective:
To examine the association of mental health with everyday discrimination during the pandemic in a large and diverse cohort of the All of Us Research Program.

Design, setting, and participants:
Using repeated assessments in the early months of the pandemic, mixed-effects models were fitted to assess the associations of discrimination with depressive symptoms and suicidal ideation, and inverse probability weights were applied to account for nonrandom probabilities of completing the voluntary survey.

Main outcomes and measures:
The exposure and outcome measures were ascertained using the Everyday Discrimination Scale and the 9-item Patient Health Questionnaire (PHQ-9), respectively. Scores for PHQ-9 that were greater than or equal to 10 were classified as moderate to severe depressive symptoms, and any positive response to the ninth item of the PHQ-9 scale was considered as presenting suicidal ideation.

Results:
A total of 62 651 individuals (mean [SD] age, 59.3 [15.9] years; female sex at birth, 41 084 [65.6%]) completed at least 1 assessment between May and July 2020. An association with significantly increased likelihood of moderate to severe depressive symptoms and suicidal ideation was observed as the levels of discrimination increased. There was a dose-response association, with 17.68-fold (95% CI, 13.49-23.17; P < .001) and 10.76-fold (95% CI, 7.82-14.80; P < .001) increases in the odds of moderate to severe depressive symptoms and suicidal ideation, respectively, on experiencing discrimination more than once a week. In addition, the association with depressive symptoms was greater when the main reason for discrimination was race, ancestry, or national origins among Hispanic or Latino participants at all 3 time points and among non-Hispanic Asian participants in May and June 2020. Furthermore, high levels of discrimination were as strongly associated with moderate to severe depressive symptoms as was history of prepandemic mood disorder diagnosis.

Conclusions and relevance:
In this large and diverse sample, increased levels of discrimination were associated with higher odds of experiencing moderate to severe depressive symptoms. This association was particularly evident when the main reason for discrimination was race, ancestry, or national origins among Hispanic or Latino participants and, early in the pandemic, among non-Hispanic Asian participants.

Annotation

The finding:
Utilizing population data from NIH’s All of Us Research Program, people who reported discrimination a few times a month or at least once a week over the past month had up to a 3-fold and 10-fold increase, respectively, in the odds of moderate to severe depressive symptoms. Everyday discrimination was associated with suicidal ideation, and associations with depressive symptoms were stronger when the main reason for discrimination was race, ancestry, or national origins.

Strength and weaknesses:
This is the largest and diverse study conducted in the United States examining the mental health effect of everyday discrimination during the COVID-19 pandemic. However, selection biases may result from a focus on English- and Spanish-language speakers and the use of a digital interface for study procedures. Furthermore, the study did not account for potential confounding by regional variation in the levels of racial discrimination and COVID-19 infection rates.

Relevance:
C-L psychiatrists must be aware of how every-day discrimination and impact the well-being and mental health of patients and healthcare staff.

PUBLICATION #3 — Diversity, Equity, and Inclusion

The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes.

Teresa Janevic, Whitney Lieb, Erona Ibroci, Jezelle Lynch, Molly Lieber, Nina M Molenaar, Anna-Sophie Rommel, Lotje de Witte, Sophie Ohrn, Juan Manuel Carreño, Florian Krammer, Lauren B Zapata, Margaret Christine Snead, Rachel I Brody, Rebecca H Jessel, Stephanie Sestito, Alan Adler, Omara Afzal, Frederieke Gigase, Roy Missall, Daniel Carrión, Joanne Stone, Veerle Bergink, Siobhan M Dolan, Elizabeth A Howell, Krammer Serology Core Study Group

Abstract: Am J Obstet Gynecol MFM. 2022 Jul;4(4):100649. doi: 10.1016/j.ajogmf.2022.100649. Epub 2022 Apr 21.

Background:
Structural racism and pandemic-related stress from the COVID-19 pandemic may increase the risk of adverse birth outcomes.

Objective: Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with 3 outcomes: SARS-CoV-2 infection, preterm birth, and delivering small-for-gestational-age newborns. Our secondary objective was to investigate the joint association of SARS-CoV-2 infection during pregnancy and neighborhood measures with preterm birth and delivering small-for-gestational-age newborns.

Study design:
We analyzed data of 967 patients from a prospective cohort of pregnant persons in New York City, comprising 367 White (38%), 169 Black (17%), 293 Latina (30%), and 87 Asian persons (9%), 41 persons of other race or ethnicity (4%), and 10 of unknown race or ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zone improvement plan code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We obtained data on preterm birth and small-for-gestational-age newborns from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zone improvement plan code to estimate associations of each neighborhood measure separately with 3 outcomes: SARS-CoV-2 infection, preterm birth, and small-for-gestational-age newborns. Covariates included maternal age, parity, insurance status, and body mass index. Models with preterm birth and small-for-gestational-age newborns as the dependent variables additionally adjusted for SARS-CoV-2 infection.

Results:
A total of 193 (20%) persons were SARS-CoV-2-seropositive, and the overall risks of preterm birth and small-for-gestational-age newborns were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered a small-for-gestational-age infant. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered a small-for-gestational-age infant. In adjusted analyses, structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and preterm birth, but not small-for-gestational-age infants. High vs low structural disadvantage was associated with an adjusted relative risk of 2.6 for infection (95% confidence interval, 1.7-3.9) and 1.7 for preterm birth (95% confidence interval, 1.0-2.9); high vs low racial-economic segregation was associated with adjusted relative risk of 1.9 (95% confidence interval, 1.3-2.8) for infection and 2.0 (95% confidence interval, 1.3-3.2) for preterm birth; high vs low community unemployment increase was associated with adjusted relative risk of 1.7 (95% confidence interval, 1.2-1.5) for infection and 1.6 (95% confidence interval, 1.0-2.8) for preterm birth. COVID-19 mortality rate was associated with SARS-CoV-2 infection but not preterm birth or small-for-gestational-age infants. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on preterm birth or small-for-gestational-age infants.

Conclusion:
Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and preterm birth, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of preterm birth independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.

Annotation

The finding:
Neighborhood measures of structural racism were associated with the incidence of both COVID-19 and preterm birth, but these associations were independent and did not have a synergistic effect. Increases in the community unemployment rate were also associated with an increased risk of preterm birth independent of SARS-CoV-2 infection.

Strength and weaknesses:
The study population was diverse and included a substantial number of Black and Latinx patients across neighborhood types. The applicability of data outside of New York is a limitation. Furthermore, researchers did not have information on disease severity.

Relevance:
C-L psychiatrists must consider the impact of systemic-racism and psychosocial stress from the COVID-19 pandemic on infant-maternal outcomes in racially and ethnically minoritized patients.