Committing to Racial Health Equity in Psychiatry: Reckoning with Racism in Restraint Use

Colin Smith, M.D.
Chief Resident, Internal Medicine-Psychiatry
Duke University Medical Center

Disclaimer: The views and opinions of the author expressed herein do not necessarily state or reflect those of Duke University, the United States Government, or any agency thereof.

“Every system is perfectly designed to get exactly the results it gets.” – W. Edwards Demming

A genuine commitment to racial health equity in psychiatry requires proactive and intentional identification, and elimination of the roots of unjust differences in care perpetrated on minoritized communities. We have a duty to our patients, ourselves, and our profession to respond, especially when we are employing inherently coercive, forceful, and morally injurious interventions such as chemical and physical restraint.

Much of the literature evaluating disparities in emergency healthcare highlights inadequate medical evaluation and treatment for communities of color. It is well established, for example, that Black patients seeking care in emergency settings are less likely to be offered thorough evaluation for chest pain¹ or analgesia for musculoskeletal and abdominal pain² compared to their white counterparts.

But what about our use of physical and chemical restraints in psychiatry? Are we systematically and forcefully treating Black patients differently than white patients? Unfortunately, the answer is yes. A pair of recent observational studies evaluating over 900,0000 patient encounters demonstrate that Black patients are significantly more likely to undergo physical restraint than white patients in the general emergency department setting after adjusting for sociodemographic and clinical factors.^3,4 On the heels of these studies, our team analyzed nearly 13,000 encounters of patients, evaluated by an emergency consultation psychiatry service, and found that Black patients are also more likely to be injected with antipsychotics than white patients.⁵ Lest we think the burden of these findings falls strictly on the shoulders of our emergency physician colleagues, preliminary results from an analysis of over 3,700 unique encounters in an urban med-psych unit show significantly higher rates of restraint and seclusion for Black patients than for white patients.⁶

What are we to make of these findings? Given the frankly racist practices that have pervaded the history of American medicine⁷ and the common human phenomenon of implicit bias, it is illogical to suggest that racial bias does not play a role in our coercive treatment of Black patients presenting in distress.⁸

Although increasing diversity among physicians mitigates—but does not eliminate—implicit bias and prejudice,⁹ people of color, and, in particular, Black individuals, still comprise a disproportionately small percentage of practicing psychiatrists.¹⁰ Diversifying the workforce and developing evidence-based, trauma-informed training programs may help, but individual level interventions alone are insufficient. 

The disproportionate use of coercive measures for Black patients in emergency psychiatry is a symptom of systemic racism and structural violence. Hyper-incarceration and police violence, endured for generations by minoritized communities, now extend into the clinical space and perpetuates stigma and justified mistrust.¹¹ Rectifying disparate restraint use on Black patients requires systemic change, such as increasing access to outpatient services and decriminalizing mental illness, in addition to reducing interpersonal bias in agitation management.

Systemic change stands to benefit patients and physicians alike. Restraints have not only been associated with aspiration, rhabdomyolysis, thrombosis, and posttraumatic stress symptoms in patients^12-14 but also serve as a morally injurious act for physicians and others involved, as evidenced by comments provided in a qualitative study assessing ethical conflict in management of agitation: “You don't have the space, you don't have the time, and you don't have the resources for these people. Now I don't have as much of a problem restraining them early. Of course, that comes with the philosophical question, ‘What the heck is now wrong with me that I'm now okay with it?'”.¹⁵ Moral injury threatens to exacerbate the toll of injustice on minoritized communities, as trainee burnout in emergency psychiatry is negatively associated with plans to treat patients insured by Medicaid.¹⁶

If we are to achieve the racial health equity that many in psychiatry are calling for, then we must address the systems that perpetuate traumatizing and criminalizing communities of color. After all, few problems have ever been solved by ignoring that they exist. 

References

1. Pezzin LE, Keyl PM, Green GB: Disparities in the emergency department evaluation of chest pain patients. Acad Emerg Med 2007; 14:149–156

2. Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012;13(2):150-174. doi:10.1111/j.1526-4637.2011.01310.x

3. Schnitzer K, Merideth F, Macias-Konstantopoulos W, Hayden D, Shtasel D, Bird S. Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Acad Emerg Med. 2020;27(10):943-950. doi:10.1111/acem.14092

4. Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open. 2021;4(1):e2035241. Published 2021 Jan 4. doi:10.1001/jamanetworkopen.2020.35241

5. Smith CM, Turner NA, Thielman NM, Tweedy DS, Egger J, Gagliardi JP. Association of Black Race With Physical and Chemical Restraint Use Among Patients Undergoing Emergency Psychiatric Evaluation [published online ahead of print, 2021 Dec 21]. Psychiatric Serv. 2021;appips202100474. doi:10.1176/appi.ps.202100474

6. Griffin Tyree, Samuel Dotson, Timothy Shea, Lucy Ogbu-Nwobodo, Stuart Beck, Derri Shtasel/ racial Inequality in restraint and seclusion on an urban ,ed-psych unit. : A 2021 Bias Project Report. MGH Psychiatry Academy Poster. https://mghcme.org/app/uploads/2021/03/POSTER-Tyree-Race-restraint-2021.pdf

7. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present.

8. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510. doi:10.1007/s11606-013-2441-1

9. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22(6):882

10. Wyse R, Hwang WT, Ahmed AA, Richards E, Deville C Jr. Diversity by Race, Ethnicity, and Sex within the US Psychiatry Physician Workforce. Acad Psychiatry. 2020;44(5):523-530. doi:10.1007/s40596-020-01276-z

11. Cook BL, Trinh NH, Li Z, Hou SS, Progovac AM. Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004-2012. Psychiatr Serv. 2017;68(1):9-16. doi:10.1176/appi.ps.201500453

12. Mohr WK, Petti TA, Mohr BD: Adverse effects associated with physical restraint. Can J Psychiatry 2003; 48:330–337

13. Hays H, Jolliff HA, Casavant MJ: The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Work- group. West J Emerg Med 2012; 13:536

14. Wong AH, Ray JM, Rosenberg A, et al: Experiences of individuals who were physically restrained in the emergency department. JAMA Netw Open. 2020; 3:e1919381

15. Wong AH, Combellick J, Wispelwey BA, Squires A, Gang M. The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department. Acad Emerg Med. 2017;24(2):226-235. doi:10.1111/acem.13117

16.  Dennis NM, Swartz MS. Emergency Psychiatry Experience, Resident Burnout, and Future Plans to Treat Publicly Funded Patients. Psychiatr Serv. 2015;66(8):892-895. doi:10.1176/appi.ps.201400234