Racial disparities in psychotic disorder diagnosis: A review of empirical literature

Gender-affirming care in the assessment and treatment of psychosis risk: Considering minority stress in current practice and future research

INTRODUCTION

Although research has documented the marked disparities in rates of psychosis-spectrum diagnoses in various socially marginalized populations, there is limited research addressing the needs of gender expansive individuals in the context of psychosis-spectrum illnesses using a minority stress lens. As clinical high-risk for psychosis (CHR-p) assessment and treatment becomes accessible to increasingly diverse populations, there is a need for clinicians to demonstrate greater clinical competency working with individuals across diverse social backgrounds and identities.

METHODS

We examined rates of gender expansive (GE) patients seeking evaluation at an urban-based CHR-p clinic and compared the diagnostic profile of GE individuals to cisgender patients. Post-hoc analyses were conducted on clinical variables with significant differences between the cisgender and GE groups.

RESULTS

The proportion of GE patients seeking evaluation increased from 2017 (9.3%) to 2021 (16.7%). Compared to cisgender youth, GE patients had significantly higher depressive, social anxiety, borderline personality disorder symptoms, higher levels of suicidality and non-suicidal self-injurious behaviour, and lower role functioning. Gender identity was predictive of suicidality controlling for social anxiety, borderline symptoms, and role functioning.

CONCLUSIONS

We review implications for CHR-p treatment and discuss ways to integrate minority stress theory and gender-affirming practices into coordinated specialty care for CHR-p patients.

Slavery and Its Afterlives in US Psychiatry

Antecedents of racist treatments of Black patients by the psychiatric profession in the United States affect the way they view treatment today. Specifically, in this essay, we explore the enduring consequences of racial science on various treatment practices. We examined a range of primary sources on the history of racial theories about the mind, medical and psychiatric publications, and hospitals. We contextualize this analysis by examining the secondary literature in the history and sociology of psychiatry. Through analyzing racial thinking from the antebellum through the Jim Crow periods, we show how US medicine and psychiatry have roots in antebellum racial science and how carceral logics underpinned the past and present politics of Black mental health. Changing this trajectory requires practitioners to interrogate the historical foundations of racist psychiatric concepts. This essay urges them to reject biological racial realism, which bears reminiscences to 19th-century racial science, and embrace the variable of race as a social construct to study social inequalities in health as a first step toward moving away from the legacies of past injustices in medicine. (Am J Public Health. 2024;114(S3):S250-S257. https://doi.org/10.2105/AJPH.2023.307554).

Longitudinal risk of suicide outcomes in people with severe mental illness following an emergency department visit and the effects of suicide prevention treatment

BACKGROUND

Individuals with severe mental illness (SMI), including bipolar disorder (BD) and schizophrenia-spectrum disorders (SSD), are at high risk for suicide. However, suicide research often excludes individuals with SMI. The current research examined differences in suicide outcomes (i.e., suicide attempt or death) for adults with and without BD and SSD diagnoses following an emergency department (ED) visit and investigated the efficacy of the Coping Long Term with Active Suicide Program (CLASP) intervention in reducing suicide outcomes among people with SMI.

METHODS

1235 adults presenting with recent suicidality were recruited from 8 different EDs across the United States. Using a quasi-experimental, stepped wedge series design, participants were followed for 52-weeks with or without subsequent provision of CLASP.

RESULTS

Participants in the SSD group and the BD group had significantly shorter time to and higher rate of suicide outcomes than participants with other psychiatric diagnoses in all study phases and in non-CLASP phases, respectively. Participants with BD receiving the CLASP intervention had significantly longer time to suicide outcomes than those not receiving CLASP; these differences were not observed among those with SSD.

LIMITATIONS

Study limitations include self-reported psychiatric diagnosis, exclusion of homeless participants, and small sample size of participants with SSD.

CONCLUSIONS

Participants with SMI were at higher risk for suicide outcomes than participants with other psychiatric diagnoses. CLASP was efficacious among those participants with BD. Psychiatric diagnosis may be a key indicator of prospective suicide risk. More intensive and specialized follow-up mental health treatment may be necessary for those with SSD.

Social victimization, default mode network connectivity, and psychotic-like experiences in adolescents

Social victimization (SV) and altered neural connectivity have been associated with each other and psychotic-like experiences (PLE). However, research has not directly examined the associations between these variables, which may speak to mechanisms of psychosis-risk. Here, we utilized two-year follow-up data from the Adolescent Brain Cognitive Development study to test whether SV increases PLE through two neural networks mediating socio-affective processes: the default mode (DMN) and salience networks (SAN). We find that a latent SV factor was significantly associated with PLE outcomes. Simultaneous mediation analyses indicated that the DMN partially mediated the SV-PLE association while the SAN did not. Further, multigroup testing found that while Black and Hispanic adolescents experienced SV differently than their White peers, the DMN similarly partially mediated the effect of SV on PLE for these racial groups. These cross-sectional results highlight the importance of SV and its potential impact on social cognitive neural networks for psychosis risk.

Racial differences in attenuated psychotic symptoms during the COVID-19 pandemic

AIM

Rates of attenuated psychotic symptoms (APS) have increased during the COVID-19 pandemic; however, it is unclear whether this is most evident among individuals from marginalized racial groups.

METHODS

The current study evaluated APS screening data across a six-year period in the state of Georgia in the United States, spanning several years prior to and during the COVID-19 pandemic to evaluate interactions between time and race. Participants included 435 clinical help-seeking individuals.

RESULTS

The rate of individuals scoring above the APS screening cut-off was higher during the pandemic compared to pre-pandemic (41% vs 23%). This pandemic-related increase in APS was significant for Black, but not White or Asian participants.

CONCLUSIONS

Findings indicate APS are increasing during the COVID-19 pandemic among clinical help-seeking populations. Black individuals may be at greater risk for developing a psychotic disorder during the pandemic, suggesting increased need for screening, mental health monitoring, and treatment.

Algorithmic fairness in precision psychiatry: analysis of prediction models in individuals at clinical high risk for psychosis

BACKGROUND

Computational models offer promising potential for personalised treatment of psychiatric diseases. For their clinical deployment, fairness must be evaluated alongside accuracy. Fairness requires predictive models to not unfairly disadvantage specific demographic groups. Failure to assess model fairness prior to use risks perpetuating healthcare inequalities. Despite its importance, empirical investigation of fairness in predictive models for psychiatry remains scarce.

AIMS

To evaluate fairness in prediction models for development of psychosis and functional outcome.

METHOD

Using data from the PRONIA study, we examined fairness in 13 published models for prediction of transition to psychosis (n = 11) and functional outcome (n = 2) in people at clinical high risk for psychosis or with recent-onset depression. Using accuracy equality, predictive parity, false-positive error rate balance and false-negative error rate balance, we evaluated relevant fairness aspects for the demographic attributes 'gender' and 'educational attainment' and compared them with the fairness of clinicians' judgements.

RESULTS

Our findings indicate systematic bias towards assigning less favourable outcomes to individuals with lower educational attainment in both prediction models and clinicians' judgements, resulting in higher false-positive rates in 7 of 11 models for transition to psychosis. Interestingly, the bias patterns observed in algorithmic predictions were not significantly more pronounced than those in clinicians' predictions.

CONCLUSIONS

Educational bias was present in algorithmic and clinicians' predictions, assuming more favourable outcomes for individuals with higher educational level (years of education). This bias might lead to increased stigma and psychosocial burden in patients with lower educational attainment and suboptimal psychosis prevention in those with higher educational attainment.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study

BACKGROUND

Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men.

OBJECTIVE

This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men.

METHODS

We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion.

RESULTS

In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide.

CONCLUSIONS

Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31241.

Infrahuman madness: Mental health nursing and the discursive production of alterity

By examining an exemplar sample of mental health nursing educational policies and related legislation, in this article, we trace the discursive production of madness as an "othered" identity category. We engage in a critical discourse analysis of mental health nursing education in Canada, drawing on provincial and federal policies and legislation as the main sources of data. Theoretically framed by critical posthumanism and mad studies, this article outlines how the mad subjectivity becomes decontextualized out of its identity-based understanding and recontextualized as an inferior category of "the human," circulating within discourses of pedagogy, economics, law, and psychiatry. The article maps the intertextual nexus of the discourse of mental health nursing education, making visible the complex, the arbitrary, and the sometimes-contradictory nature of the discipline's grappling with identity-based mental health concepts. We close with several implications for nursing policy, education, and practice.

Disparities in Psychosis Risk Symptoms for New Zealand Māori May Be Explained by Systemic Stressors and Inappropriate Conceptualization of Culturally Normative Experiences

BACKGROUND AND HYPOTHESIS

Māori, the indigenous peoples of New Zealand, experience increased rates of psychotic disorders and first-episode psychosis. However, it is unclear whether they also present with increased psychosis risk symptoms, such as subclinical psychotic-like experiences (PLEs). Measurement of risk symptoms is key for early intervention. Further, it is unclear if systemic factors such as the increased rates of social adversity and discrimination or cultural biases contribute to this disparity in psychosis rates.

STUDY DESIGN

This study surveyed 466 18- to 30-year olds in New Zealand, and compared Māori to non-Māori participant responses on the Prodromal Questionnaire Brief, alongside the history of childhood trauma, discrimination, and financial adversity.

STUDY RESULTS

Māori reported a higher number of PLEs compared to non-Māori-however, this was not associated with increased distress related to these experiences. The increased number of psychosis-like experiences reported by Māori was likely explained by systemic factors such as childhood trauma, discrimination, and financial stress. Māori were more likely to report that the PLEs were positive.

CONCLUSIONS

Measurement of psychosis risk for Māori is nuanced, and increased scores on these tools may reflect pathologizing potentially normative experiences for Māori, such as spiritual encounters or discrimination, alongside the impact of increased rates of systemic discrimination, trauma, and financial stress.

Sociodemographic reporting and sample composition over 3 decades of psychopathology research: A systematic review and quantitative synthesis

Although researchers seek to understand psychological phenomena in a population, quantitative research studies are conducted in smaller samples meant to represent the larger population of interest. This systematic review and quantitative synthesis considers reporting of sociodemographic characteristics and sample composition in the Journal of Abnormal Psychology (now the Journal of Psychopathology and Clinical Science) over the past 3 decades. Across k = 1,244 empirical studies, there were high and increasing rates of reporting of participant age/developmental stage and sex/gender, low but increasing reporting of socioeconomic status/income, and moderate and stable reporting of educational attainment. Rates of reporting of sexual orientation remained low and reporting of gender identity was essentially nonexistent. There were low to moderate but increasing rates of reporting of participant race and ethnicity. Approximately three-quarters of participants in studies over the past 3 decades were White, while the proportion of participants who were Asian, Black or African American, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or Hispanic/Latino was much lower. Approximately two-thirds of participants were female, with this proportion increasing over time. There were also notable differences in the proportion of study participants as a function of race and sex/gender for different forms of psychopathology. Basic science and theoretical psychopathology research must include sociodemographically diverse samples that are representative of and generalizable to the larger human population, while seeking to decrease stigma of psychopathology and increase mental health equity. Recommendations are made to increase sociodemographic diversity in psychopathology research and the scientific review/publication process. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Kenya Psychosis-Risk Outcomes Study (KePROS): Development of an Accelerated Medicine Partnership Schizophrenia-Aligned Project in Africa

Background and Hypothesis

The Accelerating Medicines Partnership Schizophrenia (AMP SCZ) funds a longitudinal study of 43 research sites across 5 continents to develop tools to stratify developmental trajectories of youth at clinical high risk for psychosis (CHR) and identify homogenous targets for future clinical trials. However, there are no sites in Africa, leaving a critical gap in our knowledge of clinical and biological outcomes among CHR individuals.

Study Design

We describe the development of the Kenya Psychosis-Risk Outcomes Study (KePROS), a 5-year NIH-funded project in Kenya designed to harmonize with AMP SCZ. The study will recruit over 100 CHR and 50 healthy participants and conduct multiple clinical and biomarker assessments over 2 years. Capacity building is a key component of the study, including the construction of an electroencephalography (EEG) laboratory and the upgrading of a local 3 T magnetic resonance imaging (MRI) machine. We detail community recruitment, study methodologies and protocols, and unique challenges with this pioneering research in Africa.

Study Results

This paper is descriptive only. Planned future analyses will investigate possible predictors of clinical outcomes and will be compared to results from other global populations.

Conclusions

KePROS will provide the research community with a rich longitudinal clinical and biomarker dataset from an African country in the developing Global South, which can be used alongside AMP SCZ data to delineate CHR outcome groups for future treatment development. Training in mental health assessment and investment in cutting-edge biomarker assessment and other technologies is needed to facilitate the inclusion of African countries in large-scale research consortia.

Racial and Ethnic Disparities in the Diagnosis and Early Treatment of First-Episode Psychosis

Background

Despite recognition that early intervention for first-episode psychosis (FEP) improves outcomes, Black youth with FEP continue to experience critical disparities in care. A historical lack of scientific focus on racial and ethnic factors in the study of psychosis and scant investigations among publicly insured (ie, Medicaid-enrolled) youth hinder our ability to understand and address factors that contribute to disparities in early FEP care. Strategies for improving FEP services for Black youth are reliant on more precise identification of who faces disparities and when during the early course of illness disparities are experienced.

Study Design

A retrospective longitudinal analysis of Ohio Medicaid claims data was performed for 987 982 youth aged 15-24 years between 2010 and 2020 to examine: (1) the likelihood of FEP diagnosis, (2) the type of psychotic disorder diagnosis received, and (3) receipt of treatment following psychosis onset.

Study Results

Non-Hispanic Black (NHB) youth, relative to non-Hispanic White (NHW) peers, were more likely to be diagnosed with a psychotic disorder and were further more likely to receive a diagnosis of schizophrenia relative to an affective psychotic disorder. In the first year following FEP diagnosis, NHB youth were also less likely to receive psychotherapy than NHW youth; this disparity was no longer present when examined at 2 years following FEP.

Conclusions

In this study, Black youth experienced disparities in both the diagnosis and early treatment of FEP. Additional efforts are needed to understand and address these observed disparities and to promote equitable access to FEP care during the critical early illness phases.

Cardiac healthcare disparities and electrocardiography (ECG) differences in schizophrenia at end of life

Schizophrenia is associated with early mortality of 15 to 20 years, and 80 % of deaths are due to cardiovascular disease with a three-times greater risk of sudden-cardiac-death. While lifestyle, medications, genetics, and healthcare disparities are contributing factors, the etiology of this complex process is not fully understood. The aim of this study is to examine cardiac-related healthcare utilization and electrocardiogram (ECG) outcomes in schizophrenia at the end of life (EOL). A cohort of individuals with schizophrenia (SG) (n = 610, ≥50 years) were identified retrospectively from a unified clinical data platform and measures of cardiovascular healthcare utilization were evaluated within a 12-month period prior to death. Similarly, a control group (n = 610) was randomly identified and matched by gender (53 % females) and age of death (72.8 ± 12.4 years). Statistical methods included Cochran-Mantel-Haenszel and mixed-effects logistic & linear regression tests with adjustments for match strata and marital status, race, age, and gender as covariates. Results indicate that SG was more likely to be unmarried, unemployed, or from minority groups (all p < 0.001), and more likely to have diabetes and/or cardiovascular disease (p < 0.001). SG was less likely to receive an ECG (p = 0.001) or cardiac catheterization procedure (p < 0.001). SG had a greater mean QTc (447.2 ms vs. 434.6 ms; p = 0.001) and were twice as likely to have "prolonged QT" on ECG report (p = 0.006). In conclusion, SG had reduced likelihood of cardiac-related healthcare interventions, and despite greater likelihood of prolonged QTc, a recognized biomarker of cardiac risk, ECG was less likely at EOL. Given greater cardiac comorbidity and risk of sudden cardiac death in schizophrenia, improved practice guidelines are needed.

Association of Childhood Area-Level Ethnic Density and Psychosis Risk Among Ethnoracial Minoritized Individuals in the US

Importance

The protective ethnic density effect hypothesis, which suggests that minoritized individuals who grow up in neighborhoods with a high proportion of ethnoracial minoritized groups are protected from the effects of perceived discrimination, has not been examined among individuals at clinical high risk of psychosis (CHR-P). This level of examination may help identify intervention targets for preventing psychosis among high-risk individuals.

Objective

To examine the association between area-level ethnic density during childhood, perceived discrimination, and psychosis risk outcomes among ethnoracial minoritized individuals with CHR-P.

Design, Setting, and Participants

Data were collected as part of the North American Prodrome Longitudinal Study-2 (NAPLS 2) between November 2008 and March 2013. Participants included ethnoracial minoritized youth with CHR-P. Area-level ethnoracial minoritized density pertained to the percent of ethnoracial minoritized individuals within the participant's county during childhood. Generalized mixed-effects models with random intercepts for participants, NAPLS 2 site, and county estimated the associations between area-level ethnic density and the risk of psychosis risk outcomes. Self-reported experience of discrimination was assessed. Mediation analyses computed the indirect association of perceived discrimination in the prospective correlation between ethnic density and psychosis risk outcomes. Analyses took place between December 2021 and June 2023.

Main Outcomes and Measures

Psychosis risk outcomes included remission, symptomatic, progression, and conversion to psychosis and were assessed throughout 24-month follow-up.

Results

Of 193 individuals, the mean (SD) age was 17.5 (3.4) years and 113 males (58.5%) were included. Participants self-identified as Asian (29 [15.0%]), Black (57 [29.0%]), Hispanic (any race; 87 [45.0%]), or other (First Nations, Middle Eastern, and interracial individuals; 20 [10.4%]). Greater area-level minoritized density was associated with a lower likelihood of remaining symptomatic (relative risk [RR], 0.54 [95% CI, 0.33-0.89]) and having progressively worsening symptoms (RR, 0.52 [95% CI, 0.32-0.86]) compared with being in remission. More perceived discrimination was associated with a higher risk of staying symptomatic (RR, 1.43 [95% CI, 1.09-1.88]) and progressively worsening (RR, 1.34 [95% CI, 1.02-1.78]) compared with being in remission. Perceived discrimination significantly mediated 21.7% (95% CI, 4.1%-67.0%; P = .02) of the association between area-level minoritized density and the likelihood of being in remission.

Conclusions and Relevance

This study found that among ethnoracial minority youth with CHR-P, growing up in communities with a greater proportion of ethnically minoritized individuals was associated with remission of psychosis risk symptoms partly through lower levels of perceived discrimination. Understanding how the social environment impacts early psychosis risk may help develop effective interventions to prevent psychosis, especially for vulnerable minoritized youth.

Reframing health disparities in SLE: A critical reassessment of racial and ethnic differences in lupus disease outcomes

Health disparities in the prevalence and outcomes of systemic lupus erythematosus (SLE) are well documented across racial and ethnic groups. Similar to other chronic diseases, differences in disease severity among individuals with SLE are likely influenced by both genetic predisposition and multiple social determinants of health. However, research in SLE that jointly examines the genetic and environmental contributions to the disease course is limited, resulting in an incomplete understanding of the biologic and social mechanisms that underly health disparities. While research on health disparities can reveal inequalities and inform resource allocation to improve outcomes, research that relies on racial and ethnic categories to describe diverse groups of people can pose challenges. Additionally, results from research comparing outcomes across socially constructed groups without considering other contributing factors can be misleading. We herein comprehensively examine existing literature on health disparities in SLE, including both clinical studies that examine the relationship between self-reported race and ethnicity and disease outcomes and studies that explore the relationships between genomics and lupus outcomes. Having surveyed this body of research, we propose a framework for research examining health disparities in SLE, including ways to mitigate bias in future studies.

Characteristics of International Assaultive Psychiatric Patients: Review of Published Findings, 2017-2022

Since the 1960s, empirical research has focused on a better understanding of the characteristics of assaultive psychiatric patients. International research from 1960 to 2017 indicated that male and female patients with schizophrenia and substance use disorder presented the greatest risk for assault with nursing personnel being at higher risk. This present review of studies sought to assess the latest research findings on assaultive patients for the most recent five-year period, 2017-2022. It was hypothesized that patients with schizophrenia and substance use disorders would present the greatest assault risk for nursing personnel. The studies in this review supported this hypothesis. Assaults by patients with schizophrenia and substance abuse has been a consistent finding worldwide for 62 years of published research. Explanations for these findings, the possible role of posttraumatic stress disorder (PTSD) in assaultive patients, and an updated methodological review are presented.

Examining delusional ideation: Relationships with race and socioeconomic status

Race and socioeconomic status (SES) are commonly cited as risk factors for psychosis and psychotic-like experiences (PLEs). However, few studies have investigated the relationships between race and SES with specific domains of PLEs. Specifically, little work has examined the relationships between race and SES with delusional ideation, severity (preoccupation, conviction, distress), and delusional themes. Using cross-sectional, general population data (N = 727) from the Nathan Kline Institute-Rockland (NKI-Rockland) database, we investigated racial differences in delusional ideation and severity between Black and White participants, including differences in delusional themes. Then, we investigated SES's relationship with delusional thinking and the interaction between race and SES on delusional thinking. Black American participants endorsed higher delusional ideation with stronger severity than White Americans. A significant interaction between race and delusional theme revealed that Black Americans endorse significantly more delusional ideation in themes of grandiosity, religiosity, and referential-guilt. Black Americans endorse greater delusional severity in grandiose and religious ideations. Black Americans endorse stronger preoccupation and conviction - but not distress-in their referential-guilt ideation. SES was not significantly associated with delusional thinking, nor did SES moderate the significant relationships between race and delusional ideation. These results illuminate the clear racial disparity that exist in delusional ideation within a general population, which did not extend to SES in this dataset. Future work should investigate deeper into the contributory factors to these racial disparities, particularly whether they are based in psychological and/or cultural differences or are the result of assessment/measurement bias.

Psychology's Contributions to Anti-Blackness in the United States Within Psychological Research, Criminal Justice, and Mental Health

The mass incarceration of Black people in the United States is gaining attention as a public-health crisis with extreme mental-health implications. Although it is well documented that historical efforts to oppress and control Black people in the United States helped shape definitions of mental illness and crime, many psychologists are unaware of the ways the field has contributed to the conception and perpetuation of anti-Blackness and, consequently, the mass incarceration of Black people. In this article, we draw from existing theory and empirical evidence to demonstrate historical and contemporary examples of psychology's oppression of Black people through research and clinical practices and consider how this history directly contradicts the American Psychological Association's ethics code. First, we outline how anti-Blackness informed the history of psychological diagnoses and research. Next, we discuss how contemporary systems of forensic practice and police involvement in mental-health-crisis response maintain historical harm. Specific recommendations highlight strategies for interrupting the criminalization of Blackness and offer example steps psychologists can take to redefine psychology's relationship with justice. We conclude by calling on psychologists to recognize their unique power and responsibility to interrupt the criminalization and pathologizing of Blackness as researchers and mental-health providers.

Examining racial disparities in the diagnosis of mild cognitive impairment

Black individuals are less likely to receive an accurate diagnosis of mild cognitive impairment (MCI) than their White counterparts, possibly because diagnoses are typically made by a physician, often without reference to objective neuropsychological test data. We examined racial differences in actuarial MCI diagnoses among individuals diagnosed with MCI via semi-structured clinical interview (the Clinical Dementia Rating) to examine for possible biases in the diagnostic process. Participants were drawn from the National Alzheimer's Coordinating Center Uniform Data Set and included 491 individuals self-identifying as Black and 2,818 individuals self-identifying as White. Chi-square tests were used to examine racial differences in rates of low scores for each cognitive test (domains assessed included attention, processing speed/executive functioning, memory, language, and visual skills). Next, we tested for racial differences in probability of meeting actuarial criteria for MCI by race. Compared to Black participants diagnosed with MCI via clinical interview, White individuals diagnosed with MCI via clinical interview demonstrated significantly higher rates of low demographically-adjusted z-scores on tests of memory, attention, processing speed, and verbal fluency. Furthermore, White individuals were significantly more likely to meet actuarial criteria for MCI (71.60%) than Black individuals (57.90%). Results suggest there may be bias in MCI classification based on semi-structured interview, leading to over diagnosis among Black individuals and/or under diagnosis among White individuals. Examination of neuropsychological test data and use of actuarial approaches may reduce racial disparities in the diagnosis of MCI. Nonetheless, issues related to race-based norming and differential symptom presentations complicate interpretation of results.

Antecedents to first episode psychosis and mania: Comparing the initial prodromes of schizophrenia and bipolar disorder in a retrospective population cohort

OBJECTIVE

We aim to compare the psychiatric antecedents of schizophrenia (SZ) and bipolar disorder (BD).

METHODS

Using the Rochester Epidemiology Project, we searched for residents of Olmsted County that had a diagnosis of SZ or BD. We confirmed each case using DSM-5 criteria and obtained the psychiatric antecedents.

RESULTS

We identified 205 cases with first episode psychosis or mania (SZ = 131; BD = 74). The mean age at first visit for mental health reasons was 12.3 ± 6.3 years for SZ and 13.9 ± 5.6 years for BD. The duration of the initial prodrome (time from first mental health visit to first episode) was similar for both groups (SZ 8.3 ± 6.2 years vs BD 7.3 ± 5.9 years). We found that SZ and BD have overlapping antecedents, but SZ was more common in males and in foreign born and had more learning deficits before the first episode. BD was more common in white population and had higher rates of depressive and adjustment disorders prior to first episode. BD also had more affective symptoms, nightmares, and panic attacks before the first episode. Both groups had similarly high rates of substance use (SZ 74 % vs BD 74.3 %), prescription of antidepressants (SZ 46.6 % vs BD 55.4 %) and stimulants (SZ 30.5 % vs BD 22.9 %).

CONCLUSIONS

The psychiatric antecedents of SZ and BD usually start during adolescence, overlap, and present in unspecific ways. The initial prodromes are more alike than distinct. Further studies are encouraged to continue looking for specific factors that distinguish the antecedents of these two disorders.

Inequalities in the Incidence of Psychotic Disorders Among Racial and Ethnic Groups

OBJECTIVE

The authors examined recent trends in incidence of psychotic disorders, demographic characteristics, and comorbid psychiatric and medical conditions among six racial/ethnic groups.

METHOD

A retrospective cohort study design was used to examine the incidence of psychotic disorders across race/ethnicity groups and comorbid psychiatric and medical conditions among members of Kaiser Permanente Northern California from 2009 to 2019 (N=5,994,758). Poisson regression was used to assess changes in annual incidence, and Cox proportional hazards and logistic regression models adjusted for age and sex were used to test correlates and consequences.

RESULTS

Overall, the incidence of nonaffective psychotic disorders decreased slightly over the study period. Compared with White members, the risk of nonaffective psychosis diagnosis was higher among Black (hazard ratio=2.13, 95% CI=2.02-2.24) and American Indian or Alaskan Native (AIAN) (hazard ratio=1.85, 95% CI=1.53-2.23) members and lower among Asian (hazard ratio=0.72, 95% CI=0.68-0.76) and Hispanic (hazard ratio=0.91, 95% CI=0.87-0.96) members, as well as those whose race/ethnicity was categorized as "other" (hazard ratio=0.92, 95% CI=0.86-0.99). Compared with White members, the risk of affective psychosis diagnosis adjusted for age and sex was higher among Black (hazard ratio=1.76, 95% CI=1.62-1.91), Hispanic (hazard ratio=1.09, 95% CI=1.02-1.16), and AIAN (hazard ratio=1.38, 95% CI=1.00-1.90) members and lower among Asian (hazard ratio=0.77, 95% CI=0.71-0.83), Native Hawaiian or other Pacific Islander (hazard ratio=0.69, 95% CI=0.48-0.99), and "other" (hazard ratio=0.86, 95% CI=0.77-0.96) members. Psychotic disorders were associated with significantly higher odds of suicide (odds ratio=2.65, 95% CI=2.15-3.28), premature death (odds ratio=1.30, 95% CI=1.22-1.39), and stroke (odds ratio=1.64, 95% CI=1.55-1.72) and lower odds of health care utilization (odds ratio=0.44, 95% CI=0.42-0.47).

CONCLUSIONS

This study demonstrates racial and ethnic variation in incident psychotic disorder diagnoses in the United States, compared with non-Hispanic Whites. Individuals diagnosed with psychosis face a greater burden of other negative health outcomes and lower odds of health care utilization, reflecting personal and economic impacts. Identifying risk factors for elevated rates and protective influences in subgroups can inform strategies for prevention and interventions to ameliorate severe consequences of psychotic syndromes.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis

INTRODUCTION

Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.

MATERIALS AND METHODS

The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.

RESULTS

Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.

CONCLUSIONS

Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

The illusion of inclusion: contextual behavioral science and the Black community

Anti-racism approaches require an honest examination of cause, impact, and committed action to change, despite discomfort and without experiential avoidance. While contextual behavioral science (CBS) and third wave cognitive-behavioral modalities demonstrate efficacy among samples composed of primarily White individuals, data regarding their efficacy with people of color, and Black Americans in particular, is lacking. It is important to consider the possible effects of racial stress and trauma on Black clients, and to tailor approaches and techniques grounded in CBS accordingly. We describe how CBS has not done enough to address the needs of Black American communities, using Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP) as examples. We also provide examples at the level of research representation, organizational practices, and personal experiences to illuminate covert racist policy tools that maintain inequities. Towards eradicating existing racism in the field, we conclude with suggestions for researchers and leadership in professional psychological organizations.

Harnessing Artificial Intelligence: Strategies for Mental Health Nurses in Optimizing Psychiatric Patient Care

This narrative review explores the transformative impact of Artificial Intelligence (AI) on mental health nursing, particularly in enhancing psychiatric patient care. AI technologies present new strategies for early detection, risk assessment, and improving treatment adherence in mental health. They also facilitate remote patient monitoring, bridge geographical gaps, and support clinical decision-making. The evolution of virtual mental health assistants and AI-enhanced therapeutic interventions are also discussed. These technological advancements reshape the nurse-patient interactions while ensuring personalized, efficient, and high-quality care. The review also addresses AI's ethical and responsible use in mental health nursing, emphasizing patient privacy, data security, and the balance between human interaction and AI tools. As AI applications in mental health care continue to evolve, this review encourages continued innovation while advocating for responsible implementation, thereby optimally leveraging the potential of AI in mental health nursing.

Incidence, Racial Disparities and Factors Related to Psychosis among Black Individuals in Canada: A Scoping Review

OBJECTIVE

Black communities are increasingly concerned about psychosis, a worry echoed by provincial health-care systems across Canada. Responding to the lack of evidence on psychosis in Black communities, this scoping review examined the incidence and prevalence of psychosis, access to care (pathways to care, coercive referrals, interventions, etc.), treatments received, and stigma faced by individuals with psychosis.

METHOD

To identify studies, a comprehensive search strategy was developed and executed in December 2021 across 10 databases, including APA PsycInfo, CINAHL, MEDLINE and Web of Science. Subject headings and keywords relating to Black communities, psychosis, health inequalities, Canada and its provinces and territories were used and combined. The scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping review (PRISMA-ScR) reporting standard.

RESULTS

A total of 15 studies met the inclusion criteria, all of them conducted in Ontario and Quebec. Results highlight different disparities in psychosis among Black communities. Compared to other Canadian ethnic groups, Black individuals are more likely to be diagnosed with psychosis. Black individuals with psychosis are more likely to have their first contact with health-care settings through emergency departments, to be referred by police and ambulance services, and to experience coercive referrals and interventions, and involuntary admission. Black individuals experience a lower quality of care and are the ethnic group most likely to disengage from treatment.

CONCLUSION

This scoping review reveals many gaps in research, prevention, promotion and intervention on psychosis in Black individuals in Canada. Future studies should explore factors related to age, gender, social and economic factors, interpersonal, institutional and systemic racism, and psychosis-related stigma. Efforts should be directed toward developing trainings for health-care professionals and promotion and prevention programs within Black communities. Culturally adapted interventions, racially disaggregated data, and increased research funding are needed.

Using focus groups to inform a brief video intervention to reduce public stigma toward Black youth living with psychosis

Objective

Black individuals living with psychosis are at risk for stigma and marginalization due to systematic discrimination and barriers to receiving treatment. Social contact-based interventions have the potential to reduce stigma; however, interventions with elements specific to the experiences of Black youth are limited. Therefore, we aimed to gather input from Black youth living with psychosis to develop a social contact-based, brief video intervention to reduce public stigma toward Black youth with psychosis.

Methods

Two 90-min focus groups were conducted with seven young Black individuals ages 18-30 with First Episode Psychosis from OnTrackNY. Participants were asked about their experiences of stigma and racial discrimination, and their perspectives on a video intervention. Focus group transcripts were analyzed using thematic content analysis.

Results

Themes that emerged included: the salience of stigma and racial experiences for some participants and not others; the linking of religiosity and symptoms in Black communities; the importance of taking responsibility for recovery as a coping strategy to counteract stigma; and mixed views on creating a video intervention specific to Black youth.

Conclusion

Meaningful and empowering involvement of individuals with lived experience of psychosis is essential to create stigma reducing interventions. Input from Black youth living with psychosis assisted in developing a culturally tailored brief video-based intervention to reduce public stigma toward Black youth with psychosis that included information about the protagonist's experience of race and mental illness, specifically family, religious, and community-based experiences.

Household income does not affect the pleiotropy of schizophrenia genetic liability with mental and physical health outcomes

Background and Hypothesis

Individuals with schizophrenia (SCZ) suffer from comorbidities that substantially reduce their life expectancy. Socioeconomic inequalities could contribute to many of the negative health outcomes associated with SCZ.

Study Design

We investigated genome-wide datasets related to SCZ (52,017 cases and 75,889 controls) from the Psychiatric Genomics Consortium, household income (HI; N=361,687) from UK Biobank, and 2,202 medical endpoints assessed in up to 342,499 FinnGen participants. A phenome-wide genetic correlation analysis of SCZ and HI was performed, also assessing whether SCZ genetic correlations were influenced by HI effect on SCZ. Additionally, SCZ and HI direct effects on medical endpoints were estimated using multivariable Mendelian randomization (MR).

Study Results

SCZ and HI showed overlapping genetic correlations with 70 traits (p<2.89×10 -5 ), including mental health, substance use, gastrointestinal illnesses, reproductive outcomes, liver diseases, respiratory problems, and musculoskeletal phenotypes. SCZ genetic correlations with these traits were not affected by HI effect on SCZ. Considering Bonferroni multiple testing correction (p<7.14×10 -4 ), MR analysis indicated that SCZ and HI may affect medical abortion (SCZ odds ratio, OR=1.07; HI OR=0.78), panic disorder (SCZ OR=1.20; HI OR=0.60), personality disorders (SCZ OR=1.31; HI OR=0.67), substance use (SCZ OR=1.2; HI OR=0.68), and adjustment disorders (SCZ OR=1.18; HI OR=0.78). Multivariable MR analysis confirmed that SCZ effects on these outcomes were independent of HI.

Conclusions

The effect of SCZ genetic liability on mental and physical health may not be strongly affected by socioeconomic differences. This suggests that SCZ-specific strategies are needed to reduce negative health outcomes affecting patients and high-risk individuals.

Multimodal mental health assessment with remote interviews using facial, vocal, linguistic, and cardiovascular patterns

Objective

The current clinical practice of psychiatric evaluation suffers from subjectivity and bias, and requires highly skilled professionals that are often unavailable or unaffordable. Objective digital biomarkers have shown the potential to address these issues. In this work, we investigated whether behavioral and physiological signals, extracted from remote interviews, provided complimentary information for assessing psychiatric disorders.

Methods

Time series of multimodal features were derived from four conceptual modes: facial expression, vocal expression, linguistic expression, and cardiovascular modulation. The features were extracted from simultaneously recorded audio and video of remote interviews using task-specific and foundation models. Averages, standard deviations, and hidden Markov model-derived statistics of these features were computed from 73 subjects. Four binary classification tasks were defined: detecting 1) any clinically-diagnosed psychiatric disorder, 2) major depressive disorder, 3) self-rated depression, and 4) self-rated anxiety. Each modality was evaluated individually and in combination.

Results

Statistically significant feature differences were found between controls and subjects with mental health conditions. Correlations were found between features and self-rated depression and anxiety scores. Visual heart rate dynamics achieved the best unimodal performance with areas under the receiver-operator curve (AUROCs) of 0.68-0.75 (depending on the classification task). Combining multiple modalities achieved AUROCs of 0.72-0.82. Features from task-specific models outperformed features from foundation models.

Conclusion

Multimodal features extracted from remote interviews revealed informative characteristics of clinically diagnosed and self-rated mental health status.

Significance

The proposed multimodal approach has the potential to facilitate objective, remote, and low-cost assessment for low-burden automated mental health services.

The ethnic density effect as a contextual influence in ecological disease models: Establishing its quantitative expression

Research suggests higher neighbourhood ethnic minority density to be associated with lessened chances of ethnic group illness. We focus on the density effect on psychosis, arguing that (at higher ethnic concentrations) it acts as a contextual influence attenuating the compositional influence whereby minority ethnicity is associated with higher psychosis risk. In terms of ecological disease regression, the ethnic density effect will then be apparent in nonlinear impacts of minority concentration. Contextual effects may also be evident in spatially varying regression coefficient models for psychosis. Nonlinearity or heterogeneity may be associated with other contextual processes where geography modifies demography (e.g. deprivation amplification). We illustrate these issues with an analysis of psychosis prevalence in 4835 London neighbourhoods. The data are collected in primary care (during 2019/20) using clinical diagnosis (e.g. based on referrals to specialists or psychosis hospitalisation), and refer to patients currently under care: such care may extend retrospectively over several years. The data offer a complete population perspective in contrast to survey data, which typically offer limited geographic perspectives. We consider impacts on psychosis prevalence of non-white ethnicity, as well as those of deprivation, social fragmentation and urbanicity. We find evidence suggesting nonlinear impacts of non-white ethnicity on psychosis (essentially flat risk above a threshold concentration), but find no evidence for deprivation amplification.

Examining racial disparity in psychotic disorders related ambulatory care visits: an observational study using national ambulatory medical care survey 2010-2015

BACKGROUND

One of the most consistent research findings related to race and mental health diseases is the disproportionately high rate of psychotic disorder diagnoses among people of color, specifically people of African descent. It is important to examine if a similar pattern exists among specific psychotic disorders. We aimed to examine the racial/ethnic differences in ambulatory care visits diagnosed with schizophrenia-spectrum disorders (SSDs).

METHODS

We analyzed data from the National Ambulatory Medical Care Survey (NAMCS) 2010-2015. The study sample included physician office-based visits by individuals diagnosed with SSDs, including schizophrenia, schizoaffective, and unspecified psychotic disorder (n = 1155). We used descriptive and bivariate analysis by race/ethnicity and three multinomial logistic regression models to test the association between the SSDs and race/ethnicity, adjusting for age, gender, insurance, disposition, medication Rx, and co-morbidity, considering the design and weight.

RESULT

Of the 1155 visits for SSDs, 44.8% had schizophrenia, 37.4% had schizoaffective disorder diagnosis, and 19.0% had unspecified psychosis disorder. We found significant racial disparities in the diagnosis of SSDs. Black patients were overrepresented in all three categories: schizophrenia (24%), schizoaffective disorder (17%), and unspecified psychosis disorder (26%). Also, a notable percentage of Black patients (20%) were referred to another physician in cases of schizophrenia compared to other ethnoracial groups (p < 0.0001). Moreover, we found a significant disparity in insurance coverage for schizoaffective disorder, with a higher percentage of Black patients (48%) having Medicaid insurance compared to patients from other ethnoracial groups (p < 0.0001). Black patients had nearly twice the odds of receiving a diagnosis of schizophrenia compared to White patients [AOR = 1.94; 95% CI: 1.28-2.95; P = 0.001]. However, they had significantly lower odds of being diagnosed with schizoaffective disorder [AOR = 0.42, 95% CI: 0.26-0.68; P = 0.003]. Race/ethnicity was not associated with receiving an unspecified psychosis disorder.

CONCLUSIONS

Our results show that SSDs, more specifically schizophrenia, continue to burden the mental health of Black individuals. Validation of our findings requires rigorous research at the population level that reveals the epidemiological difference of SSDs diagnoses in different race/ethnicity groups. Also, advancing our understanding of the nature of disparity in SSDs diagnoses among the Black population requires disentangling etiologic and systemic factors in play. This could include psychological stress, the pathway to care, services use, provider diagnostic practice, and experiencing discrimination and institutional and structural racism.

Estimates of Gaps in Supportive Housing Among Racially and Ethnically Diverse Older Adults with Serious Mental Illness in New York City Boroughs: Manhattan, Bronx, and Brooklyn

OBJECTIVE

This study aimed to estimate gaps in supportive housing services for racially and ethnically diverse older adults with SMI residing in supportive housing.

METHODS

This study had a total of 753 respondents split into two diagnostic groups, the Delusional and Psychotic Disorders Group, and the Mood (Affective) Disorder Group. Demographic and primary ICD diagnosis data (F2x and F3x) were extracted from medical records. Three elements were measured: supportive housing service needs, fall prevention, and activities in daily living and instrumental activities in daily living. Descriptive statistics (i.e., frequencies and percentages) were used in assessing the demographic characteristics of the sample.

RESULTS

Respondents had reasonable fall prevention measures in place, did not have challenges carrying out activities in daily living or instrumental activities of daily living and did not need homecare services (n = 515, 68.4%). Respondents needed support managing chronic medical conditions (n = 323, ∼43%). Approximately 57% of the total respondents in this study (n = 426) reported the need for hearing, vision, and dental services. Respondents showed high levels of food insecurity (n = 380, 50.5%).

CONCLUSIONS

This is the most extensive study of racially and ethnically diverse older adults with SMI residing in supportive housing. Three areas of unmet need were found: accessing hearing, vision, and dental services, managing chronic health conditions, and food insecurity. These findings can be used to develop new research programs addressing the needs of older adults with SMI and improve late-life circumstances for older adults with SMI.

Racial and ethnic differences in patterns of use and discontinuation of long-acting injectable antipsychotics using Medicaid claims data

Introduction

In general, racial and ethnic differences exist in antipsychotic prescription practices. However, little is known about such differences between individual long-acting injectable (LAI) antipsychotic formulations, specifically. This study's primary objective was to determine racial and ethnic differences among LAI antipsychotic use. Secondary objectives were to identify if discontinuation rates differed between agents and by race or ethnicity.

Methods

International Classification of Diseases, 10th edition (ICD-10) codes were used to identify patients with schizophrenia and related disorders (18-64 years) who received an LAI antipsychotic between 2016 and 2020 using Merative Multi-State Medicaid databases. Using National Drug Code numbers for LAI antipsychotics, pharmacy claims were identified and data analyzed. Cochran-Mantel-Haenszel tests and odds ratio estimators were used to investigate conditional association between race or ethnicity and medication, while controlling for age, sex, health plan, and prescription year. Kaplan-Meier survival curves were examined, and stratified log-rank tests were conducted to compare the time until discontinuation distributions by race or ethnicity.

Results

The analysis included 37 712 patients. Blacks received an LAI first-generation antipsychotic more often than Whites (OR: 1.64, 95% CI: [1.56, 1.73], Hispanics (OR: 1.46, 95% CI: [1.21, 1.75]) and others (OR: 1.44, 95% CI: [1.20, 1.73]). Aside from fluphenazine decanoate showing earlier discontinuation rates for Whites over Blacks (P = .02), no significant differences in discontinuation across race or ethnicity were identified.

Discussion

Despite no significant differences in second-generation antipsychotic LAI discontinuation rates between Blacks and other racial or ethnic groups, Blacks received second-generation antipsychotic LAIs significantly less often than other groups. Further studies are needed to determine why differences may be occurring.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Psychotic Disorders: I. Clinical Outcomes

BACKGROUND

Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD.

STUDY DESIGN

We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD.

STUDY RESULTS

Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied.

CONCLUSIONS

SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs' contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

Quality Improvement Framework to Examine Health Care Disparities in Behavioral Emergency Management in the Inpatient Medical Setting: A Consultation-Liaison Psychiatry Health Equity Project

BACKGROUND

De-escalation of behavioral emergencies in the inpatient medical setting may involve restrictive clinical interventions that directly challenge patient autonomy.

OBJECTIVE

We describe a quality improvement framework used to examine associations between patient characteristics and behavioral emergency de-escalation strategies. This project may inform other Consultation-Liaison Psychiatry teams seeking to promote equity in care.

METHODS

We examined behavioral emergency response team (BERT) management at an urban, tertiary-care medical center in the United States over a 3-year period. BERT data from an existing dataset were combined with demographic information from the hospital's electronic medical record. Race and ethnic identities were categorized as Black, Hispanic, Asian, White, and unknown. BERT events were coded based on the most restrictive intervention utilized per unique patient. Cross-tabulations and adjusted odds ratios from multivariate logistic regression were used to identify quality improvement targets in this exploratory project.

RESULTS

The sample included N = 902 patients and 1532 BERT events. The most frequent intervention reached was verbal de-escalation (n = 419 patients, 46.45%) and the least frequent was 4-point restraints (n = 29 patients, 3.2%). Half of BERT activations for Asian and a third for Hispanic patients required interpreter services. Anxiety and cognitive disorders and 2 BERT interventions, verbal de-escalation, and intramuscular/intravenous/ medications, were significantly associated with race/ethnic category. The most restrictive intervention for BERTs involving Black and Asian patients were verbal de-escalation (60.1%) and intramuscular/intravenous(53.7%), respectively. These proportions were higher compared with other race/ethnic groups. There was a greater percentage of patients from the unknown (6.3%) and Black (5.9%) race/ethnic groups placed in 4-point restraints compared with other groups (3.2%) that did not reach statistical significance. A logistic regression model predicting 4-point restraints indicated that younger age, multiple BERTs, and violent behavior as a reason for BERT activation, but not race/ethnic group, resulted in significantly higher odds.

CONCLUSIONS

This project illustrates that a quality improvement framework utilizing existing clinical data can be used to engage in organizational introspection and identify potential areas of bias in BERT management. Our findings suggest opportunities for further exploration, enhanced education, and programmatic improvements regarding BERT intervention; 4-point restraints; interpreter services; and the influence of race on perception of psychopathology.

Practitioner Review: Psychosis in children and adolescents

Psychotic symptoms, including hallucinations, delusions, and disorganized thinking and behaviors, are the hallmarks of schizophrenia; but may also present in the context of other psychiatric and medical conditions. Many children and adolescents describe psychotic-like experiences, which can be associated with other types of psychopathology and past experiences (e.g., trauma, substance use, and suicidality). However, most youth reporting such experiences do not have, nor will ever develop, schizophrenia or another psychotic disorder. Accurate assessment is critical because these different presentations have different diagnostic and treatment implications. For this review, we focus primarily on the diagnosis and treatment of early onset schizophrenia. In addition, we review the development of community-based first-episode psychosis programming, and the importance of early intervention and coordinated care.

Racial and Ethnic Bias in the Diagnosis of Alcohol Use Disorder in Veterans

OBJECTIVE

Studies show that racially and ethnically minoritized veterans have a higher prevalence of alcohol use disorder (AUD) than White veterans. The investigators examined whether the relationship between self-reported race and ethnicity and AUD diagnosis remains after adjusting for alcohol consumption, and if so, whether it varies by self-reported alcohol consumption.

METHODS

The sample included 700,012 Black, White, and Hispanic veterans enrolled in the Million Veteran Program. Alcohol consumption was defined as an individual's maximum score on the consumption subscale of the Alcohol Use Disorders Identification Test (AUDIT-C), a screen for unhealthy alcohol use. A diagnosis of AUD, the primary outcome, was defined by the presence of relevant ICD-9 or ICD-10 codes in electronic health records. Logistic regression with interactions was used to assess the association between race and ethnicity and AUD as a function of maximum AUDIT-C score.

RESULTS

Black and Hispanic veterans were more likely than White veterans to have an AUD diagnosis despite similar levels of alcohol consumption. The difference was greatest between Black and White men; at all but the lowest and highest levels of alcohol consumption, Black men had 23%-109% greater odds of an AUD diagnosis. The findings were unchanged after adjustment for alcohol consumption, alcohol-related disorders, and other potential confounders.

CONCLUSIONS

The large discrepancy in the prevalence of AUD across groups despite a similar distribution of alcohol consumption levels suggests that there is racial and ethnic bias, with Black and Hispanic veterans more likely than White veterans to receive an AUD diagnosis. Efforts are needed to reduce bias in the diagnostic process to address racialized differences in AUD diagnosis.

Delirium is under-reported in discharge summaries and in hospital administrative systems: a systematic review

Background

Accurate recording of delirium in discharge summaries (DS) and hospital administrative systems (HAS) is critical for patient care.

Objective

To systematically review studies reporting the frequency of delirium documentation and coding in DS and HAS, respectively.

Method

We searched Medline, Embase, PsycINFO and Web of Science databases from inception to 23 June 2021. Eligibility criteria included requiring the term delirium in DS or HAS. Screening and full-text reviews were performed independently by two reviewers. Risk of bias (RoB) was assessed using the Effective Public Health Practice Project tool.

Results

The search yielded 7,910 results; 24 studies were included. The studies were heterogeneous in design and size (N=25 to 809,512). Mean age ranged from 57 to 84 years. Four studies reported only overall DS documentation and HAS coding in whole hospital or healthcare databases. Twenty studies used additional delirium ascertainment methods (e.g. chart review) in smaller patient subsets. Studies reported either DS figures only (N=8), HAS figures only (N=11), or both (N=5). Documentation rates in DS ranged from 0.1% to 64%. Coding rates in HAS ranged from 1.5% to 49%. Some studies explored the impact of race, and nurse versus physician practice. No significant differences were reported for race; one study reported that nurses showed higher documentation rates in DS relative to physicians. Most studies (N=22) had medium to high RoB.

Conclusion

Delirium is a common and serious medical emergency, yet studies show considerable under-documentation and under-coding in healthcare systems. This has important implications for patient care and service planning. Healthcare systems need to take action to reach satisfactory delirium documentation and coding rates.

Stigma, mental illness & ethnicity: Time to centre racism and structural stigma

This article critically reviews previous research in the field of stigma, mental illness and 'race' and ethnicity, and argues for a shift of focus from individual and community blame, as inferred by mental illness stigma, to a more comprehensive view of how stigma operates against a backdrop of structural and institutional racism. Ethnic minority people have poorer mental health outcomes compared with White majority populations. Dominant narratives of greater mental illness stigma in ethnic minority populations, due to religious, spiritual or traditional beliefs and leading to a lower use of services, have taken centre stage in the explanations for these consequent poorer outcomes. This article argues that this 'fact' has become taken for granted as knowledge without corresponding comparative research evidence. Research in the field has also failed to robustly consider how racism might operate in conjunction with different forms of mental illness stigma (particularly structural stigma) to exacerbate mental illness and influence pathways to mental health treatment. Future research should centre the role of racism and structural stigma in explaining the poorer mental health outcomes for ethnic minority people.

Barriers to School-Based Mental Health Resource Utilization Among Black Adolescent Males

Black adolescent males use available mental health services at a disproportionately lower rate compared to males of other racial groups. This study examines barriers to school-based mental health resource (SBMHR) use among Black adolescent males, as a means of addressing reduced usage of available mental health resources and to improve these resources to better support their mental health needs. Secondary data for 165 Black adolescent males were used from a mental health needs assessment of two high schools in southeast Michigan. Logistic regression was employed to examine the predictive power of psychosocial (self-reliance, stigma, trust, and negative previous experience) and access barriers (no transportation, lack of time, lack of insurance, and parental restrictions) on SBMHR use, as well as the relationship between depression and SBMHR use. No access barriers were found to be significantly associated with SBMHR use. However, self-reliance and stigma were statistically significant predictors of SBMHR use. Participants who identified self-reliance in addressing their mental health symptoms were 77% less likely to use available mental health resources in their school. However, participants who reported stigma as a barrier to using SBMHR were nearly four times more likely to use available mental health resources; this suggests potential protective factors in schools that can be built into mental health resources to support Black adolescent males' use of SBMHRs. This study serves as an early step in exploring how SBMHRs can better serve the needs of Black adolescent males. It also speaks to potential protective factors that schools provide for Black adolescent males who have stigmatized views of mental health and mental health services. Future studies would benefit from a nationally representative sample allowing for more generalizable results regarding barriers and facilitators to Black adolescent males' use of school-based mental health resources.

A systematic review of persons of color participation in first episode psychosis coordinated specialty care randomized controlled trials in North America

The population of persons of color (POC) are increasing in the United States. Unfortunately, POC are significantly impacted by serious mental illness; psychosis represents a mental health disparity among POC. Fortunately, first episode coordinated specialty care (CSC) is an effective treatment for individuals who are in the early phases of a psychotic disorder. This systematic review of the literature examined POC inclusion rates in randomized controlled trials (RCT) examining First Episode Psychosis (FEP) programs. Our review yielded seven articles that met inclusion criteria. Our findings were mixed-researchers conducting RCTs on FEP programs did an excellent job including African American participants suggesting that findings from RCTs on FEP programs may generalize to African American participants. Regarding Latines, they were broadly underrepresented in RCTs on FEP CSC. Based on the data, we cannot definitively conclude to what extent findings from RCTs on FEP CSC generalize to Latines although results from studies that included a reasonable number of Latines offer promising results. Asians were overrepresented in three of the seven studies included in this review; thus it seems that the findings from RCTs on FEP CSC generalize to the Asian population in the United States.

Cumulative Risk and Externalizing Behaviors during Infancy in a Predominantly Latine Sample

Externalizing behavior problems are among the top mental health concerns in early childhood, and many parenting interventions have been developed to address this issue. To better understand predictors of parenting intervention outcomes in high-risk families, this secondary data analysis evaluated the moderating effect of cumulative risk on child externalizing behaviors, parenting skills, and intervention dropout after completion of a home-based adaptation of the child-directed interaction phase of parent-child interaction therapy (PCIT) called the Infant Behavior Program (IBP). The participants included 58 toddlers (53% male; average age of 13.5 months; and 95% Hispanic or Latine) who were part of a larger randomized control trial in which families were randomly assigned to receive the IBP or treatment as usual (TAU). Cumulative risk was found to moderate the effect of the intervention group on child externalizing behaviors such that the participants in the intervention group with higher cumulative risk scores had greater reductions in externalizing behaviors. A potential explanation for these unexpected findings may be that the obstacles to treatment that were previously imposed by comorbid risk factors (i.e., lack of transportation, time commitment, and language barriers) were adequately addressed such that the families who most needed the intervention were able to remain fully engaged.

The relationship of history of psychiatric and substance use disorders on risk of dementia among racial and ethnic groups in the United States

Introduction

Dementia is characterized by significant declines in cognitive, physical, social, and behavioral functioning, and includes multiple subtypes that differ in etiology. There is limited evidence of the influence of psychiatric and substance use history on the risk of dementia subtypes among older underrepresented racial/ethnic minorities in the United States. Our study explored the role of psychiatric and substance use history on the risk of etiology-specific dementias: Alzheimer's disease (AD) and vascular dementia (VaD), in the context of a racially and ethnically diverse sample based on national data.

Methods

We conducted secondary data analyses based on the National Alzheimer's Coordinating Center Uniform Data Set (N = 17,592) which is comprised a large, racially, and ethnically diverse cohort of adult research participants in the network of US Alzheimer Disease Research Centers (ADRCs). From 2005 to 2019, participants were assessed for history of five psychiatric and substance use disorders (depression, traumatic brain injury, other psychiatric disorders, alcohol use, and other substance use). Cox proportional hazard models were used to examine the influence of psychiatric and substance use history on the risk of AD and VaD subtypes, and the interactions between psychiatric and substance use history and race/ethnicity with adjustment for demographic and health-related factors.

Results

In addition to other substance use, having any one type of psychiatric and substance use history increased the risk of developing AD by 22-51% and VaD by 22-53%. The risk of other psychiatric disorders on AD and VaD risk varied by race/ethnicity. For non-Hispanic White people, history of other psychiatric disorders increased AD risk by 27%, and VaD risk by 116%. For African Americans, AD risk increased by 28% and VaD risk increased by 108% when other psychiatric disorder history was present.

Conclusion

The findings indicate that having psychiatric and substance use history increases the risk of developing AD and VaD in later life. Preventing the onset and recurrence of such disorders may prevent or delay the onset of AD and VaD dementia subtypes. Prevention efforts should pay particular attention to non-Hispanic White and African American older adults who have history of other psychiatric disorders.Future research should address diagnostic shortcomings in the measurement of such disorders in ADRCs, especially with regard to diverse racial and ethnic groups.

Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center

INTRODUCTION

Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel.

METHODS

To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses.

RESULTS

Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment.

CONCLUSIONS

Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

Racial disparities and predictors of functioning in schizophrenia

Black Americans are diagnosed with schizophrenia spectrum disorders at more than twice the rate of White individuals and experience significantly worse outcomes following diagnosis. Little research has examined specific factors that may contribute to worse functional outcomes among Black Americans diagnosed with schizophrenia. One approach to understanding why racial disparities emerge is to examine established predictors of functioning in this population: neurocognition, social cognition, and symptom severity. The present study aims to broaden existing literature on racial differences within these domains by (a) examining racial differences in functioning and these established predictors of functioning (i.e., neurocognition, social, and symptom severity) and (b) investigating whether cognition and symptom domains similarly predict functioning between Black and White Americans with schizophrenia. Sixty-six participants' baseline neurocognition, social cognition, symptom severity, and functioning were assessed. Black participants demonstrated lower neurocognition scores and higher levels of disorganized symptoms relative to White participants. No racial differences in functioning or social cognition were observed. Further, race did not moderate the relationship between any of these established predictors and functioning outcomes. The largely nonsignificant differences in known predictors of functioning highlight the need to explore further domains that may be more relevant for understanding racial disparities in schizophrenia. Considering that psychosocial treatments for schizophrenia spectrum disorders often focus on cognition, these results underscore the importance of identifying whether these domains or other treatment targets may be better in addressing racial disparities in functioning. Possible areas of exploration for future work (e.g., structural factors, racism-related stress) are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Risk for alcohol use problems in severe mental illness: Interactions with sex and racial/ethnic minority status

BACKGROUND

Alcohol use disorder (AUD) is exceedingly common among individuals with bipolar disorder and schizophrenia. However, studies on alcohol use in psychiatric illness rely largely on population surveys with limited representation of severe mental illness (SMI); schizophrenia and bipolar disorder.

METHODS

Using data from the Genomic Psychiatry Cohort (GPC) (Pato MT, 2013), associations of bipolar disorder and schizophrenia with alcohol use problems were examined in a diverse US based sample, considering the influence of self-described race (African Ancestry (AA), European Ancestry (EA), or Latinx Ancestry (LA)), sex, and tobacco use. Participants answered alcohol use problem items derived from the CAGE instrument, yielding a summed "probable" alcohol use disorder (pAUD) risk score.

RESULTS

This study included 1952 individuals with bipolar disorder with psychosis (BDwP), 409 with bipolar disorder without psychosis (BD), 9218 with schizophrenia (SCZ), and 10,416 unaffected individuals. We found that SMI (BDwP, BD, SCZ) was associated with elevated AUD risk scores (B = 0.223, p < 0.001), an association which was strongest in females, particularly those of AA and LA, and in tobacco users. Schizophrenia was associated with the greatest increase in pAUD score (B = 0.141, p < 0.001). pAUD risk scores were increased among participants with bipolar disorder, with greater increases in BDwP (B = 0.125, p < 0.001) than in BD without psychosis (B = 0.027, p < 0.001).

LIMITATIONS

Limitations include reliance on self-report data, screening items for AUD, voluntary recruitment bias, and differences in race/sex distribution between groups, which were statistically adjusted for in analytic models.

CONCLUSIONS

SMI is associated with risk for AUD, particularly among females from racial minority groups, smokers, and those with psychotic disorders.