Clinicians' Racial Bias Contributing to Disparities in Electroconvulsive Therapy for Patients From Racial-Ethnic Minority Groups

A Culturally Adapted Perioperative Mental Health Intervention for Older Black Surgical Patients

OBJECTIVES

Perioperative mental health of older Black surgical patients is associated with poor surgical outcomes; however, evidence-based perioperative interventions are lacking. Our two study objectives included: first, examine factors affecting perioperative care experiences of older Black surgical patients with mental health problems, and second, ascertain design and implementation requirements for a culturally-adapted perioperative mental health intervention.

DESIGN SETTING AND PARTICIPANTS

We conducted six focus groups with older Black patients (n = 15; ≥50 years; surgery within the past 5 years and/or interest in mental health research; history of distress, anxiety, or depression coping with surgery/hospitalization/) from a large academic medical center. We engaged study partners, including interventionists and community members, to gather insights on intervention and implementation needs. We followed a hybrid inductive-deductive thematic approach using open coding and the National Institute on Minority Health and Health Disparities Research Framework.

RESULTS

Patients reported that their psychological well-being and long-term mental health outcomes were not appropriately considered during perioperative care. Perceived stressors included interpersonal and structural barriers to using mental healthcare services, clinician treatment biases and ageism in care, and lack of healthcare professional connections/resources. Patients utilized various coping strategies, including talk therapy, faith/spirituality, and family and friends.

CONCLUSION

This study offers valuable insights into the experiences of older Black surgical patients and the critical elements for developing a personalized perioperative mental health intervention to support their well-being before, during, and after surgery. Our findings demonstrated a need for a patient-centered and culturally adapted intervention targeting the individual/behavioral and interpersonal levels. Informed by the cultural adaptation framework, we propose a multi-component intervention that integrates psychological and pharmacological components.

Racial/Ethnic Disparities in Psychiatric Traits and Diagnoses within a Community-based Sample of Children and Youth: Disparités raciales/ethniques dans les traits et diagnostics psychiatriques au sein d'un échantillon communautaire d'enfants et de jeunes

OBJECTIVE

Racial/ethnic disparities in the prevalence of psychiatric disorders have been reported, but have not accounted for the prevalence of the traits that underlie these disorders. Examining rates of diagnoses in relation to traits may yield a clearer understanding of the degree to which racial/ethnic minority youth in Canada differ in their access to care. We sought to examine differences in self/parent-reported rates of diagnoses for obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders after adjusting for differences in trait levels between youth from three racial/ethnic groups: White, South Asian and East Asian.

METHOD

We collected parent or self-reported ratings of OCD, ADHD and anxiety traits and diagnoses for 6- to 17-year-olds from a Canadian general population sample (Spit for Science). We examined racial/ethnic differences in trait levels and the odds of reporting a diagnosis using mixed-effects linear models and logistic regression models.

RESULTS

East Asian (N = 1301) and South Asian (N = 730) youth reported significantly higher levels of OCD and anxiety traits than White youth (N = 6896). East Asian and South Asian youth had significantly lower odds of reporting a diagnosis for OCD (odds ratio [OR]East Asian = 0.08 [0.02, 0.41]; ORSouth Asian = 0.05 [0.00, 0.81]), ADHD (OREast Asian = 0.27 [0.16, 0.45]; ORSouth Asian = 0.09 [0.03, 0.30]) and anxiety (OREast Asian = 0.21 [0.11, 0.39]; ORSouth Asian = 0.12 [0.05, 0.32]) than White youth after accounting for psychiatric trait levels.

CONCLUSIONS

These results suggest a discrepancy between trait levels of OCD, ADHD and anxiety and rates of diagnoses for East Asian and South Asian youth. This discrepancy may be due to increased barriers for ethnically diverse youth to access mental health care. Efforts to understand and mitigate these barriers in Canada are needed.

Electroconvulsive Therapy in the United States: A 2022 Survey of Practice

OBJECTIVES

This study aimed to describe current US electroconvulsive therapy (ECT) practice, identify practice changes over time, and inform discussion of practice.

METHOD

Our anonymous survey was open on SurveyMonkey.com from January to June 2022. We sent invitations to providers identified using a Medicare provider database, an advanced PubMed search function, and professional group listservs. Participants were instructed to submit 1 survey per ECT site. We examined frequency of responses, tabulated individual comments, and grouped data for comparison.

RESULTS

We received responses from 74 US practice sites encompassing 283 providers. Forty-nine percent (n = 36) of respondents practiced at general academic medical centers, 23% (n = 17) at general medical centers, 16% (n = 12) at freestanding psychiatric hospitals, and 7% (n = 5) at Veterans Affairs medical centers. Proportions of female (29%) and Black or African American (AA) (1%) ECT providers were markedly lower than proportions of female (60%) and Black or African American ECT patients (10%). The median number of treatments for a major depressive episode was 10. The preferred electrode placement was right unilateral (66%, n = 45). The favored dosing strategy was seizure threshold titration. Quantitative outcome measures were used by 89% (n = 66) of sites for depressive symptoms and 84% (n = 62) for cognitive adverse effects.

CONCLUSIONS

This survey is the first nationwide survey of ECT practice in nearly 40 years. Our results describe changes in practice over time and highlight the need to increase the number of female and Black or African American ECT providers. A comprehensive network of ECT sites could facilitate more frequent nationwide surveys.

Educating the next generation of psychiatrists in the use of clinical neuromodulation therapies: what should all psychiatry residents know?

A variety of neuromodulation treatments are available today and more are on the way, but are tomorrow's psychiatrists prepared to incorporate these tools into their patients' care plans? This article addresses the need for training in clinical neuromodulation for general psychiatry trainees. To ensure patient access to neuromodulation treatments, we believe that general psychiatrists should receive adequate education in a spectrum of neuromodulation modalities to identify potential candidates and integrate neuromodulation into their multidisciplinary care plans. We propose curricular development across the four FDA-cleared modalities currently available in psychiatric practice: electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). With a focus on psychiatry residency training, the article delineates core learning components for each neuromodulation technique. For each modality, we review the clinical training status, the respective FDA-cleared indications, mechanisms of action, clinical indications and contraindications, adverse effects, informed consent process, dosing considerations, and clinical management guidelines. The approach outlined in this article aims to contribute to the development of a well-rounded generation of psychiatry trainees with the capacity to navigate the growing field of neuromodulation. Whether or not a psychiatrist specializes in delivering neuromodulation therapies themselves, it is incumbent on all psychiatrists to be able to identify patients who should be referred to neuromodulation therapies, and to provide comprehensive patient care before, during and after clinical neuromodulation interventions to optimize outcomes and prevent relapse.

Pronounced Regional Variation in Esketamine and Ketamine Prescribing to US Medicaid Patients

Ketamine and esketamine are efficacious for treatment-resistant depression. Unlike other antidepressants, ketamine lacks a therapeutic delay and decreases the risk for suicide. This cross-sectional study geographically characterized ketamine and esketamine prescribing to United States (US) Medicaid patients. Ketamine and esketamine prescription rates and spending per state were obtained. Between 2009 and 2020, ketamine prescribing rates peaked in 2013 followed by a general decline. For ketamine and esketamine in 2019, Montana (967/million enrollees) and Indiana (425) showed significantly higher prescription rates, respectively, relative to the national average. A total of 21 states prescribed neither ketamine nor esketamine in 2019. There was a 121.3% increase in esketamine prescriptions from 2019 to 2020. North Dakota (1,423) and North Carolina (1,094) were significantly elevated relative to the average state for esketamine in 2020. Ten states prescribed neither ketamine nor esketamine in 2020. Medicaid programs in 2020 spent 72.7-fold more for esketamine ($25.3 million) than on ketamine (0.3 million). Despite the effectiveness of ketamine and esketamine for treatment-resistant depression and anti-suicidal properties, their use among Medicaid patients was limited and highly variable in many areas of the US. Further research to better understand the origins of this state-level variation is needed.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation

PURPOSE

Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.

METHODS

A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.

RESULTS

Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.

CONCLUSIONS

The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

Psychotic Misdiagnosis of Racially Minoritized Patients: A Case-Based Ethics, Equity, and Educational Exploration

The overdiagnosis and misdiagnosis of racially minoritized groups as having a primary psychotic disorder is one of psychiatry's longest-standing inequities born of real-time clinician racial bias. Evidence suggests that providers assign a diagnosis of schizophrenia and/or schizoaffective disorder according to race more than any other demographic variable, and this inequity persists even in the absence of differences in clinician symptom ratings. This case report describes the journey of one young Black woman through her racialized misdiagnosis of schizophrenia and the process by which interdisciplinary, health equity-minded providers across the spectrum of medical education and practice joined together to provide a culturally informed, systematic rediagnosis of major depressive disorder and post-traumatic stress disorder. Expert discussion is provided by three Black academic psychiatrists with expertise in social justice and health equity. We provide an evidence-based exploration of mechanisms of clinician racial bias and detail how the psychosis misdiagnosis of racially minoritized groups fails medical ethics and perpetuates iatrogenic harm to patients who truly need help with primary mood, trauma, and substance use disorders.

Confluence of law enforcement, mental health, and race

Disparities in victimization by law enforcement for both people of color and individuals with mental health disorders is gaining national attention following the deaths of George Floyd, Sandra Bland, TAmir Rice, and many others. Despite this, the discussion around the intersectionality of race, psychiatric illness, and law enforcement is still in its infancy, the purpose of this article is to discuss the confluence of race and psychiatric illness as vulnerabilities in various contacts with law enforcement in order to further highlight this issue and to ignite further needed research on this topic. Possible solutions such as police-hiring practices, bias training, and trauma-informed policing will be discussed.

Being an anti-racist clinician

Racism is a pervasive problem in Western society, leading to mental and physical unwellness in people from racialized groups. Psychology began as a racist discipline and still is. As such, most clinical training and curricula do not operate from an anti-racist framework. Although most therapists have seen clients with stress and trauma due to racialization, very few were taught how to assess or treat it. Furthermore, clinicians and researchers can cause harm when they rely on White-dominant cultural norms that do not serve people of colour well. This paper discusses how clinicians can recognize and embrace an anti-racism approach in practice, research, and life in general. Included is a discussion of recent research on racial microaggressions, the difference between being a racial justice ally and racial justice saviour, and new research on what racial allyship entails. Ultimately, the anti-racist clinician will achieve a level of competency that promotes safety and prevents harm coming to those they desire to help, and they will be an active force in bringing change to those systems that propagate emotional harm in the form of racism.

Key learning aims

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A Brief Online Implicit Bias Intervention for School Mental Health Clinicians

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools-where most youth in the U.S. access mental healthcare. Clinicians (N = 12) in the feasibility study-a non-randomized open trial-rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians' VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth's care experience.