Faculty Bibliography

Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.

Major depression disorder is one of the most common mental disorders in the United States. However, Black Americans are often underdiagnosed, misdiagnosed, or not treated for depression. Limited research has been conducted on the utility of diagnostic tools in identifying depression in the Black community and could explain lack of research and public health attention to mental illness in this population. Other explanations discussed include greater ability to cope with stressful situations and the myth of the "˜resiliency expectation,"™ social activism and positive health outcomes, and lack of trust in institutions due to structural and interpersonal racism. Further research that provides contextualized results is warranted to better understand and recognize symptoms of depression, and development of more effective treatment modalities. [Psychiatr Ann. 2022;52(12):504-508.].

Suicide is a critical public health problem. Over the past decade, suicide rates have increased among Black and Latinx adults in the U.S. Though depression is the most prevalent psychiatric contributor to suicide risk, Black and Latinx Americans uniquely experience distress and stress (e.g., structural adversity) that can independently operate to worsen suicide risk. This makes it important to investigate non-clinical, subjective assessment of mental health as a predictor of suicide ideation. We also investigate whether social support can buffer the deleterious impact of poor mental health on suicide ideation.We analyzed data from 1,503 Black and Latinx participants of the Washington Heights Community Survey, a 2015 survey of residents of a NYC neighborhood. Multivariable logistic regression was conducted to examine the effect of subjectively experienced problems with anxiety and depression on suicide ideation independent of depression diagnosis, and the role of social support as a moderator.Estimated prevalence of past two-week suicide ideation was 5.8%. Regression estimates showed significantly increased odds of suicide ideation among participants reporting moderate (OR = 8.54,95% CI = 2.44-29.93) and severe (OR = 16.84,95% CI = 2.88-98.46) versus no problems with anxiety and depression, after adjustment for depression diagnosis. Informational support, i.e., having someone to provide good advice in a crisis, reduced the negative impact of moderate levels of anxiety and depression problems on suicide ideation.Findings suggest that among Black and Latinx Americans, subjective feelings of anxiety and depression account for a significant portion of the suicide ideation risk related to poor mental health. Further, social support, particularly informational support, may provide protection against suicide ideation.

BACKGROUND:Black women and Latinas in their thirties continue to be at risk for HIV transmission via heterosexual intercourse. METHODS:Informed by the Theory of Gender and Power, this study investigated a longitudinal path model linking experiences of ethnic-racial discrimination in late adolescence to sexual risk behaviors in adulthood among 492 Black women and Latinas. We also tested whether ethnic-racial identity exploration served as a resilience asset protecting women against the psychological impact of ethnic-racial discrimination. Survey data from female participants in the Harlem Longitudinal Development Study, which has followed a cohort of New York City Black and Latinx youth since 1990, were analyzed. Data for this analysis were collected at four time points when participants were on average 19, 24, 29, and 32 years of age. Structural equation modeling was used to examine a hypothesized pathway from earlier ethnic-racial discrimination to later sexual risk behaviors and the protective role of ethnic-racial identity exploration. RESULTS:Results confirmed that ethnic-racial discrimination in late adolescence was linked with sexual risk behaviors in the early thirties via increased levels of affective distress in emerging adulthood, experiences of victimization in young adulthood, and substance use in the early thirties among women low in ethnic-racial identity exploration. We also found that ethnic-racial identity served as a resilience asset, as the association between discrimination in late adolescence and affective distress in emerging adulthood was not significant among women with higher levels of ethnic-racial identity exploration. CONCLUSIONS:The results provide important preliminary evidence that ethnic-racial identity exploration may serve as a resilience asset among Black women and Latinas confronting racial discrimination. Further, we suggest that ethnic-racial identity exploration may constitute an important facet of critical consciousness.

Background: CL psychiatrists are uniquely positioned to combat structural racism in medicine Currently, there are no published papers examining racial bias in the management of psychiatric emergencies in the general medical hospital. Given the potential for restrictive clinical interventions that directly challenge a patient's autonomy (including intramuscular injections and restraints), our group embarked on a long-term, quality improvement project to detect and address racial bias affecting the clinical management of these psychiatric emergencies.
Method(s): Our institution has a multidisciplinary behavioral code team known as the Behavioral Emergency Response Team (BERT) that responds to behavioral emergencies throughout the medical hospital. Secondary BERT event data occurring from 2017 to 2020 was combined with demographic data from the electronic medical record. Race and ethnic data were collapsed into unique, phenotypic categories. BERT events were coded based on the most restrictive intervention utilized. Descriptive statistics were used to describe the sample and examine whether race / ethnicity correlated with BERT intervention utilized, diagnostic impression, reason for BERT activation, or recurrent BERTs.
Result(s): Our sample included 1532 BERT events representing N = 902 unique patients. The main interaction of BERT intervention by Race / Ethnic category reached statistical significance (p=0.04). Though most BERTs only required verbal de-escalation (n=419, 46.45%), 3% of BERTs (n = 29) escalated to 4-pt restraints (most restrictive intervention). Though reaching level 5 was rare, Black patients had a statistically significant higher likelihood of receiving this intervention compared with White patients (6% v 2%, p=0.027) and compared with all other non-Black patients (6% v 2%, p=0.040). Although the overall comparison for Race/Ethnicity and the diagnostic impression "Psychosis" did not reach significance (p=0.086), targeted analysis showed that Black patients were significantly more likely to have "Psychosis" listed as a contributing factor compared with White patients (p=0.009) and all other non-Black patients (p=0.016). Several other comparisons with Race / Ethnic category reached statistical significance: Age (p=0.048), and need for interpreter yes/no (p<0.001). Closer examination of the interaction of Race/Ethnicity x Need for Interpreter revealed that half of events involving Asian patients (n=22, 53.66%) and a third of events involving Hispanic patients (n=29, 30.53%) required interpreter services.
Discussion(s): This study demonstrates the feasibility of investigating racial bias in behavioral emergency management. The results of this preliminary analysis suggest multiple areas for enhanced education, self-awareness development, and programmatic improvement to target systemic racism, decrease racial bias, and improve patient care. These areas include bias in restraints use, the role of language in behavioral emergencies, and the influence of race on perception of underlying diagnosis.
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Background: Community pharmacies offer a population-wide approach to scale opioid overdose prevention programs (OOPP). This qualitative study identified factors influencing implementation of New York State"™s OOPP to inform the uptake of naloxone dispensation in rural and small metro area pharmacies. Methods: In-person interviews were conducted among licensed retail, independent, or supermarket pharmacists (n = 60) in the mid-Hudson valley area of New York in high- and medium-overdose regions. The semi-structured 29-item survey captured attitudes and experiences related to pharmacy participation in naloxone dispensation. Results: Data revealed pharmacist support for naloxone dispensation. Barriers to OOPP success included: (1) Insufficient retail pharmacy leadership support for administrative and clinical tasks for OOPP tasks; (2) excessive opioid analgesic prescribing by physicians; (3) limited uptake of naloxone by prescribers and patients; (4) out-of-pocket costs for patients to obtain naloxone; (5) lack of time, staffing, and space to provide opioid overdose prevention counseling; (6) concern for increased overdose fatalities and injection drug use in the pharmacy premises if pharmacists dispensed sterile syringes, naloxone, and/or Buprenorphine-naloxone; and (7) stigmatizing attitudes toward persons who use opioids. Conclusion: Multi-level intervention efforts that include pharmacist-prescriber communication and training, and stigma-reducing efforts in rural and small metro area regions are needed.

Background/UNASSIGNED:Mobile health (mHealth) tools offer an effective and personalized approach to enhance chronic disease management and may partially offset provider-level barriers to increasing buprenorphine prescribing in primary care. This study assessed the feasibility of integrating a text messaging-based medical management tool (TeMeS) in primary care among patients initiating buprenorphine. Methods/UNASSIGNED:TeMeS messages are categorized per the medical management model, programed in a HIPAA-compliant texting software (Apptoto©), and delivered in a tiered fashion over 8-weeks to patients. This mixed-methods evaluation of TeMeS utilized key stakeholder feedback (patients, physicians, administrators, nursing), text messaging software process measures, thematic analysis of patient participant text message content, and electronic administrative data (eg, appointment adherence, treatment retention) at 2-months. Results/UNASSIGNED:The study team approached 65 patients and n = 14 (21%) were ineligible or declined to participate in the study. Most eligible participants owned a smartphone (90%), responded to at least one text query (88%) over an average of 24 days, and few requested to stop receiving texts (6%). Participant text replies included responses to cognitive behavioral therapy-based queries (13.8%), confirming or rescheduling appointments (6.1%), and insurance, pharmacy, or clinical issues pertaining to buprenorphine dispensation or dosing (2%). Suggestions for design modifications included personalizing message content and adjusting message frequency per patient risk of illicit opioid reuse, use of video-based informational content, and real-time provider and staff support for emergent issues. Conclusion/UNASSIGNED:Our findings highlight the acceptability, feasibility, and high rates of engagement of utilizing text messaging to enhance self-management among patients initiating buprenorphine treatment.