Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status.

Importance: Black patients are more likely than White patients to be restrained during behavioral crises in emergency departments (EDs). Although the perils of policing mental health for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the association between Black race and use of physical restraint in EDs. Objective: To evaluate the degree to which police transport mediates the association between Black race and use of physical restraint in EDs. Design, Setting, and Participants: This retrospective, cross-sectional study used electronic health record data from ED visits by adults (aged ≥18 years) to 3 hospitals in the southeastern US and 10 in the northeastern US between January 1, 2015, and December 31, 2022. Data were analyzed from September 1, 2022, to May 30, 2023. Exposures: Race, ethnicity, and police transport to the hospital. Main Outcomes and Measures: The primary outcome variable was the presence of an order for restraints during an ED visit. Results: A total of 4 263 437 ED visits by 1 257 339 patients (55.5% of visits by female and 44.5% by male patients; 26.1% by patients 65 years or older) were included in the study. Black patients accounted for 27.5% of visits; Hispanic patients, 17.6%; White patients, 50.3%; and other or unknown race or ethnicity, 4.6%. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of experiencing restraint compared with White patients (adjusted odds ratio [AOR], 1.33 [95% CI, 1.28-1.37]). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared with all other patients (AOR, 1.38 [95% CI, 1.34-1.42]). Patients brought to the ED under police transport had increased odds of experiencing restraint compared with all other modes of transport (AOR, 5.51 [95% CI, 5.21-5.82]). The estimated proportion of use of restraints for Black patients mediated by police transport was 10.70% (95% CI, 9.26%-12.53%). Conclusions and Relevance: In this cross-sectional study of ED visits across 13 hospitals, police transport may have mediated the association between Black race and use of physical restraint. These findings suggest a need to further explore the mechanisms by which transport to emergency care may influence disparate restrictive interventions for patients experiencing behavioral emergencies.

Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis.

Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.

Racial Inequities in Police Transport for Patients to the Emergency Department: A Multicenter Analysis.

INTRODUCTION: Police involvement in patient transport to emergency medical care has increased over time, yet studies assessing racial inequities in transport are limited. This study evaluated the relationship between race and police transport to the emergency department for adult patients. METHODS: This cross-sectional study evaluated adult (aged ≥18 years) visits at 13 different emergency departments across two regional hospital systems in the Southeastern and Northeastern U.S. from 2015 to 2022. Data were extracted from electronic health records. This analysis evaluated the association between race and transport by police transport using generalized linear multivariable mixed model with a binary logistic link for presence of police transport. Data were nested by patient and adjusted for site, demographics, and diagnostic visit characteristics. RESULTS: Of 4,291,809 adult emergency department visits, 25,901 (0.6%) involved transport by police. Of the 25,901 visits in police-involved encounters, 10,513 (40.6%) patients were Black, and 9,827 (37.9%) were White. The adjusted model showed that Black patients were at higher odds of transport by police than White patients (AOR=1.64; 95% CI=1.57-1.72). Male sex, younger age (18-35 years), history of behavioral health diagnosis, and emergency department psychiatric or substance use disorders were independently associated with increased odds of police transport. CONCLUSIONS: This analysis revealed racial inequities in police-involved transport to emergency medical care, highlighting an urgent need to evaluate drivers of inequities and the ways in which police transport influences clinical outcomes.

An overview of clinical machine learning applications in neurology.

Machine learning techniques for clinical applications are evolving, and the potential impact this will have on clinical neurology is important to recognize. By providing a broad overview on this growing paradigm of clinical tools, this article aims to help healthcare professionals in neurology prepare to navigate both the opportunities and challenges brought on through continued advancements in machine learning. This narrative review first elaborates on how machine learning models are organized and implemented. Machine learning tools are then classified by clinical application, with examples of uses within neurology described in more detail. Finally, this article addresses limitations and considerations regarding clinical machine learning applications in neurology.

Dextromethorphan-bupropion (Auvelity) for the Treatment of Major Depressive Disorder.

Depression is a significant cause of morbidity and mortality globally. Although various pharmacologic options exist for depression, treatments are limited by delayed or incomplete therapeutic response, low rates of remission, and adverse effects necessitating effective, fast-acting, and better tolerated alternatives. The purpose of this review is to describe the safety and efficacy of dextromethorphan-bupropion (Auvelity), a Food and Drug Administration approved treatment for major depressive disorder in adults. Dextromethorphan modulates glutamate signaling through uncompetitive antagonism of N-methyl-D-aspartate receptors and sigma-1 agonism, while bupropion increases the bioavailability of dextromethorphan by CYP2D6 inhibition. In a phase 3 trial with dextromethorphan-bupropion 45-105 mg for patients with major depressive disorder saw significant reductions in their Montgomery-Åsberg Depression Rating Scale total scores compared to placebo. A phase 2 trial comparing dextromethorphan-bupropion 45-105 mg to bupropion monotherapy led to significant reduction in Montgomery-Åsberg Depression Rating Scale score. Changes in Montgomery-Åsberg Depression Rating Scale with dextromethorphan-bupropion were seen within two weeks in both clinical trials. Remission and response rates were significantly higher with dextromethorphan-bupropion in both studies. The medication was well-tolerated in both trials, with the most common adverse events being rated as mild-to-moderate. Two long-term, open-label studies with dextromethorphan-bupropion saw large reductions in Montgomery-Åsberg Depression Rating Scale scores that were maintained through 12 and 15 months of treatment. In both long-term studies, remission rates approached 70%, while response rates were greater than 80%. These data suggest that dextromethorphan-bupropion is an effective, fast-acting, and well tolerated option for depression treatment and produced remission in a large percentage of patients.

Perspective: A resident's role in promoting safe machine-learning tools in sleep medicine.

Residents and fellows can play a helpful role in promoting safe and effective machine-learning tools in sleep medicine. Here we highlight the importance of establishing ground truths, considering key variables, and prioritizing transparency and accountability in the development of machine-learning tools within the field of artificial intelligence. Through understanding, communication, and collaboration, in-training physicians have a meaningful opportunity to help progress the field toward safe machine-learning tools in sleep medicine. CITATION: Smith CM, Vendrame M. Perspective: a resident's role in promoting safe machine-learning tools in sleep medicine. J Clin Sleep Med. 2023;19(11):1985-1987.

Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study.

OBJECTIVE: Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU). METHODS: Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis. RESULTS: Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received. CONCLUSIONS: This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.

Sublingual Dexmedetomidine for the Treatment of Agitation in Patients with Schizophrenia and Bipolar Disorder.

Acute agitation is common amongst individuals with bipolar disorder and schizophrenia and represents a medical emergency. Commonly used medications for agitation, such as benzodiazepines and antipsychotics, are often delivered intramuscularly and may cause adverse effects. Non-invasive, effective, and safe alternative treatment options are needed. The purpose of this review article is to describe the efficacy and safety of sublingual formulation of dexmedetomidine (Igalmi), a selective α2-adrenergic receptor agonist, U.S. Food and Drug Administration approved for the treatment of acute agitation in adults with schizophrenia or bipolar I and II disorder. In two phase 3 trials, two dose strengths of sublingual dexmedetomidine 180 µg and 120 µg were safe and effective in managing acute agitation in patients with bipolar disorder or schizophrenia. Both doses significantly reduced Positive and Negative Syndrome Scale-Exited Component scores two hours after receiving a single dose as compared to placebo, indicating a substantial improvement in agitation. The beneficial effects of sublingual dexmedetomidine were achieved without serious adverse events with the most common side effect being mild somnolence. The clinical trial data suggest that sublingual dexmedetomidine represents a safe and effective treatment option in the armamentarium for acute agitation for people with schizophrenia or bipolar disorder.

Mental Health Outcomes Among American Indian and Alaska Native U.S. Army Soldiers: A Serial Cross-Sectional Analysis.

INTRODUCTION: American Indian and Alaska Native (AI/AN) individuals in the USA experience higher rates of mental illness and preventable death than the general population. Published research demonstrates that AI/AN veterans experience similar disparities to other minorities compared to non-minority veterans; few studies, however, have assessed mental health outcomes in AI/AN active duty military members. The objective of this study was to determine differences in depression, anxiety, hazardous alcohol consumption, and suicidal ideation among AI/AN soldiers compared to soldiers of other races during the Coronavirus Disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS: We conducted repeated cross-sectional electronic surveys to assess the mental health of active duty and activated reserve U.S. Army soldiers within three commands in the Northwestern Continental United States , Republic of Korea, and Germany during May-June 2020 (T1) and December 2020-January 2021 (T2). The primary exposure of interest in the present analysis was race and ethnicity, and the primary outcomes were probable depression with functional impairment (subsequently "depression"), probable anxiety with functional impairment (subsequently "anxiety"), hazardous alcohol use, and suicidal ideation. Multivariable logistic regression models were used to determine the association between demographics and COVID-19 concerns on mental health outcomes for each time point. RESULTS: A total of 21,293 participants responded to the survey at T1 (participation rate = 28.0%), and 10,861 participants responded to the survey at T2 (participation rate = 14.7%). In the multivariable model, AI/AN participants had 1.36 higher adjusted odds of suicidal ideation (95% CI: 1.02-1.82) at T1 and 1.50 greater adjusted odds of suicidal ideation at T2 (95% CI: 1.00-2.24), when compared to non-Hispanic White participants. During T1, there was no significant difference detected between AI/AN and non-Hispanic White participants for anxiety (adjusted odds ratio: 1.21; 95% CI: 0.91-1.60) (Table IV). However, AI/AN participants had 1.82 greater adjusted odds of anxiety when compared to non-Hispanic White participants at T2 (adjusted odds ratio: 1.82; 95% CI: 1.29-2.57). There were no significant differences detected between AI/AN participants and non-Hispanic White participants in multivariable models for either depression or hazardous alcohol use at both time points. CONCLUSIONS: Although we hypothesized that all adverse mental health outcomes would be higher for AI/AN service members at both time points, there were no significant differences at each of the time points analyzed for most of the outcomes analyzed. However, differences in suicidal ideation were found at both time points. Analyses and proposed interventions should account for diversity and heterogeneity of AI/AN populations.

Long-Term Effect of Group Support Psychotherapy on Depression and HIV Treatment Outcomes: Secondary Analysis of a Cluster Randomized Trial in Uganda.

OBJECTIVE: We aimed to determine the effect of group support psychotherapy (GSP) compared with group HIV education (GHE) on depression and HIV treatment outcomes 24 months after treatment. We further aimed to investigate the mediating role of depression and antiretroviral therapy (ART) adherence in the relationship between GSP and viral load suppression. METHODS: Thirty HIV clinics across three districts were randomly assigned to deliver either GSP or GHE for depression. Depression and optimal (≥95%) ART adherence was assessed at baseline and 6, 12, 18, and 24 months after treatment. Viral load was drawn from the medical charts at baseline and 12 and 24 months after treatment. Multilevel mixed-effects regression models and generalized structural equation modeling were used to estimate 24-month outcomes and mediation effects. RESULTS: Participants ( N = 1140) were enrolled from HIV clinics offering either GSP ( n = 578 [51%]) or GHE ( n = 562 [49%]). Fewer GSP than GHE participants met the criteria for depression at 24 months after treatment (1% versus 25%; adjusted odds ratio [aOR] = 0.002, 95% confidence interval [CI] = 0.0002-0.018). More GSP than GHE participants reported optimal (≥95%) ART adherence (96% versus 88%; aOR = 20.88, 95% CI = 5.78-75.33) and improved viral suppression (96% versus 88%; aOR = 3.38, 95% CI = 1.02-11.02). The indirect effects of GSP through sequential reduction in depression and improvement in ART adherence at 12 months may partially explain the higher viral suppression rates at 24 months in GSP than GHE groups. CONCLUSION: In settings where the HIV epidemic persists, depression treatment with GSP may be critical for optimal HIV treatment outcomes.Trial Registration: The Pan African Clinical Trials Registry, number PACTR201608001738234.

Mental Health Support of Frontline Medical Personnel in the Javits New York Medical Station Federal COVID-19 Treatment Center.

Background: The federal government responded to the early epicenter of the COVID-19 pandemic in the United States by mobilizing uniformed services and other federal medical personnel to treat patients at the Javits New York Medical Station. Deployment of large numbers of personnel required flexible psychiatric and psychological support. Observations: This report details the establishment of mental health support services for frontline personnel in a large convention center and explores lessons learned to encourage future mental health professionals to apply creative and assertive mental health interventions in disaster settings. Conclusions: Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating services throughout the civilian medical system. We suggest mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario.

Mental Illness in Adults With HIV and HCV Infection: Indian Health Service, 2001-2020.

INTRODUCTION: Mental health disorders (MHDs) and substance use disorders (SUDs) in people living with HIV, hepatitis C virus (HCV) infection, and HIV/HCV coinfection are common and result in significant morbidity. However, there are no national prevalence estimates of these comorbidities in American Indian and Alaska Native (AI/AN) adults with HIV, HCV infection, or HIV/HCV coinfection. This study estimates the prevalence of MHD and SUD diagnoses in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection within the Indian Health Service (IHS). METHODS: In 2021, a cross-sectional study using data from the National Patient Information Reporting System was completed to identify MHD or SUD diagnoses in AI/AN adults with HIV, HCV infection, or HIV/HCV coinfection within the IHS during fiscal years 2001‒2020. Logistic regression was used to compare the odds of MHD or SUD diagnoses, adjusting for age and sex. RESULTS: Of AI/AN adults diagnosed with HIV, hepatitis C virus infection, or HIV/HCV coinfection, the period prevalence of MHD or SUD diagnoses ranged from 57.2% to 81.1%. Adjusting for age and sex, individuals with HCV infection had higher odds of receiving a MHD diagnosis (AOR=1.57; 95% CI=1.47, 1.68) or SUD diagnosis (AOR=3.40; 95% CI=3.18, 3.65) than those with HIV, and individuals with HIV/HCV coinfection had higher odds of receiving a MHD diagnosis (AOR=1.60; 95% CI=1.35, 1.89) or SUD diagnosis (AOR=2.81; 95% CI=2.32, 3.41) than those with HIV. CONCLUSIONS: MHD and SUD diagnoses were common in AI/AN adults diagnosed with HIV, HCV infection, or HIV/HCV coinfection, highlighting the need for culturally appropriate screening and treatment programs sensitive to the diverse strengths of AI/AN populations and structural challenges they endure.

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

OBJECTIVE: Few studies have examined the disproportionate use of restraints for Black adults receiving emergency psychiatric care. This study sought to determine whether the odds of physical and chemical restraint use were higher for Black patients undergoing emergency psychiatric care compared with their White counterparts. METHODS: This single-center retrospective cohort study examined 12,977 unique encounters of adults receiving an emergency psychiatric evaluation between January 1, 2014, and September 18, 2020, at a large academic medical center in Durham, North Carolina. Self-reported race categories were extracted from the electronic medical record. Primary outcomes were the presence of a behavioral physical restraint order or chemical restraint administration during the emergency department encounter. Covariates included age, sex, ethnicity, height, time of arrival, positive urine drug screen results, peak blood alcohol concentration, and diagnosis of a bipolar or psychotic disorder. RESULTS: A total of 961 (7.4%) encounters involved physical restraint, and 2,047 (15.8%) involved chemical restraint. Models with and without a race covariate were compared by using quasi-likelihood information criterion scores; in each instance, the model with race performed better than the model without. Black patients were more likely to be physically (adjusted odds ratio [AOR]=1.35; 95% confidence interval [CI]=1.07-1.72) and chemically (AOR=1.33; 95% CI=1.15-1.55) restrained than White patients. CONCLUSIONS: After analyses were adjusted for measured confounders, Black patients undergoing psychiatric evaluation were at higher odds of experiencing physical or chemical restraint compared with White patients, which is consistent with the growing body of evidence revealing racial disparities in psychiatric care.

COVID-19-associated psychosis: A systematic review of case reports.

OBJECTIVES: To describe the comorbidities, presentations, and outcomes of adults with incident psychosis and a history of COVID-19. METHODS: We completed a descriptive systematic review of case reports according to PRISMA guidelines, including cases of adult patients with incident psychosis and antecedent or concurrent COVID-19. We extracted patient demographics, comorbidities, clinical course, and outcomes, and assessed cases for quality using a standardized tool. RESULTS: Of 2396 articles, we included 40 reports from 17 countries, comprising 48 patients. The mean age of patients was 43.9 years and 29 (60%) were males. A total of 7 (15%) had a documented psychiatric history, 6 (13%) had a substance use history and 11 (23%) had a comorbid medical condition. Delusions were the most common (44 [92%]) psychiatric sign and psychosis lasted between 2 and 90 days. A total of 33 (69%) patients required hospitalization to a medical service and 16 (33%) required inpatient psychiatric admission. The majority (26 [54%]) of cases did not assess for delirium and 15 (31%) cases were judged to be of high risk of bias. CONCLUSIONS: Despite the growing awareness of COVID-19's association with incident psychosis at a population level, cases of COVID-19-associated psychosis often lacked clinically relevant details and delirium was frequently not excluded. PROSPERO registration number: CRD42021256746.

Schizotypal personality disorder disguised as dissociative identity disorder.

A 20-year-old man was admitted to an inpatient psychiatric unit for self-professed dissociative identity disorder. His presentation of multiple personalities without amnesia, dissociation or depersonalisation led to further examination of personality and cultural factors that may contribute to this uncommon presentation. Careful clinical investigation supported a diagnosis of schizotypal personality disorder with elements of fantastical thinking influenced by media presentations of dissociative identity disorder.

Mental health interventions for persons living with HIV in low- and middle-income countries: a systematic review.

INTRODUCTION: Addressing the intersection between mental health and HIV is critical for the wellbeing of persons living with HIV (PLWH). This systematic review synthesized the literature on mental health interventions for PLWH in low- and middle-income countries (LMICs) to determine intervention components and explore their relationship with intervention effectiveness. METHODS: We included only controlled clinical trials of interventions aiming to improve the mental health of PLWH. We conducted a search in the following databases: PubMed, CINAHL, PsycINFO and EMBASE for eligible studies describing the evaluation of interventions for mental health problems among PLWH in LMICs published through August 2020. Two reviewers independently screened references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria. RESULTS: We identified a total of 30 eligible articles representing 6477 PLWH who were assigned to either the intervention arm (n = 3182) or control arm (n = 3346). The mental health interventions evaluated were psychological (n = 17, 56.67%), pharmacological (n = 6, 20.00%), combined psychological and pharmacological (n = 1, 3.33%) and complementary/alternative treatments (n = 6, 20.00%). The mental health problems targeted were depression (n = 22, 73.33 %), multiple psychological symptoms (n = 1, 3.33%), alcohol and substance use problems (n = 4, 13.33%), post-traumatic stress disorder (n = 1, 3.33%) and HIV-related neuro-cognitive impairment (n = 2, 6.67%). Studies of interventions with significant effects had significantly a higher number of active ingredients than those without significant effects [3.41 (2.24) vs. 1.84 (1.46) Mean (SD)] [Mean difference = -1.56, 95% CI = -3.03 to -0.09, p = 0.037]. CONCLUSIONS: There continue to be advances in mental health interventions for PLWH with mental illness in LMICs. However, more research is needed to elucidate how intervention components lead to intervention effectiveness. We recommend scale up of culturally appropriate interventions that have been successfully evaluated in low- and middle-income countries.