The Rich Nonprofits Get Richer: Centering Psychiatric Grant Funding at the Margins.

Community psychiatrists serve multiple institutional roles, and at times these roles may include the review of grant proposals from nonprofit organizations. In this column, the authors argue that privilege and social capital can easily become concentrated among a small group of centralized model organizations and influence the grant review process. Established and wealthy nonprofits can co-opt the growing interest in health equity by leveraging their existing resources, thereby excluding emerging organizations within communities in need. By applying a structural lens to this problem, funding entities can identify approaches that more effectively promote equity throughout the grant life cycle.

Racial and Ethnic Inequities in Inpatient Psychiatric Civil Commitment.

OBJECTIVE: Involuntary psychiatric treatment may parallel ethnoracial inequities present in the larger society. Prior studies have focused on restraint and seclusion, but less attention has been paid to the civil commitment system because of its diversity across jurisdictions. Using a generalizable framework, this study investigated inequities in psychiatric commitment. METHODS: A prospective cohort was assembled of all patients admitted to an inpatient psychiatric unit over 6 years (2012-2018). Patients were followed longitudinally throughout their admission; raters recorded legal status each day. Sociodemographic and clinical data were collected to adjust for confounding variables by using multivariate logistic regression. RESULTS: Of the 4,393 patients with an initial admission during the study period, 73% self-identified as White, 11% as Black, 10% as primarily Hispanic or Latinx, 4% as Asian, and 3% as another race or multiracial. In the sample, 28% were involuntarily admitted, and court commitment petitions were filed for 7%. Compared with White patients, all non-White groups were more likely to be involuntarily admitted, and Black and Asian patients were more likely to have court commitment petitions filed. After adjustment for confounding variables, Black patients remained more likely than White patients to be admitted involuntarily (adjusted odds ratio [aOR]=1.57, 95% confidence interval [CI]=1.26-1.95), as were patients who identified as other race or multiracial (aOR=2.12, 95% CI=1.44-3.11). CONCLUSIONS: Patients of color were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalization, and Black patients and patients who identified as other race or multiracial were particularly vulnerable, even after adjustment for confounding variables.

Demilitarizing Hospital Restraints: Recognizing the Stones in Our Glass Houses.

As the debate within the United States about reforming its militarized police force continues, psychiatrists need to critically reflect on their profession's role in perpetuating structural violence. Research shows that the now well-documented disproportionate use of force against people of color in many communities is also mirrored in the hospital setting. The authors of this Open Forum provide a structurally informed perspective on the use of restraints in their practice, highlight the persistence of police weaponry in hospitals despite recommendations to abolish it, and call on regulatory authorities and clinicians to make changes that address these health inequities.

Delirium in COVID-19: A case series and exploration of potential mechanisms for central nervous system involvement.

INTRODUCTION: Neuropsychiatric manifestations of the coronavirus disease 2019 (COVID-19) have been described, including anosmia, ageusia, headache, paresthesia, encephalitis and encephalopathy. Little is known about the mechanisms by which the virus causes central nervous system (CNS) symptoms, and therefore little guidance is available regarding potential workup or management options. CASES: We present a series of four consecutive cases, seen by our psychiatry consultation service over a one-week period, each of which manifested delirium as a result of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). DISCUSSION: The four cases highlighted here all occurred in older patients with premorbid evidence of cognitive decline. Unique features seen in multiple cases included rigidity, alogia, abulia, and elevated inflammatory markers. In all four cases, a change in mental status was the presenting symptom, and three of the four cases lacked significant respiratory symptoms. In addition to discussing unique features of the cases, we discuss possible pathophysiologic explanations for COVID-19 delirium. CONCLUSIONS: Delirium should be recognized as a potential feature of infection with SARS-CoV-2 and may be the only presenting symptom. Based on the high rates of delirium demonstrated in prior studies, hospitals should consider adding mental status changes to the list of testing criteria. Further research is needed to determine if delirium in COVID-19 represents a primary encephalopathy heralding invasion of the CNS by the virus, or a secondary encephalopathy related to systemic inflammatory response or other factors.

Rising placebo response rates threaten the validity of antipsychotic meta-analyses.

BACKGROUND: Network meta-analyses (NMAs) are an increasingly important tool in comparative psychopharmacology. As do traditional metaanalyses, these studies assume that there are no unaccounted effect modifiers that could confound comparisons across time. Research methodologies, however, have changed markedly in recent decades. This is clearly seen in rising placebo response rates in modern antipsychotic and antidepressant trials (placebo inflation). The current study aimed to evaluate if NMAs display evidence of a confounding bias that varies with time. METHODS: Efficacy rankings from 2 landmark antipsychotic meta-analyses were cross-referenced and regressed against FDA approval dates. Two prominent NMAs of antidepressants were analyzed for comparison because these 2 drug classes display distinct patterns of rising placebo response rates. RESULTS: Newer antipsychotic medications consistently rank worse than older agents (rho = 0.49, 0.74; P = .066, .0016). This trend remains robust when excluding outliers (ie, first-generation antipsychotics and non-FDA- approved medications) and analyzing effect sizes rather than efficacy rankings (r = 0.83, 0.77; P = .0028, .0051). Antidepressant meta-analyses do not display a similar temporal pattern. CONCLUSIONS: Rankings of antipsychotics, but not antidepressants, show evidence of a confounding temporal bias. Poorly compensated placebo inflation is one potential explanation for this finding.