Emergency Department Staff More Likely to Restrain Black Children Than White Children, Report Finds

Black children are almost twice as likely to be physically restrained in the emergency department compared with White children, according to a research letter published this week in JAMA Pediatrics. Use of physical restraints is an uncommon but serious intervention that has been found to increase the risk of injury, trauma, and death.

“Racial and ethnic disparities in restraint use likely reflect racism at multiple levels within and beyond the emergency care continuum,” wrote Katherine A. Nash, M.D., of Yale University School of Medicine and colleagues. “Potential drivers include interpersonal racism in the perception of threat or aggression, institutional racism leading to disparities in access to behavioral health care, and structural racism leading to disproportionate experiences with risk factors for mental illness, including poverty, trauma, and discrimination.”

The researchers examined the health records of nearly 552,000 emergency department visits by children from less than a year old to age 16 at 11 emergency departments within a New England health care system between 2013 and 2020. They found that physical restraints were ordered for 532 visits (0.1%). The majority of the children who were physically restrained were publicly insured, had a behavioral health problem, and were males above the age of 10. 

Results were adjusted for age, sex, language spoken, insurance, school month, behavioral health presenting problem, presence of an outpatient psychotropic medication, and history of behavioral health condition. They found that emergency department staff were 1.8 times more likely to use physical restraints on Black pediatric patients than White pediatric patients. They found no difference in the use of physical restraints on White versus Hispanic pediatric patients.

The researchers noted that previous research showed that Black adult patients are also more likely to be physically restrained in emergency rooms. Physical restraint should be used only after trying behavior de-escalation or chemical restraint, they added.

“Documenting racial and ethnic inequities is important but insufficient,” the authors concluded. “Physical restraint is a traumatic experience that can have lasting consequences for a child’s development and well-being. Further research should identify interventions that address inequities in physical restraint use and ensure a health care system that is a therapeutic rather than traumatic environment.”

For related information, see the Psychiatric Services article “The Role of the Psychiatrist in Seclusion and Restraint.”

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CMS Proposes Adding Payment for Telehealth Services by Mental Health Professionals

The federal government is proposing to permanently allow payment under the Medicare program for “audio-only” telehealth mental health services. These services have been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency. The government also would retain other temporarily reimbursed telehealth services through 2023 in order to evaluate whether those services should be permanently added to the list of covered Medicare services.

The recommended changes are part of the proposed 2022 Physician Fee Schedule by the Centers for Medicare and Medicaid Services (CMS). A final rule will be issued later this year; look for further reporting in Psychiatric News.

The proposed telehealth recommendations are a victory for psychiatrists and their patients for which APA has strongly advocated.

“Audio-only services have been a lifeline for patients for whom it is the only option when seeking mental health and substance use disorder treatment,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter to CMS Administrator Chiquita Brooks-LaSure. “Patients who cannot interact with their physician via a live, synchronous audio-video connection may need to rely on audio-only care for myriad reasons: they may lack access to sufficient broadband internet or access to the technology itself (e.g., they may not own a smartphone, tablet, or PC); their diagnosis may preclude using such technology; or they may not consent to being seen via video.”

He added, “We appreciate [that] CMS is proposing to make permanent—or otherwise continue to temporarily extend and evaluate—many of the telehealth provisions that clinicians and patients have relied on over the course of the public health emergency.”

Coverage of audio-only services would be restricted to clinicians who have the capability to furnish two-way audiovisual services and who have seen the patient in person at least once in the previous six months. In its comments to CMS, APA urged CMS to waive the six-month in-person requirement, emphasizing that the need for an in-person visit should be left to the psychiatrist’s clinical judgment.

The proposed rule also includes changes to the physician payment formula. Importantly, CMS is proposing a reduction to the “conversion factor” used in the formula that is likely to result in an overall reduction in physician payment. The change is partly the result of a budget neutrality adjustment that requires improvements in payment for Evaluation and Management Services last year to be offset in 2022 to maintain budget neutrality.

According to an AMA analysis of the impact of the proposed changes on different specialties, psychiatry would experience an overall reduction in payment of 3.1%; how individual practices will be affected would depend on practice and billing patterns.

In the letter to CMS, Levin urged CMS and the Department of Health and Human Services to work together with Congress to waive the budget neutrality adjustment set to go into place for 2022. “The reduction in the Medicare conversion factor will have a significant financial impact on psychiatrists who treat Medicare patients and comes at a time when practices have already experienced financial losses due to the COVID-19 public health emergency,” Levin wrote. “Payment cuts will only further compound the growing access problem for patients with mental health and/or substance use disorders.”

For more information, see the Psychiatric News article “CMS Proposes Permanent Payment for Telehealth Services Allowed During Pandemic.” A report on the final rule will appear in the December issue of Psychiatric News.

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ECT May Reduce Risk of Death in Older Patients Hospitalized for Psychiatric Disorders

Patients aged 65 or older who received electroconvulsive therapy (ECT) while hospitalized for a psychiatric disorder were found to have a lower rate of death in the year following discharge than similar patients who did not receive ECT while hospitalized, reports a study in AJP in Advance.

“This report adds to a growing body of research suggesting a positive effect of ECT from a population health perspective,” wrote Taeho Greg Rhee, Ph.D., of the University of Connecticut and colleagues. “Future efforts should focus on ways to ensure broader implementation of this treatment and to improve the maintenance therapy of severely ill patients who receive ECT.”

In this observational study, Rhee and colleagues used Medicare claims data to compare the mortality of Medicare beneficiaries 65 and up who received at least one ECT session during a psychiatric hospitalization between 2011 and 2015 with those who did not receive ECT during a psychiatric hospitalization. The final sample included 10,460 ECT patients and 31,160 control patients who were matched based on such characteristics as age, gender, and number of psychiatric hospitalizations in the previous year. The authors compared the mortality rates of patients due to various causes at one, two, three, six, and 12 months after their discharge from the hospital.

Patients who received at least one ECT session had a 39% lower rate of all-cause mortality 12 months after discharge compared with patients who did not receive ECT, while patients who received at least five sessions of ECT within a 30-day period had a 44% lower all-cause mortality rate.

In looking at different mortality categories, the authors found that ECT patients were less likely to die from smoking-related diseases, circulatory diseases, diabetes, and cancer. “While several mechanisms may be at play, one potential way in which ECT might lead to reduction in mortality risk is that improved functioning following ECT allows patients to maintain a healthier lifestyle and to better engage in treatment for whatever medical conditions they face,” they wrote.

Older patients who received any ECT or at least five sessions of ECT also had a 44% and 59% lower rate of suicide after three months, respectively, compared with patients who received no ECT, but by one year suicide rates of both groups were similar. “This is in line with the traditional understanding of the treatment course of ECT, where a large portion of ECT patients relapse after 6 months without a continuation treatment,” the authors wrote.

To read more on this topic, see the Psychiatric News article “When Is ECT Right for Your Patients With Depression?”

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APA Joins Other Health Organizations in Support of Collaborative Care Bill

APA has joined 17 other health organizations in supporting the Collaborate in an Orderly and Cohesive Manner (COCM) Act. The COCM Act was introduced by Reps. Lizzie Fletcher (D-Texas) and Jaime Herrera Beutler (R-Wash.) in the House of Representatives on Friday. If enacted, this legislation would improve access to evidence-based mental health care and substance use treatment by supporting and investing in the implementation of the Collaborative Care Model in primary care offices.

In the Collaborative Care Model, a primary care physician, a psychiatric consultant, and a care manager work as a team to identify and provide evidence-based treatment for patients with mental health conditions, measure their progress, and adjust care when appropriate. More than 90 research studies have demonstrated this model’s efficacy in improving patient outcomes. Furthermore, treatment provided through the Collaborative Care Model is covered by Medicare, most private insurers, and many states’ Medicaid programs.

However, the Collaborative Care Model has not been implemented on a wide scale yet in the United States. The COCM Act will provide primary care practices with startup funds and technical assistance as they adopt the model. The bill also provides funds for research to build the evidence base for other models of integrated behavioral health care.

“The Collaborative Care Model is a proven method of reaching more Americans with quality mental health care services,” said APA President Vivian Pender, M.D., in a news release issued by the supporting organizations. “The mental health impacts of COVID-19 and the way it uprooted our lives led to high levels of anxiety and depression and record overdoses in our country. We applaud Reps. Fletcher and Herrera Beutler for introducing this legislation, which promotes an innovative solution that will help more Americans get the high-quality treatment they need.”

For more information on the Collaborative Care Model and training provided by APA, see the APA webpage Learn About the Collaborative Care Model.

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APA Reflects on 20th Anniversary of 9/11

To mark the 20th anniversary of the terror attacks on September 11, 2001, APA released a statement today in honor of the thousands of men and woman who perished and the first responders who put their own lives on the line.

“We salute the first responders in New York, Washington, D.C., and Pennsylvania who bravely put themselves into harm’s way to rescue as many people as they could. We think of the efforts of psychiatrists and mental health clinicians in those regions, who from the very beginning treated many who suffered from trauma, from substance use disorders, and from other mental illness as a result of this tragedy. We remember the service members who deployed across the world in the resulting wars and the families they had to leave behind,” the APA statement read.

In the years since these attacks, there has been an enormous body of research on the effects of 9/11 on mental illness and substance use. In the September issue of Psychiatric News, psychiatrists reflect on how the attacks elevated disaster psychiatry and altered the way that psychiatrists understand psychological and behavioral responses to disasters.

“As we continue to face the aftermath of that day, whether in the form of quiet remembrances or the ongoing turmoil in Afghanistan, we urge everyone impacted to know that in times of tragedy and distress, we, as psychiatrists, are here to support you, and mental health help is available,” APA wrote.

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Survey Finds Marijuana Use Soared Among College Students, While Alcohol Use Dropped

Drug use trends among young adults have shifted dramatically in recent years, with 44% of college students reporting past-year marijuana use in 2020, according to the 2020 Monitoring the Future (MTF) study issued yesterday. Marijuana use was similar among young adults not enrolled in college, with 43% reporting past-year use.

“The pandemic has caused fundamental changes in the daily lives of teens and adults,” John E. Schulenberg, Ph.D., of the University of Michigan Institute for Social Research and colleagues wrote. “This endemic disruption is likely to affect substance use, and MTF is uniquely designed to examine such potential period effects and quite likely lasting cohort effects.”

Since 1980, the MTF study has annually tracked substance use among college students and noncollege adults aged 19 to 22. Data for 2020 were collected between March 2020—when much of the nation began pandemic lockdowns and virtual school—and November 2020. The 2020 results are based on the online responses of 1,550 college-aged adults.

The study revealed that past-year use of hallucinogens—including LSD, psilocybin, mushrooms, and other psychedelic substances—had also significantly increased among college students, from 5% in 2019 to nearly 9% in 2020. Among noncollege adults, past-year hallucinogen use remained consistent at around 10% in 2020, compared with 8% the previous year.

College students reported significantly lower alcohol use on several key measures in 2020, compared with the prior year. For example, 56% of students reported using alcohol in the past 30 days (down from 62% in 2019), and 28% reported being drunk in the past 30 days (down from 35%). In addition, 24% of college students reported binge drinking (consuming five or more alcoholic drinks in a row at least once in the past two weeks) in 2020, down from 32% in 2019. Among young adults not in college, trends in alcohol use across all measures were stable over the past five years, with 49% of noncollege respondents reporting alcohol use in the past 30 days, 22% reporting being drunk in the past 30 days, and 24% reporting binge drinking at least once in the past two weeks.

“While binge drinking has been gradually declining among college students for the past few decades, this is a new historic low, which may reflect effects of the COVID-19 pandemic in terms of reduced time with college friends,” said Schulenberg in a media release.

Psychiatrist Encourages Informing Patients About Marijuana Risks

“The changes that we’re seeing now have been unfolding for the past 10 to 15 years,” Elie G. Aoun M.D., an assistant professor of clinical psychiatry at Columbia University, told Psychiatric News. Marijuana is easier to use without detection than alcohol, particularly the edible and vaped forms of the drug. It may also be easier for young adults to obtain, since many states now allow purchase by young adults at age 18, compared with age 21 for alcohol.

Aoun said patients may have the misconception that marijuana use is “healthy,” he said. “However, the vast majority of people are not using marijuana for its medical benefits. People use it as a drug because they want to achieve a state of feeling high and of feeling pleasure. That can be a personal choice. But it doesn’t come without costs.” He noted that marijuana use may cause sleep disturbances, cognitive distress, reduced motivation and energy, memory difficulties, poorer performance at work and school, and, for those with psychiatric disorders, deteriorating psychiatric symptoms.

What’s the bottom line? “We need to talk, talk, talk with our patients and have honest conversations about marijuana use. We shouldn’t shy away from this just because marijuana has become so available,” he said. “We can apply the same model with our patients that we use with alcohol: Recognize that it’s not necessarily a bad thing [for people] to have a drink, but that it can be problematic when they’re having consequences, when they have an addiction, or when they’re using it because they’re too depressed or anxious.”

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Study Reveals Patterns of Youth Emergency Visits for Suicide During the Pandemic

Youth aged 5 to 17 were more likely to present to an emergency department (ED) for suicidal thoughts and behaviors in the second half of 2020 compared with the same period in 2019, a study in JAMA Psychiatry has found.

Specifically, suicide-related ED visits among female youth from June 1 to December 15, 2020, were significantly higher than in the corresponding months in 2019. Youth with no history of outpatient mental health or suicide visits and those with comorbid psychiatric conditions documented at the ED visit also had a higher risk of presenting with suicide-related problems from September to December 2020 compared with the same period in 2019.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Ridout, M.D., Ph.D., of The Kaiser Permanente Medical Group and colleagues.

Ridout and colleagues analyzed electronic health record data for patients aged 5 to 17 years seeking emergency care for suicidal thoughts or behaviors at Kaiser Permanente Northern California from January 1, 2020, to December 15, 2020, and for the same dates in 2019. The researchers focused on four time frames: pre–COVID-19 pandemic period (January 1 to March 9), the period during which shelter-in-place orders were in effect in the Bay Area and California (March 10 to May 31), the summer (June 1 to August 31), and the fall (September 1 to December 15).

There were 2,123 youth with suicide-related ED encounters in 2020 compared with 2,339 in 2019. The following patterns were found:

• The incidence rates of suicide-related ED encounters were significantly lower in March through May 2020 compared with this period in 2019—likely because of shelter-in-place orders at the beginning of the pandemic—before returning to prepandemic levels in June through December 2020.
• Female youth had an 11.4% higher risk of presenting with suicidal thoughts or behaviors during the fall compared with the same period in 2019, while male youth had a 21.3% lower risk of presenting with suicidal thoughts or behaviors during this period.
• Relative to all youth ED encounters, youth with no history of outpatient mental health encounters during the previous two years had a 129.4% higher risk of a suicide-related ED encounter during the fall of 2020 compared with fall of 2019.
• There was a 6.7% higher risk of having a comorbid psychiatric nonsubstance diagnosis at the time of the suicide-related ED encounter during the fall of 2020 compared with 2019.

“Preventive efforts, including mental health screening, psychoeducation, and support in connecting to care, may be particularly valuable for these youth and their families,” the researchers wrote. “Innovative and immediately accessible tools for mental health care, such as technology-based care, may address the needs of this population as well.”

For related information, see the Psychiatric Services article “Universal Suicide Risk Screening for Youth in the Emergency Department: A Systematic Review.”

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