Racial disparities in the management of emergency department patients presenting with psychiatric disorders

Purpose: Emergency departments (ED) provide critical resources including stabilization, diagnosis of underlying medical precipitants and transfer to psychiatric hospitals for mental health emergencies. Our objective was to examine the association of race and/or ethnicity and the administration of chemcial sedation using a nationally representative sample of ED visits for psychiatric disorders. Methods: We analyzed data from 2008 to 2018 through the National Hospital Ambulatory Medical Survey database, a national probability survey based on ED chart abstraction. All ED visits for psychiatric disorders were included. Our primary outcome variable was receipt of chemical sedation among patients presenting with a complaint related to a psychiatric condition. We defined receipt of chemical sedation by the receipt of a first or second-generation antipsychotic or ketamine that was given in the ED. Our secondary outcome was receipt of psychiatric treatment defined as admission to a mental health and/or detox unit at the same hospital or transfer to a psychiatric facility. We used logistic regression models and used marginal effects to report the average adjusted probability in outcomes for different patient characteristics. Results: Nationally after weighting, 76,200,000 of 1,480,102,130 total ED visits (5.1%, 95% CI 4.9%–5.4%) were designated to be for treatment of a psychiatric disorder. When controlling for patient age, sex, initial pulse, presence of chronic medical conditions, geographic region, EMS arrival and nightshift arrival, among patients presenting with psychiatric disorders, Black race was associated with a 2.2% point (95% CI 0.8–3.7, P <.01) greater probability of receiving chemical sedation than non-Hispanic (NH) white race and/or ethnicity (3.0%) and this difference remained significant when accounting for admission or transfer to psychiatric facilities. However, when accounting for the percent of hospital population that was Black (P <.01), individual patient race was no longer associated with a significant increase in receipt of chemical sedation. There was no significant association between race and/or ethnicity and admission or transfer to psychiatric facilities. Conclusion: Nationally, Black patients presenting to the ED are more likely to receive chemical sedation than NH-white patients for psychiatric complaints, and this appears to be because hospitals serving a high proportion of Black patients use more chemical sedation, suggesting structural racism is a potential root cause.