The Role of Race on Restraint Use: Racial Bias in Healthcare, Psychiatric Diseases, and Utilization of Restraints (Part 2 in a 3-Part Series)

June 25, 2021

Vera Pertsovskaya; Divya Shan; Andrew C. Meltzer, MD

leather restraints

Racial Bias in Healthcare

Restraint use, like other disparities in healthcare, can stem from the impact of racial bias in clinical encounters. A disparity, according to the Institute of Medicine in its Unequal Report, is a difference in the quality of healthcare provided to patients that is not attributable to the patients’ wishes or healthcare needs (Smedley et al., 2002). The majority of clinician bias is associated with implicit attitudes, which are unconscious thoughts and feelings that can influence behavior. Clinician bias is common, with physicians often having positive attitudes toward white patients and negative attitudes toward non-white patients (Hall, 2015). A recent systematic review found that health care professionals tend to associate Black patients with being less cooperative, compliant, and responsible in comparison to white patients (Hall, 2015), while another study found that clinicians tend to associate Hispanic patients with medical non-compliance and partaking in risky behaviors (Bean et al., 2013). This bias can manifest in terms of talking to patients with a condescending tone, not providing interpreters when necessary, and not recommending treatment plans due to assumptions about the patient’s likelihood to adhere (Dehon et al., 2017).

Although there is no conclusive evidence to establish a direct relationship between implicit physician bias and clinical decision making (Dehon et al., 2017), implicit bias among healthcare professionals indirectly emerges in terms of access to care, the quality of healthcare received, and health outcomes. For example, a National Healthcare Disparities report found that non-white patients received less patient-centered care and worse overall quality of treatment (U.S. Department of Health and Human Services, 2018). Indeed, analysis of data from 350 EDs across the U.S. found that white patients who present with abdominal pain are nearly three times as likely to be treated with analgesics in comparison to minority patients (Shah, 2015). Additionally, Black patients were both less likely to receive percutaneous coronary intervention after being diagnosed with acute coronary syndrome (Musey, 2016) and thrombolytic therapy for acute ischemic stroke (Aparicio et al., 2015). It also should be noted that even after adjusting for medical comorbidities, Black patients being treated in the ED in comparison to white patients experienced longer wait times and were twice as likely to be triaged to a lower level of acuity (Schrader et al., 2013). These systemic inequities contribute to the higher rates of asthma, diabetes, HIV/AIDS, hypertension, obesity, preterm births, and tuberculosis present among minorities (U.S. Department of Health and Human Services, 2018).

Racial Disparities in Psychiatric Diseases

Disparities are also present between racial groups not only in the access to and utilization of mental health services, but also in receiving appropriate treatment for psychiatric disorders (U.S. Department of Health and Human Services, 1999). While Black patients are 50% less likely to be treated for similar psychiatric disorders as white patients, they are more likely to have chronic conditions, such as major depression (Kessler et al., 2005; Williams et al., 2007). Although it should be noted that research has indicated that clinicians tend to overdiagnose Black patients with schizophrenia (Strakowski et al., 1996). Moreover, when controlling for behavior, traumatic experiences, and other confounding variables, Black adolescents were found to have a higher likelihood of being diagnosed with conduct disorder, whereas white adolescents were more likely to be diagnosed with ADHD (Baglivio et al., 2016). This is significant as these disparities in psychiatric diagnoses and treatments predispose Black patients to poorer health outcomes. These disparities quite possibly arise from the physicians’ implicit biases — physicians who tend to see Black patients as being more aggressive and hostile may diagnose these patients with more severe and chronic disorders. A substantial amount of research, in both the outpatient and inpatient settings, indicates that Black patients are more likely to be seen by healthcare providers as being aggressive which can cause a greater chance of security being called, the patient being involuntarily hospitalized, and placed in both seclusion and in restraints (Rosenfield, 1984; Sleath et al., 1998; Whaley, 1998). For patients who do not have equal access to mental health or drug treatment services, a deteriorating clinical condition may culminate with being restrained in the ED.

Racial Bias in Utilization of Restraints

The lack of standardized thresholds to initiate use of restraints causes the utilization of physical and chemical restraints to be partially determined by the clinician’s implicit bias. Indeed, several studies have indicated that racial disparities are present in the decision to restrain a patient. For example, one study found that 73% of patients who were physically restrained in the ED were Black (Zun, 2003), and another study determined that even when controlling for confounding variables, such as sex, diagnosis, homelessness, age, and violence, Black patients were more likely to be restrained while in the ED (Schnitzer et al., 2020). These racial disparities are consistent even beyond the ED, as a study that used a nationally representative sample of nursing homes in the U.S. found that even when controlling for dementia, fall rate, and ADLs impairments, there is a statistically significant correlation between race and the use of physical restraints (Cassie, 2013). Although states have passed legislation to limit the utilization of restraints in medical facilities, it is clear that a significant racial disparity yet remains.


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