Study Finds Gender and Racial Disparities in Youth Psychiatric Inpatient Admissions

According to new research published in JAMA, there are concerning disparities in the boarding rates of both children and adolescents who are in emergency departments for severe mental health symptoms. These findings illustrate a significant need for targeted resources that will reduce boarding while promoting an equitable access to care.^1,2

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For this cross-sectional analysis, data from May 2020 to June 2022 that included youths aged 5 to 17 years who boarded in a Massachusetts emergency departments for 3 or more midnights while awaiting inpatient psychiatric care. The purpose of this study, according to the investigators, is to summarize characteristics of youth—including age, gender, race or ethnicity, insurance, diagnosis, and barriers to placement—who boarded the emergency departments to test for any disparities in boarding lengths and inpatient admission rates following boarding. Additionally, the investigators also evaluated whether statewide demand for inpatient psychiatric care had any associations with individual outcomes.²

A total of 4942 boarding episodes from this dataset were identified. Of these events, 2648 were for cisgender females (54%), 1958 (40%) for cisgender males, and 336 (7%) for transgender or nonbinary youth. Additionally, the investigators observed that 1337 youth (27%) were younger than 13 years of age, with depression being the most common diagnosis (n = 2138, 43%).²

The findings demonstrated that from the total number of events, approximately 56% (n = 2748) resulted in inpatient admission, of which 171 transgender and nonbinary youths (51%) and 1558 cisgender females (59%) received inpatient care (−9.1%; 95% CI, −14.7% to −3.6%). Transgender or nonbinary youths were also boarded for a mean (SD) of 10.4 (8.3) midnights compared with cisgender females, who were boarded for 8.6 (6.9) midnights (adjusted difference: 2.2 midnights; 95% CI, 1.2-3.2 midnights). Further, there were fewer Black youths who were admitted into inpatient care compared with their White counterparts (n = 382, 51% and n = 1231, 56%, respectively; adjusted difference: −4.3%; 95% CI, −8.4% to −0.2%). The authors also observed that for every additional 100 youth boarding statewide on the day of assessment, the percentage of youth was approximately 19.4% lower (95% CI, −23.6% to −15.2%) and boarding times were 3.0 midnights longer (95% CI, 2.4-3.7 midnights).²

“The experience of boarding—of being stuck in 1 emergency department room, under 24-hour, 1-on-1 supervision, for days or weeks at a time, with little definitive mental health treatment and not knowing how long you’ll be stuck there—is detrimental to children’s wellbeing,” said Lindsay Overhage, MD/PhD student and researcher, department of Health Care Policy at Harvard Medical School, in a news release. “In fields other than psychiatry, the sickest person in the emergency department gets admitted first for inpatient care. But many inpatient units don’t feel equipped to deal with kids who have the most severe psychiatric symptoms, so by default these kids end up languishing in emergency departments.”¹

According to the authors, study limitations include the data’s potential lack of generalizability to other US states, health system changes resulting from the COVID-19 pandemic, and the study only included youths with boards lasting 3 or more midnights and excluded all other youths with mental health emergency department visits. Despite the limitations, the investigators note that the findings can contribute to further research and developments in policies that can help reduce boarding while ensuring equity in access to inpatient care.²

“Our study found that several non-clinical factors, including statewide demand for inpatient care, appear to play a role in the admission decision, and that racial and gender disparities permeate the process,” said senior study author Nicole M. Benson, MD, MBI, associate chief medical information officer at McLean Hospital, assistant professor of psychiatry at Harvard Medical School, in the news release. “Boarding is a culmination of problems and lack of access throughout the mental health care system, not just inpatient care. Solving it will take resources and interventions at many levels.”¹

References

1. McLean Hospital. Study identifies racial and gender disparities in youth psychiatric emergency department boarding. News release. July 8, 2024. Accessed July 9, 2024. https://www.eurekalert.org/news-releases/1050576

2. Overhage LN, Lê Cook B, Rosenthal MB, McDowell A, Benson NM. Disparities in Psychiatric Emergency Department Boarding of Children and Adolescents. JAMA Pediatr. Published online July 08, 2024. doi:10.1001/jamapediatrics.2024.1991