This week Mad in America examines three studies around racial bias in hospital and mental health settings. The first study finds that people with limited English proficiency are more likely to be physically restrained and given antipsychotics in US hospitals. The second reports that ethnic minorities are more likely to be chemically restrained in inpatient psychiatric settings in Europe. The third reports that UK clinicians largely link racial disparities in psychiatric detention to structural inequality, unconscious biases affecting subjective risk assessments, credibility bias, and racism embedded in institutional practices.
Hospitalized Patients with Limited English Proficiency More Likely to be Physically and Chemically Restrained
A new study published in the Journal of General Internal Medicine finds that hospitalized patients with limited English proficiency (LEP) were more likely to be physically restrained and/or given antipsychotics compared to non-LEP patients. This research, led by Rachel Borczuk from Harvard Medical School in Boston, also reports that patients with LEP and a delirium diagnosis were most likely to be restrained and drugged.
The goal of this study was to investigate whether LEP predicted higher rates of physical and chemical restraint in hospitalized patients. The authors hypothesized that language barriers could make verbal de-escalation techniques more difficult, leading hospital staff to rely more heavily on physical and chemical restraint for patients with LEP.
The authors used data from 132,767 patients discharged from a single academic medical hospital in the US between January 2019 and June 2023. Ten-point-eight percent of these patients were classified as having LEP due to a language other than English being listed as primary in their electronic medical record. The authors examined rates of physical restraint and antipsycotic use as well as demographic information, clinical characteristics, hospitalization factors, and illness-related factors that may have effected rates of physical and chemical restraint.
Patients with LEP were 18% more likely to receive an antipsychotic or physical restraint. This included 30% increased odds of physical restraint and 12% increased odds of antipsychotic use. Patients diagnosed with delirium, a condition where communication and reorientation are especially important, had a 42% higher likelihood of being physically restrained or given antipsychotics.
This research had four key limitations. The data came from a single US hospital, limiting generalizability within the US and to populations outside the US. LEP was determined based on primary language listed in the electronic medical record. Some patients that were proficient in English may have listed a primary language other than English. The design of the study means the findings can only speak to links, not causes. This data cannot definitively say that LEP caused increased physical and chemical restraint, only that these factors are related. The data lacked detailed information on the context for hospital staff using restraints. The study did not assess whether interpreters were available or used leading up to physical or chemical restraint.
Ethnic Minorities More Likely to be Chemically Restrained in Inpatient Mental Health Settings
A study published in BMJ Mental Health finds that ethnic minorities are more likely to be chemically restrained in adult inpatient mental health settings throughout Europe. This study, led by Martin Locht Pedersen from the University of Southern Denmark, also reports that while some studies provided potential explanations for this disparity, few provided evidence for these explanations. This means this disparity is likely under-researched.
The goal of this study was to investigate whether ethnic minority patients and service users were more likely to receive rapid tranquilisation in inpatient psychiatric facilities. The authors also wanted to examine explanations given for any observed disparities in chemical restraint between ethnic majority and minority patients and service users.
The researchers conducted a systematic review and meta-analysis of previous research around this topic. To be included in the current work, studies had to examine adult psychiatric inpatient settings, report rapid tranquilisation rates, and compare rates between ethnic groups. In total, the authors examined 15 studies including 38,622 participants throughout Europe.
Compared to White or native-born populations, ethnic minorities were 49% more likely to be chemically restrained. The included studies offered several explanations for this disparity including differences in clinician perceptions of risk or aggression, communication barriers, institutional and structural factors, cultural misunderstandings, and bias in clinical decision-making. The authors note that few studies provided any evidence for these explanations.
This study had several limitations. The designs of included studies means the data can only speak to associations rather than causes. This means the authors cannot definitively say that ethnic minority identity caused increased chemical restraint. Included studies varied significantly in terms of how ethnicity was categorized, definitions of rapid tranquilisation, clinical settings, and healthcare systems, making comparisons difficult. Some included studies had broad ethnic categories such as “ethnic minority,” which limited the authors ability to examine differences between different ethnic minority groups. Included studies mostly came form Western Europe, limiting generalizability to other populations.
UK Clinicians Link Racial Disparities in Psychiatric Detention to Structural Inequality, Credibility Bias, Subjective Risk Assessments, and Institutional Racism
A new article published in PLOS Mental Health finds that UK psychiatrists and other approved mental health professionals report that racial disparities in psychiatric detention may be driven by structural inequalities, subjective risk assessment, and Black patients’ accounts having less credibility with police and psychiatric professionals. This research, led by Caroline Leah from Manchester Metropolitan University, also finds that clinicians largely did not link racial disparities in psychiatric detention to overt racism but rather to factors such as unconscious bias, institutional practices, and entering psychiatric care through police involvement.
The goal of this study was to examine how mental health professionals see the role of race in psychiatric detention and whether the concept of testimonial injustice (Black patients’ accounts being seen as less credible) helps to explain racial disparities in psychiatric detention rates. The authors conducted semi-structured interviews with 13 psychiatrists, other approved mental health professionals, and police officers about racial disparities in psychiatric detention, race, stigma, credibility, and risk assessment. They then identified three recurring themes in the interview data: racial stereotyping and risk assessment, stigma and the denial of care, and race anxiety and colorblind racism.
Notably, patients and service users were not interviewed about their views of racial disparities in psychiatric detention. The authors also did not disclose the participants’ racial identities. In other words, this research about racial disparities in psychiatric detention does not include interviews with patients and may not include interviews with any minority participants. This research did include a co-design event where the themes were discussed and checked by stakeholders including minorities.
Participants acknowledged that Black people were disproportionately detained in psychiatric settings and reported that Black men were often framed as inherently risky due to racist assumptions within institutional judgments. As a consequence of this structural racism, participants believed Black men often faced undue escalation, particularly from police officers. One clinician described an instance of unnecessary police escalation against a patient during a routine mental health assessment:
“At that point, two police officers burst in and tried to restrain him, even though he didn’t need restraining …but they came in to restrain him, at which point he started to retaliate because there’s two men on him and then I heard one of the police on the radio saying, ‘we need back up there’s a big Black man resisting’…At the end of it 15 officers turned up … You just think, if that was a big White man and they had said, we need back up, there’s a big White man here, would 15 coppers show up? I don’t think so. I think it’s just institutional racism, that term ‘big Black man.’”
Police participants seemingly verified the existence of racist assumptions in their own interviews. Speaking of Black men, one police officer said “They do seem very strong, very vocal, and a lot of time not willing to engage on even simple instructions.” Another said “They’re muscular, they go in the gym all the time.” A third police officer reported that “a lot of the white male offenders we used to get in custody, they’re skinny little things and they’re easier to restrain. I think Black men are more powerful.”
These racist assumptions were also expressed by healthcare professionals. One clinician reported hospital staff telling them to be careful assessing a threatening, muscular Black man that was handcuffed and having suicidal thoughts. When the clinician entered the room and the handcuffs were removed, the patient “got the blanket and put it over his chest and he looked scared, and he was unwell.”
Black men are often described as threatening and aggressive. This primes clinicians to see their behavior in terms of threat rather than as expressions of distress and contributes to negative outcomes and reluctance to seek mental health services. As mental health and risk assessments are largely subjective, these stereotypes and biases can have a tremendous effect, resulting in higher rates of psychiatric detention for Black people.
Participants reported that patients’ own explanations of their experiences were often seen as untrustworthy due to credibility bias against people with mental health diagnoses. This was viewed as especially problematic for Black patients whose accounts were often discredited due to both racist and ableist biases.
While participants largely believed there were racist biases within institutional practices that led to these distorted views, many emphasized that they did not see this mostly as a problem of individuals’ overt racism, but rather as a reflection of unconscious biases held by healthcare workers and clinicians. It is worth noting that the inclusion of patient and service user perspectives may have changed this finding significantly. Participants also pointed to structural inequalities, service access barriers delaying treatment, and historical mistrust between minority communities and mental-health services as fueling racial disparities in psychiatric detention.
This study had two main limitations. Patient perspectives were not included. All the participants were fom the UK, limiting generalizability to other populations.
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Borczuk, R., Wilson, L., Anderson, T. S., & Herzig, S. J. (2026). Disparities in physical restraints and antipsychotic use in hospitalized patients with limited English proficiency. Journal of General Internal Medicine. (Link)
Leah, C., Dixon, J., Craig, E., Heyes, K., Best, D., Bergqvist, A., & Haines-Delmont, A. (2026). Stigma, race, and testimonial injustice in mental health detention: Professionals experience of compulsory assessment and treatment under the Mental Health Act 1983. PLOS Mental Health, 3(3). (Link)
Pedersen, M. L., Bricca, A., Baker, J., Schjerning, O., Munk-Olsen, T., & Gildberg, F. A. (2025). Ethnic disparities in rapid tranquillisation use and justifications in adult mental health inpatient settings: A systematic review and meta-analysis. BMJ Mental Health, 28(1). (Link)