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Psychiatric Evaluations in Emergency Departments

Psychiatric Evaluations in Emergency Departments

 

In the article by Drs Kunen and Mandry, “Should Emergency Medicine Physicians Screen for Psychiatric Disorders?” (Psychiatric Times, October 2006), no mention was made of formally assessing a patient's mental status to diagnose delirium.

Of all psychiatric syndromes presenting in the emergency department (ED), delirium is surely the most critical. If present, no other diagnosis can apply. The authors focus exclusively on other psychiatric diagnoses instead—as though delirium were not a priority. Taking a sound psychosocial and symptom history of a patient is crucial but not sufficient, since no diagnosis is possible without a mental status exam (MSE).

The article also exposes a larger problem. Most nonpsychiatric physicians, even in the ED, not only fail to assess patients for DSM-IV diagnoses, but they never perform an MSE. There is a cavalier notion that an experienced clinician can just “tell” whether a patient has cognitive or attention problems. This casual attitude often means that patients with fluctuating levels of consciousness get confused with being “uncooperative” or “obnoxious” and that gross organic deficits may be assumed to reflect poor education, etc.

Since delirium can be the earliest indicator of reversible medical conditions, not screening patients can lead to serious, and even fatal, errors. It also becomes a model for medical students who get little support for anything other than performing the occasional mini-MSE on geriatric patients.

Shouldn't we consider a formal MSE to be as fundamental as checking a patient's vital signs in an ED evaluation? Shouldn't delirium be the number one psychiatric diagnosis to rule out?

Ironically, Dr Ronald Pies wrote a fine article on delirium in the same issue (“Treating Delirium: When theBrain Goes Off Track,” page 74). Unfortunately, no linkage was made!

Sara Hartley, MD
Oakland, Calif

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