Medical and psychiatric comorbidities
ED patients with substance use problems often present with a complex array of symptoms that include neurological deficits, cardiopulmonary crises, cognitive disorders, and suicidal ideation. Accurate assessment and care of such patients is difficult in an ED setting. These patients often require a greater array of services and a longer period of stabilization than can be provided in an ED.
Substance use disorders also interact synergistically with many comorbid psychiatric disorders; this further complicates the care of such patients. For example, substance use can increase suicidal thinking among depressed patients, and substance use can amplify delusions, hallucinations, and paranoia among psychotic patients.34,35 Patients with substance use disorders are often nonadherent, and the more severe the comorbid disorders the less likely that the patients will adhere to therapy.36-38 The high hospitalization rates of patients with psychiatric comorbidities, including substance use, clearly indicate that ED physicians recognize the difficulty in caring for such patients in the ED.
Although there are several possible reasons why the hospitalization rate is so high for patients with 2 or more psychiatric disorders, we note 2 important reasons. First, the psychiatric disorders that are diagnosed by the ED physicians are often the more severe disorders, such as substance use, psychosis, and depression. Second, compared with patients with a single psychiatric diagnosis, patients with psychiatric comorbidities have significantly more serious illness, greater functional impairments, higher ED visit and suicide rates, and extended illness duration because of reduced treatment adherence. Thus, the higher hospitalization rates of patients with psychiatric comorbidities reflect both the seriousness of the individual diagnoses and the synergistic effects of these co-occurring mental disorders.
It is important to emphasize that the comorbidity rate based on data analysis from NHAMCS is far below the comorbidity rate documented by the NCS-R study, which suggests that many high-need psychiatric patients are not being identified in EDs. The failure to identify and treat these patients is unsound medical practice, since untreated psychiatric disorders that co-occur with medical conditions decrease treatment adherence and increase health care costs, morbidity, and mortality.39,40
Some argue that emergency medicine should focus only on urgent or emergent accidents, injuries, or diseases. A major problem with this position is that approximately 50% of all ED visits are neither urgent nor emergent, so ED physicians are already performing nontrauma evaluations.1 Failure to take the opportunity to provide services to patients with psychiatric problems is short-sighted, since medical patients with psychiatric comorbidity and patients with 2 or more psychiatric disorders disproportionately use health care resources and experience increased functional impairments.41 The failure to initiate screening, provide treatment, or arrange for outpatient services can exacerbate the psychiatric and medical problems of these patients and also increase the future burden on the health care system.
Findings indicate that the psychiatric diagnoses of ED physicians only moderately match those of psychiatrists and correlate poorly with standardized tests—strong indications that there is a need for psychiatric expertise in the ED.42,43 With more time and effort expended in assessing ED patients with psychiatric issues, different avenues of treatment may be identified that would reduce the need to hospitalize so many of these patients. It may well be that ED physicians have difficulty discriminating those psychiatric patients who are truly disabled and require intensive inpatient hospitalization from those who could benefit from diversion to outpatient treatment centers.
Psychiatric disorders in general, and psychiatric comorbidity in particular, represent a significant burden not only to the patients and their families but to the health care system as well. There is a good deal of resistance to the idea that EDs could play an increasing role in addressing the psychiatric needs of patients. The time has come, however, to acknowledge that patient care could be significantly enhanced if mental health professionals were routinely available in EDs to help screen for psychiatric disorders and to participate in treatment planning. By assuming responsibilities for psychiatric screening and identification of alternative treatment venues, mental health professionals could reduce the diagnostic burdens of ED physicians, increase diagnostic accuracy, and provide critically needed services to a large segment of the population whose mental health needs are routinely ignored.