Psychiatric Times.
No. 11
Should Emergency Medicine Physicians Screen for Psychiatric Disorders?
By Seth Kunen, PhD, PsyD, and Cris V. Mandry, MD |
October 1, 2006
Comorbidities
Another major problem with ignoring psychiatric disorders that are not the chief complaint is that psychiatric disorders frequently co-occur with serious health problems and, if left untreated, can complicate or slow recovery.23 Patients with significant medical illnesses were found to have a rate of psychiatric disorders twice that seen in healthy subjects,24 and the rate of medical illnesses in persons with severe psychiatric disorders is significantly higher than the rate of medical illnesses in persons without severe psychiatric disorders.25 Two of the most common psychiatric disorders found among the seriously medically ill are substance use disorders (SUD) and depression.24
Certain medical illnesses, such as stroke, heart attack, and cancer, can cause depressive illness and consequently prolong recovery.26 Depression is not only a frequent sequela of coronary heart disease (CHD), but it is also a risk factor for CHD in men and women and a risk factor for increased CHD mortality in men.27 In our analysis of the CDC data, we found that myocardial infarction (MI) had been diagnosed in 0.56% of subjects aged 15 years and older and none had a joint diagnosis of depression. In contrast, other studies indicate that the depression rate among patients with MI may be as high as 40%.28
In addition, it is important to note that there are significant correlations among depressive disorders, SUD, serious medical illness, and suicide.24,25,29 Suicide was the 11th leading cause of death in the United States in 2000 and it accounts for more deaths each year than homicides.21 As many as 500,000 patients each year are treated in EDs for injuries associated with attempted suicides,30 and more than 90% of those who kill themselves have a major mental disorder such as depression or SUD.31,32
Countertransference
As noted above, several factors contribute to the low psychiatric diagnostic rate among ED patients. These factors include overcrowding, physician beliefs about the scope of practice of emergency medicine, and physician attitudes that psychiatric problems are relatively minor threats to health. Another factor worth noting involves countertransference reactions of physicians to patients. Among physicians not trained to recognize countertransference reactions, such reactions may go unnoticed and may interfere with the diagnostic process and subsequent medical care of the patient.
Countertransference has a significant impact on patient care in many areas.33 Patient populations, such as violent patients,34 battered women,35,36 psychotic and uncooperative patients,37 patients with dual diagnoses,38 suicidal patients,39 and patients with personality disorders,40 may elicit strong countertransference reactions from ED physicians including premature discharge, envy, sadism (excessive use of restraint, seclusion, and overmedication), denial, misdiagnosis, anger, hate, rescue fantasies, and helplessness. In addition, patients who are poor, unkempt, illiterate, noncompliant, and of different racial and ethnic groups may also elicit countertransference reactions that interfere with accurate psychiatric diagnosis and appropriate medical care.
Consequences of psychiatric underdiagnosis
There are significant social consequences associated with the underdiagnosis of psychiatric problems among ED patients. The national psychiatric rates of whites and African Americans are approximately equal (about 20% to 28%9); in the CDC study,1 the psychiatric rates among whites and African Americans in ED settings, while significantly lower than the national rates, were also about equal. Given that African Americans are twice as likely as whites to go to an ED1 and more likely to seek mental health care in EDs,41 the psychiatric underdiagnosis in EDs will differentially increase the unmet mental health burdens of African Americans who experience significant disparities in access to and use of most health care services.42 In the surgeon general's report on minority mental health, it was noted that there was a greater incidence of mental illness in racial and ethnic minorities and that this stemmed from less access to mental health services as well as poorer quality of mental health services.41
Another reason to address psychiatric problems in the ED is that it has the potential to reduce the use of the ED by some high-frequency ED patients. High-frequency ED patients with psychiatric disorders have disproportionately higher use of all types of health care services and have higher median financial charges per ED visit than low-frequency ED users.43-48 The identification and management (either through treatment or referral for treatment) of disorders such as depression, SUD, and panic disorder has the potential to increase the operating efficiency of EDs while reducing pain and suffering, unnecessary medical expenses, and unnecessary return visits.
For example, it was found in one study49 that the case management of high-frequency ED patients with psychosocial problems produced substantial benefits in several areas: (1) there was a 60% decrease in the median number of ED visits in the subsequent year; (2) median ED costs decreased 53%, from $4124 to $2195; (3) median inpatient costs decreased 66%, from $8330 to $2786; (4) homelessness decreased by 57%; (5) drug and alcohol(Drug information on alcohol) use decreased by 24%; and (6) primary care service use increased 74%. For every dollar invested in case management, there was a $1.44 reduction in hospital costs.
Although many physicians are opposed to the idea of giving antidepressants to their patients who have mood disorders in the ED setting, reasonable arguments can be made in favor of starting some patients on antidepressant medication in the ED. For example, it has been noted by some investigators50,51 that the newer SSRIs are much safer than the older antidepressants and that patients with depression who are not motivated to comply with recommendations to seek mental health services may be more likely to if antidepressant therapy is initiated in the ED.
Screening
It would be sound medical practice for ED physicians to routinely screen for psychiatric disorders such as SUD and depression (and suicidal ideation), particularly among gravely ill and injured patients. Routine screening for depression among adults in a variety of clinical settings received a B rating recommendation from the US Preventive Services Task Force.52 (The task force found at least fair evidence that screening for depression in patients improves important health outcomes; they concluded that benefits outweigh risks and recommended that clinicians routinely provide screening for depression to eligible patients.)
There are several quick screening instruments that busy ED physicians and nurses can use to help screen for psychiatric disorders. These include the Beck Depression Inventory,53 the Center for Epidemiologic Studies Depression Scale,54 and the Zung Depression Scale.55 Screening for depression, particularly among the elderly, can be done quickly and efficiently by using a 3-item depression screen.56
Several brief screening instruments are available for use in the identification of alcohol and drug abuse problems.57,58 While it should be recognized that the predictive ability of most suicide scales is limited, 2 useful suicide screening inventories are the Beck Hopelessness Scale59 and the Child Hopelessness Scale (a derivative of the Beck Hopelessness Scale).60
In addition, physicians can screen for psychotic symptoms with instruments such as the Brief Psychiatric Rating Scale,61 the Mini-Mental State Exam,62 or the Severity and Acuity of Psychiatric Illness Scales.63 This latter scale requires several hours of training but can be administered in about 5 minutes by interviewing the patient's spouse or significant other. A 3-question instrument has been shown to have adequate sensitivity and specificity for identifying intimate-partner violence among ED patients.64
In summary, enlarging the scope of emergency medicine to include screening for psychiatric disorders has the potential to significantly improve the quality of the services provided by the health care safety net, particularly for those patients who rely on EDs for most of their health care needs.
Dr Kunen is a clinical assistant professor of medicine and director of research at the Louisiana State University Emergency Medicine Residen-cy Program at Earl K. Long Medical Center in Baton Rouge. He reports that he has no conflicts of interest concerning the subject matter of this article.
Dr Mandry is a clinical associate professor of medicine and program director of the Louisiana State University Emergency Medicine Residency Program at the Earl K. Long Medical Center in Baton Rouge. He reports that he has no conflicts of interest concerning the subject matter of this article.
References:
1.McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary.
Adv Data. 2004;340:1-34.
2. McCaig LF. National Hospital Ambulatory Medical Care Survey: 1992 emergency department summary.
Adv Data. 1994;245:1-12.
3. Walls CA, Rhodes KV, Kennedy JJ. The emergency department as usual source of medical care: estimates from the 1998 National Health Interview Survey.
Acad Emerg Med. 2002;9:1140-1145.
4. Brewster LR, Rudell LS, Lesser CS. Emergency room diversions: a symptom of hospitals under stress.
Issue Brief Cent Stud Health Syst Change. 2001;38:1-4.
5. American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?
Pediatrics. 2004;114:878-888.
6. Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects.
Ann Emerg Med. 2000;35:63-68.
7. Yamane K.
Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. Washington, DC: US General Accounting Office; March 2003.
8. Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study.
J Am Acad Child Adolesc Psychiatry. 1996;35: 865-877.
9. US Dept of Health and Human Servcies.
Mental Health: A Report of the Surgeon General. Rockville, Md: National Institutes of Mental Health; 1999.
10. Meldon SW, Emerman CL, Schubert DS. Recognition of depression in geriatric ED patients by emergency physicians.
Ann Emerg Med. 1997;30:442-447.
11. Schriger DL, Gibbons PS, Langone CA, et al. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system.
Ann Emerg Med. 2001;37:132-140.
12. Zane RD, McAfee AT, Sherburne S, et al. Panic disorder and emergency services utilization.
Acad Emerg Med. 2003;10:1065-1069.
13. Klitzman RL, Greenberg JD. Patterns of communication between gay and lesbian patients and their health care providers.
J Homosex. 2002;42:65-75.
14. Magura S, Kang SY. The validity of self-reported cocaine use in two high-risk populations.
NIDA Res Monogr. 1997;167:227-246.
15. Rew L, Esparza D. Barriers to disclosure among sexually abused male children: implications for nursing practice.
J Child Adolesc Psychiatr Ment Health Nurs. 1990;3:120-127.
16. Morrison LL, Downey DL. Racial differences in self-disclosure of suicidal ideation and reasons for living: implications for training.
Cultur Divers Ethnic Minor Psychol. 2000;6:374-386.
17. Williams LS. Failure to pursue indications of spousal abuse could lead to tragedy, physicians warned.
CMAJ. 1995;152:1488-1491.
18. Murray C, Lopez A, eds.
The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, Mass: Harvard School of Public Health; 1996.
19. Hockberger RS, Binder LS, Graber MA, et al; American College of Emergency Physicians Core Content Task Force II. The model of the clinical practice of emergency medicine.
Ann Emerg Med. 2001;37:745-770.
20. Emergency Medical Treatment and Active Labor Act (EMTALA). No 99-272, Title IX, Sec 9121(b), 100 Stat 164 (codified at 42 USC Sec 1395dd); 1986.
21. Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000.
Natl Vital Stat Rep. 2002;50:1-119.
22. O'Connell H, Chin AV, Cunningham C, Lawlor BA. Recent developments: suicide in older people.
BMJ. 2004;329:895-899.
23. Ramirez A, House A. ABC of mental health. Common mental health problems in hospital.
BMJ. 1997; 314:1679-1681.
24. House A, Farthing M, Peveler R. Psychological care of medical patients.
BMJ. 1995;310:1422-1423.
25. Dickey B, Normand SL, Weiss RD, et al. Medical morbidity, mental illness, and substance use disorders.
Psychiatric Serv. 2002;53:861-867.
26. Strock M.
Depression. Bethesda, Md: National Institute of Mental Health; 2000.
27. Ferketich AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to heart disease among women and men in the NHANES I study: National Health and Nutrition Examination Survey.
Arch Intern Med. 2000;160:1261-1268.
28. Cheok F, Schrader G, Banham D, et al. Identification, course, and treatment of depression after admission for a cardiac condition: rationale and patient characteristics for the Identifying Depression As a Comorbid Condition (IDACC) project.
Am Heart J. 2003;146: 978-984.
29. Angst J, Angst F, Stassen HH. Suicide risk in patients with major depressive disorder.
J Clin Psychiatry. 1999;60(suppl 2):57-62.
30. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 emergency department summary.
Adv Data. 1997;(293):1-20.
31. Conwell Y, Brent D. Suicide and aging. I: patterns of psychiatric diagnosis.
Int Psychogeriatr. 1995;7: 149-164.
32. Moscicki EK. Identification of suicide risk factors using epidemiologic studies.
Psychiatr Clin North Am. 1997;20:499-517.
33. Schwartz RC, Wendling HM. Countertransference reactions toward specific client populations: a review of empirical literature.
Psychol Rep. 2003;92:651-654.
34. Tardiff K. Management of the violent patient in an emergency situation.
Psychiatr Clin North Am. 1988;11: 539-549.
35. Keller LE. Invisible victims: battered women in psychiatric and medical emergency rooms.
Bull Menninger Clin. 1996;60:1-21.
36. Butterfield MI, Panzer PG, Forneris CA. Victimization of women and its impact on assessment and treatment in the psychiatric emergency setting.
Psychiatr Clin North Am. 1999;22:875-896.
37. Adler LE, Griffith JM. Concurrent medical illness in the schizophrenic patient: epidemiology, diagnosis, and management.
Schizophr Res. 1991;4:91-107.
38. Shaffer HJ, Costikyan NS. Cocaine psychosis and AIDS: a contemporary diagnostic dilemma.
J Subst Abuse Treat. 1988;5:9-12.
39. Gabbard GO. Miscarriages of psychoanalytic treatment with suicidal patients.
Int J Psychoanal. 2003;84 (Pt 2):249-261.
40. McIntyre SM, Schwartz RC. Therapists' differential countertransference reactions toward clients with major depression or borderline personality disorder.
J Clin Psychol. 1998;54:923-931.
41. US Dept of Health and Human Services.
Mental Health: Culture, Race, and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md: National Institutes of Mental Health; 2001.
42. Smedley BD, Stith AY, Nelson AR, eds.
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, the National Academy Press; 2003.
43. Arfken CL, Zeman LL, Yeager L, White A, et al. Case-control study of frequent visitors to an urban psychiatric emergency service.
Psychiatric Serv. 2004;55: 295-301.
44. Byrne M, Murphy AW, Plunkett PK, et al. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics.
Ann Emerg Med. 2003;41:309-318.
45. Curran GM, Sullivan G, Williams K, et al. Emergency department use of persons with comorbid psychiatric and substance abuse disorders.
Ann Emerg Med. 2003; 41:659-667.
46. Hansagi H, Allebeck P, Edhag O, Magnusson G. Frequency of emergency department attendances as a predictor of mortality: nine-year follow-up of a population-based cohort.
J Public Health Med. 1990;12: 39-44.
47. Kennedy D, Ardagh M. Frequent attenders at Christchurch Hospital's Emergency Department: a 4-year study of attendance patterns.
N Z Med J. 2004; 117:U871.
48. Williams ER, Guthrie E, Mackway-Jones K, et al. Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department: a comparison with routine attenders.
J Psychosom Res. 2001;50:161-167.
49.Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hospital service use among ED frequent users.
Am J Emerg Med. 2000;18: 603-608.
50. Glick RL, Ghaemi SN. The emergency treatment of depression complicated by psychosis or agitation.
J Clin Psychiatry. 2000;61(suppl 14):43-48.
51. Glick RL. Starting antidepressant treatment in the emergency setting.
Psychiatr Issues Emerg Care Set. 2004;3:6-10.
52. US Preventive Services Task Force. Screening for depression: recommendations and rationale.
Ann Intern Med. 2002;136:760-764.
53.Beck AT, Ward CH, Medelson M, et al. Beck Depression Inventory. Available at
http://harcourtassessment.com/HAIWEB/Cultures/en-us/default. Accessed August 8, 2006.
54. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population.
App Psychol Meas. 1977;1:385-401.
55. Zung WW. A self-rating depression scale.
Arch Gen Psychiatry. 1965;12:63-70.
56. Fabacher DA, Raccio-Robak N, McErlean MA, et al. Validation of a brief screening tool to detect depression in elderly ED patients.
Am J Emerg Med. 2002;20: 99-102.
57. Cherpitel CJ, Borges G. Screening for drug use disorders in the emergency department: performance of the rapid drug problems screen (RDPS).
Drug Alcohol Depend. 2004;74:171-175.
58. Cherpitel CJ, Bazargan S. Screening for alcohol problems: comparison of the audit, RAPS4 and RAPS4-QF among African American and Hispanic patients in an inner city emergency department.
Drug Alcohol Depend. 2003;71:275-280.
59. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale.
J Consult Clin Psychol. 1974;42:861-865.
60. Kazdin AE, Rodgers A, Colbus D. The hopelessness scale for children: psychometric characteristics and concurrent validity.
J Consult Clin Psychol. 1986;54: 241-245.
61. Overall JE, Gorham DR. The brief psychiatric rating scale.
Psychol Rep. 1962;10:799-812.
62. Folstein MF, Folstein SE, McHugh HR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician.
J Psych Res. 1975;12: 189-198.
63. Lyons JS. The Severity and Acuity of Psychiatric Illness Scales. PsychCorp: San Antonio, Tex; 1998.
64. Feldhaus KM, Koziol-McLain J, Amsbury HL, et al. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department.
JAMA. 1997;277:1357-1361.
65. Kunen S, Niederhauser R, Smith PO, et al. Race disparities in psychiatric rates in emergency departments.
J Consult Clin Psychol. 2005;73:116-126.
66. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey.
Arch Gen Psychiatry. 1994;51: 8-19.
67. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
Arch Gen Psychiatry. 2004;61: 807-816.
