Seth Kunen, PhD

Emergency medicine provides care to a vast number of patients each year. In 2005, 115.3 million people visited emergency departments (EDs).

 Although the number of people who visit an ED significantly increased from 96.5 million in 1995 to 115.3 in 2005, the number of ED facilities decreased from 4176 to 3795 in the same period.

 This created additional pressure on ED physicians to reduce patient throughput time and the potential for increased neglect of psychiatric disorders.

This article provides an overview of the prevalence of psychiatric comorbidity among patients who present to the ED and documents the relationship of psychiatric comorbidity to disposition decisions. In addition, the implications of the observed comorbidity rates and disposition decisions are discussed.

In 2002, 43% of all hospitalizations originated in the ED-a 17% increase since 1997.

 Hospitalization costs consume one-third of the entire US health care budget and make hospitalization the single most costly component of the health care system.

 It is of considerable interest, from both economic and mental health perspectives, to determine how often ED patients with single and multiple psychiatric disorders are hospitalized. At present, little is known about the extent of psychiatric comorbidity (defined as 2 or more co-occurring psychiatric disorders) in patients who present to the ED.

Before assessing comorbidity rates, we summarize the psychiatric prevalence obtained in the National Comorbidity Survey Replication (NCS-R) study.

 The data show that the 12-month prevalence of any psychiatric disorder was 26%. Of the total number of patients identified with a psychiatric disorder, 55% had a diagnosis of 1 disorder; 22.3% had 2 diagnoses; and 23% had 3 diagnoses. Estimated prevalences for the 4 most frequently occurring disorders were anxiety disorders, 18.0%; mood disorders, 9.5%; impulse control disorders, 8.9%; and substance use disorders, 3.8%.3 Other researchers have reported 12-month substance use disorder rates to be as high as 9.35%.

There are several reasons to expect rates of psychiatric disorders among ED patients to equal (or exceed) those reported in the NCS-R study:

• There is a concentration of the homeless, chronically ill, uninsured, and impoverished in ED populations.

• The poor who rely on EDs for routine health care have relatively limited access to quality mental health care services.

• A strong relationship has been found between poverty and mental illness.

Low rates of psychiatric disorders might be expected if ED physicians focus primarily on presenting physical complaints because of time constraints and, perhaps, because of a lack of interest in psychiatric problems in this setting. In 2001, 6% of all ED visits were for mental health issues.

 This 6% rate is far lower than the 26% reported by the NCS-R studyand indicates that ED physicians are not consistently screening for mental health disorders.

The deinstitutionalization of mental health patients and a shortage of community-based psychiatric services have been identified as major contributors to the increased visits to EDs by patients with psychiatric disorders over the past decade.

 Psychiatric patients require intensive ED staff resources and close supervision, and when inebriated, psychotic, or belligerent, these patients can disrupt the care provided to other patients.

 According to the recent American College of Emergency Physicians study, 62% of ED directors surveyed said that psychiatric patients in the EDs received no psychiatric services before hospital admission or transfer.

Close to one-quarter of the ED directors (23%) surveyed indicated that they had no community psychiatric resources available for psychiatric patients; over half (59%) reported that there were no services available for persons with substance use disorders or dual diagnoses.

While there are many community-based studies of psychiatric comorbidity, few researchers have examined how psychiatric comorbidity influences the disposition of ED patients.

 This is surprising because, compared with patients with a single psychiatric diagnosis, patients with multiple psychiatric disorders often have more severe pathology, increased illness duration, reduced treatment responsiveness and adherence, greater functional impairment, higher suicide rates, and increased ED visits.

In our literature review, we found only 1 study that explicitly examined how psychiatric comorbidity influenced hospitalization decisions. In that study, which used data from the 2004 National Hospital Ambulatory Medical Care Survey (NHAMCS), ED patients with psychiatric comorbidity had a 5-fold increase in hospitalization relative to patients without psychiatric comorbidity.

We analyzed data from NHAMCS for 3 consecutive years (2002 through 2004).

 There were 91,118 visits by patients 15 years and older. We created psychiatric categories (such as depression, psychosis, substance use disorders) to be compatible with those in 

. The weighting, strata, and cluster factors provided by NHAMCS were used to estimate pop-ulation parameters and associated standard errors.

Approximately 6% of all 91,118 patients received a diagnosis of at least 1 psychiatric disorder (95% confidence interval (CI), 6.1% - 6.7%). The 4 most frequently occurring psychiatric categories were:

• Substance use disorders (2.27%; 95% CI, 2.10% - 2.46%).

• Mood disorders (1.63%; 95% CI, 1.50% - 1.78%).

• Anxiety disorders (1.24%; 95% CI, 1.14% - 1.35%).

• Psychoses (1.20%; 95% CI, 1.09% - 1.32%).

Approximately 1.3% (95% CI, 1.13% - 1.39%) of all patients visiting the ED had at least 2 psychiatric disorders. This represented about 2.8 million psychiatric comorbidity patient visits during the 3 years. The hospitalization rate of patients with 2 or more psychiatric disorders (48.49%) was much greater than the hospitalization rate of patients with 1 or no psychiatric disorder.

We also compared the hospitalization rate of patients with only psychiatric comorbidities and no medical conditions with that of patients with only a medical condition. Far more patients with comorbidities who had no medical condition were hospitalized than were patients with medical diagnoses and no psychiatric diagnosis (52.1% vs 17.93%, respectively). The 4 most frequently occurring comorbidity pairs were:

• Substance use disorders plus mood disorders.

• Substance use disorders plus psychoses.

• Substance use disorders plus substance use disorders (these represent diagnoses from 2 different drug categories).

It is sobering to realize that when studies are designed to assess the prevalence of specific mental disorders in patients who present to the ED, the rates of several specific mental disorders are higher than the total annual psychiatric rate found in the NHAMCS data. For example, studies that explicitly screened for depression found the depression rate among ED patients to be at least 20%.

 Part of the reason for the low rate of depression diagnoses (1.63%) in the NHAMCS data is that physicians infrequently screen for depressive symptoms.

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.

 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.

 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.

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.

 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.

 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.

 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.


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Articles

Psychiatric Comorbidity in Emergency Department Patients

Emergency department (ED) visits have increased substantially from 89 million in 1992 to more than 110 million in 2002, while the number of EDs decreased by about 15% during the same period.

 An estimated 1.7 million people rely entirely on EDs for all their health care needs.

 The demand for emergency services continues to increase while the availability of inpatient hospital beds and alternative sources of urgent care has decreased, resulting in widespread overcrowding.

 The consequences of overcrowding include increased ambulance diversion, longer hours of patient "boarding" in the ED, and increased numbers of patients who leave either before being evaluated or against medical advice.

 We suspect that another consequence of ED overcrowding is an increased tendency to disregard psychiatric problems, especially if the psychiatric problem is not the chief complaint.

The annual incidence rate of psychiatric problems in the United States is estimated to be between 20% and 28% for both children

 When the rates of specific mental disorders are studied in ED patients, the psychiatric rates are often much higher than the respective national rates,

 so it is reasonable to assume that the overall psychiatric rate in ED patients is at least 20% to 28%.

The CDC surveyed EDs to determine the number of patients who received a psychiatric diagnosis in these facilities.

 Our analysis of the CDC data indicates that the rates of psychiatric diagnosis are much lower in EDs than in the general population (see Box, "Analyzing the CDC Data"). The data indicate that the majority of severe psychiatric disorders among ED patients are being missed.

In our experience, the argument offered most frequently by ED physicians to justify ignoring or overlooking psychiatric disorders that are not the chief presenting complaint is that the scope of practice of emergency medicine should include only emergent or acute injuries and physical illnesses. However, adherence to that model is no longer tenable, since about half of ED visits are for conditions that are neither emergent nor acute.

 It is also important to note that many patients who experience health-threatening problems related to psychiatric issues--such as battered wives, sexually abused children, HIV/AIDS patients, and psychotic individuals who are relapsing or actively experiencing hallucinations--are reluctant to volunteer information about their problems because of fear of negative consequences.

 These patients need to be encouraged to disclose their problems, and the ED physician needs to initiate inquiries into psychosocial and psychiatric issues, otherwise lethal consequences may ensue.

Many ED physicians believe that mental disorders, in general, are relatively minor threats to health. However, this view is not supported by public health research, which has shown that psychiatric illness, and depression in particular, is second only to cardiovascular disease as a major cause of lost years of productive life.

 The view that psychiatric disorders are relatively minor threats to health is a perspective that also is not shared by the Emergency Medicine Core Content Task Force.

In this model of the clinical practice of emergency medicine, the task force listed 3 levels of acuity of common conditions presenting in EDs:

Critical: life-threatening illness or injury with a high probability of mortality if not treated.

Emergent: illness or injury that may progress in severity or result in complications with a high probability of morbidity if left untreated.

Lower acuity: illness or injuries that have a low probability of progression to more serious complications.

Eighteen categories of medical conditions were described and one, psychobehavioral disorders, deals with psychiatric conditions. Of the 35 individual psychobehavioral disorders listed in these categories, 20 (57%) were designated as either emergent or critical problems.

The provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA)

 are relevant to the issue of whether emergency medicine should include psychiatric issues within its scope of practice. EMTALA prevents hospitals from "dumping" unwanted patients and guarantees all ED patients the right to a medical examination to determine whether a medical emergency exists and to stabilize patients before transfer. EMTALA specifically includes psychiatric problems and substance abuse as part of the definition of a medical emergency. The central issue is whether it is legal or ethical for ED physicians to routinely ignore significant psychiatric issues that are not the chief presenting complaint.

A 65-year-old white man presented to the ED with a fractured metatarsal as a result of a motor vehicle accident. The ED physician appropriately diagnosed and treated the fracture, gave the patient pain medication, and scheduled an orthopedic appointment for the patient. Just prior to discharge, the physician asked the patient how he was feeling, and the patient said he had been feeling "somewhat down and tired for a while." When asked about the pain in his foot, the patient said the pain medication seemed to be working. The patient arranged a ride home and the physician discharged the patient.

The physician did not inquire further about the nature of the accident or what the patient meant by "somewhat down and tired for a while," and the patient did not volunteer any additional information. Later that night, the patient committed suicide. If the physician had asked the patient about the circumstances surrounding the accident, the physician would have learned that the patient recently had been drinking heavily because of an emotionally troubling divorce and that he was depressed and having suicidal thoughts. Collectively, the sociodemographic characteristics of this patient (age, race, marital status, depressed, excessive alcohol use, retired) are strong indicators of potential suicide.

Did this physician violate EMTALA? Is he guilty of medical malpractice? Would the physician be found "not culpable" because the patient did not initiate a discussion of psychiatric issues? EMTALA requires that the hospital must provide for an "appropriate medical screening examination to determine if an emergency medical condition exists." An appropriate medical examination should have included additional questions about the patient's emotional status. The heart of EMTALA is the concern with transferring a medically unstable patient to another facility--and sending a patient home can be considered a transfer. Therefore, the physician placed the hospital at risk for having violated EMTALA and increased his risk of being subject to a medical malpractice suit.

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.

 Patients with significant medical illnesses were found to have a rate of psychiatric disorders twice that seen in healthy subjects,

 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.

 Two of the most common psychiatric disorders found among the seriously medically ill are substance use disorders (SUD) and depression.

Certain medical illnesses, such as stroke, heart attack, and cancer, can cause depressive illness and consequently prolong recovery.

 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.

 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%.

In addition, it is important to note that there are significant correlations among depressive disorders, SUD, serious medical illness, and suicide.

 Suicide was the 11th leading cause of death in the United States in 2000 and it accounts for more deaths each year than homicides.

 As many as 500,000 patients each year are treated in EDs for injuries associated with attempted suicides,

 and more than 90% of those who kill themselves have a major mental disorder such as depression or SUD.

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.

 Patient populations, such as violent patients,

 and patients with personality disorders,

 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%

 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 ED

 and more likely to seek mental health care in EDs,

 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.

 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.

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.

 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.

 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 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 investigators

 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.

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.

 (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,

 the Center for Epidemiologic Studies Depression Scale,

 Screening for depression, particularly among the elderly, can be done quickly and efficiently by using a 3-item depression screen.

Several brief screening instruments are available for use in the identification of alcohol and drug abuse problems.

 While it should be recognized that the predictive ability of most suicide scales is limited, 2 useful suicide screening inventories are the Beck Hopelessness Scale

 and the Child Hopelessness Scale (a derivative of the Beck Hopelessness Scale).

In addition, physicians can screen for psychotic symptoms with instruments such as the Brief Psychiatric Rating Scale,

 or the Severity and Acuity of Psychiatric Illness Scales.

 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.

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.

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Emergency department (ED) visits have increased from 89 million in 1992 to more than 110 million in 2002, while the number of EDs decreased by about 15% during the same period. One suspected consequence of ED overcrowding is an increased tendency to disregard a psychiatric problem, especially if it is not the chief complaint.

Seth Kunen, PhD

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