|Year : 2019 | Volume
| Issue : 2 | Page : 208-214
Frequency of psychiatric disorders in nonemergent admissions to emergency department
ME Canakci1, N Acar2, C Yenilmez3, E Ozakin2, FB Kaya2, E Arslan4, T Caglayan5, H Dolgun6
1 Department of Emergency, Eskisehir State Hospital, Eskişehir, Turkey
2 Department of Emergency Medicine, Eskisehir Osmangazi Unviersity, Eskişehir, Turkey
3 Department of Psychiatry, Eskisehir Osmangazi Unviersity, Eskişehir, Turkey
4 Department of Emergency, Van Education and Research Hospital, Van, Turkey
5 Department of Emergency, Agri State Hospital, Agri, Turkey
6 Department of Emergency, Siverek State Hospital, Şanlıurfa, Turkey
|Date of Acceptance||22-Oct-2018|
|Date of Web Publication||7-Feb-2019|
Dr. M E Canakci
Department of Emergency, Eskisehir State Hospital, Eskişehir
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Repeated admissions of patients with undiagnosed psychiatric problems in emergency departments (ED) is a major contributor to patient unsatisfaction and overcrowding in EDs. We evaluated the presence of psychiatric disorders in non-emergent admissions in the ED of a tertiary care hospital. Materials and Methods: This cross-sectional study was carried out in Eskisehir Osmangazi University Hospital between December 2015 and March 2016. The study group consists of 4320 non-emergent patients (31% of all admissions to non-emergent ED). Psychiatric assessments of patients were done using the Primary Care Evaluation of Mental Disorders (PRIME-MD) scale prior to their discharge from the ED. The Mann-Whitney U, Kruskal-Wallis and Chi-square tests, as well as multivariate logistic regression, were performed for statistical analysis. Results: The mean age was 30 ± 11.7 years years ranging from 18 to 78 years. Among non-emergent cases, 44% had at least one psychiatric disorder. The most frequent psychiatric disorder was mood disorder (major and minor depression). Females with a comorbid disease and lower education level had increased risk for mood disorders, anxiety disorders, and somatoform disorders. Single males with a comorbid disease had increased risk for alcohol dependence. Conclusions: Undiagnosed patients with psychiatric disorders appear to be frequent users of medical emergency department services. These results might be helpful in developing more effective strategies to serve the mental health needs of the undiagnosed. People's awareness of psychiatric disorders should be increased.
Keywords: Emergency department, nonemergent admissions, primary care evaluation of mental disorders, psychiatric disorders
|How to cite this article:|
Canakci M E, Acar N, Yenilmez C, Ozakin E, Kaya F B, Arslan E, Caglayan T, Dolgun H. Frequency of psychiatric disorders in nonemergent admissions to emergency department. Niger J Clin Pract 2019;22:208-14
|How to cite this URL:|
Canakci M E, Acar N, Yenilmez C, Ozakin E, Kaya F B, Arslan E, Caglayan T, Dolgun H. Frequency of psychiatric disorders in nonemergent admissions to emergency department. Niger J Clin Pract [serial online] 2019 [cited 2019 Apr 21];22:208-14. Available from: http://www.njcponline.com/text.asp?2019/22/2/208/251791
| Introduction|| |
Emergency departments (ED) are struggling with overcrowds. Previous studies have shown that redundant crowds in the ED are associated with increased morbidity and mortality rates, as well as increased patient-care costs.,,, There are several suspected factors for this serious problem, including societal issues, availability of specialty departments, resource allocations, and unavailability of beds in intensive care units or inpatient services for boarding of patients for hospitalization. One of the most significant contributors to overcrowding is the presence of non-emergent admissions in EDs. Theoretically, non-emergent admissions to EDs are considered to be between actual emergent admissions that need prompt action and regular outpatient admissions. The distinction between these clinical severity grades can only be made when a reliable triage mechanism is present. From this point of view, triage systems in EDs are initial and crucial mechanisms for efficient patient management and effective allocation of medical resources. The functionality and operability of triaging in EDs necessitate the utilization of validated guidelines, patient approach methodologies, and rapid assessment tools.
Currently, available literature data suggests that the frequency of psychiatric disorders in patients admitted to primary care facilities is higher than the general population.,, This high frequency has also been reported by several previous studies conducted in ED settings.,,, Nevertheless, these disorders generally go unnoticed or underdiagnosed, which resulted in continuous admissions of these patients with implicit complaints about seeking medical attention. As a consequence, psychiatric illness rates were found to be higher in patients admitted to the ED with non-emergent complaints than in those with serious emergencies. Previous reports about the frequency of psychiatric disorders in EDs revealed that 12% to 22% of patients admitted to primary care had anxiety disorders, and most frequent subgroups of those panic disorders were generalized anxiety disorders and panic disorders. When the excess workload due to overcrowding in EDs is considered, those patients should easily be left unnoticed without using structured assessment tools during initial triage.
Recognizing the patients with undiagnosed psychiatric problems in primary care settings has been addressed in many studies, and several instruments have been developed and tested for this aim. These instruments include the rapid screening instrument for generalized anxiety in elderly primary care attenders (FEAR), Anxiety Screening Questionnaire (ASQ-15), Duke anxiety–depression scale, and the Primary Care Evaluation of Mental Disorders (PRIME-MD). The latter of these is a two-stage rapid screening tool, which has been found to be a valid and reliable tool to obtain a Diagnostic and Statistical Manual Version IV – DSM-IV diagnosis of major depression, somatoform disorders, and alcohol abuse. In this study, we aimed to evaluate the presence of psychiatric disorders in non-emergent admissions in a tertiary care university hospital's ED.
| Materials and Methods|| |
Study group and procedure
This is a cross-sectional study. The Ethics Committee of Eskisehir Osmangazi University and Eskisehir Osmangazi University Medical Practice and Research Hospital Management reviewed and approved the study. All participants were given informed consent. Study procedures were in accordance with the Helsinki Declaration of 2014.
The study was performed in Eskisehir, which is a province located in central Turkey with a population of 844,842. There are three universities in the city and one medical school. The study was carried out in Eskisehir Osmangazi University Hospital's Emergency Department between December 2015 and March 2016. There was 842 nonmedical staff working in the 900-bed hospital, which provided service to a 110,000 m 2 area.
In accordance with the purpose of the study, a two-part questionnaire was prepared. The first part focused on the sociodemographic characteristics, including age, sex, education level, marital status, family status, and the personal/family status of physician-diagnosed diseases. The second part consisted of the PRIME-MD.
According to the initial triage of the patients over 18 years-of-age, a total of 14,067 were considered to be non-emergent cases (Triage Category 3). Patients with a prior diagnosis of a psychiatric disease were excluded from the study. Patients were informed about the study protocol, and 4320 (31%) of them were given consent to participate in the study. Participants were invited for the administration of the PRIME-MD scale prior to their discharge from the ED. The questionnaire was completed by the researchers in a face-to-face conversation. Questionnaire administration required between 15 and 20 min to complete. A research assistant who has not been involved in the primary management of the patient during the ED course has administered the scales.
The general characteristics of patients in triage category 3 were self-admittance to ED, having good general status, no-need for hospitalization/monitoring/supervision, and having simple health problems that can be easily managed in outpatient setting. Examples of this group of complaints are upper respiratory tract infections, urinary tract infections, sprains, and muscle spasms, etc.
Primary care evaluation of mental disorders scale
The psychiatric disorder of the patients was assessed by PRIME-MD. The questionnaire was developed by Spitzer et al. in 1994. The Turkish version was validated by Corapcioglu et al. in 1996. The Turkish version of PRIME-MD was shown to be a valid and reliable tool for the identification of psychiatric disorders in primary care patients. PRIME-MD is a fully structured initial interview scale designed for short-term and accurate diagnosis of the most prevalent mental disorders in primary health care institutions by primary care physicians, such as mood disorders, anxiety disorders, somatoform disorders and possible alcohol abuse. The scale consists of two components, a patient-administered screening questionnaire, and a clinician-applied detailed assessment interview. Initially, the patient completes a 27-item questionnaire that investigates five groups of disorders including depressive, anxiety, alcohol use, somatoform, and eating disorders. Next, a clinician investigates the responses, focuses on the positive domains, and applies diagnostic algorithms for each of the positive signals.,
Descriptive statistics were presented with mean ± standard deviation for numerical variables, and with frequency and percent for categorical variables. Independent group comparisons were made with the Mann-Whitney U test between two groups, and with Kruskal-Wallis test between three and more groups. Categorical data were compared with the Chi-square test. Then, we performed multivariate logistic regression to determine the factors related to the psychiatric disorder. The model included independent variables that were found to be significant. Statistical significance was considered as a P value less than 0.05. All analyses were done with SPSS 21 software (IBM Inc., Armonk, NY, USA).
| Results|| |
Data from a total of 4320 patients were included in the analyses. The mean age of the participants was 30 ± 11.7 years, and 54.1% of them were females. More than half of the participants were single (55.1%), and most of them have graduated from university (39.5%), and high school (37.6%). About 84.3% of the participants had no other comorbid illness. Most frequent diagnoses in the patients with comorbidity were hypertension (2.4%) and diabetes mellitus (2.3%). Most frequent diagnoses on discharge among all non-emergent admissions were upper respiratory tract infection (28.9%), soft-tissue disorders (17.2%), and dyspepsia/gastroesophageal reflux (7.7%). PRIME-MD assessments revealed that nearly half of the participants had one or more psychiatric disorders. Accordingly, 27.2% of them had one, 11.2% had two, and 5.6% had three or more psychiatric diagnoses. The general characteristics of the participants are presented in [Table 1].
The most frequent diagnoses were minor depressive disorder (24.7%), major depressive disorder (12.2%), and somatoform disorder, NOS (not otherwise specified) (8.2%). Minor depressive disorder (P < 0.001), major depressive disorder (P < 0.001), dysthymia (P < 0.001), anxiety disorder, NOS (P = 0.003), generalized anxiety disorder (P < 0.001), panic disorder (P = 0.002), organic disease associated anxiety (P = 0.024), hypochondriasis (P = 0.036), somatoform disorder (P < 0.001), multisomatoform disorder (P = 0.001), and chronic pain (P = 0.009) were significantly higher in proportion in females. But, probable alcohol abuse/dependence was found to be significantly more frequent in males (P < 0.001). Distribution of the PRIME-MD based diagnoses according to sex, marital status, and presence of comorbidity is shown in [Table 2] and [Figure 1].
|Table 2: Distribution of the primary care evaluation of mental disorders based diagnoses according to sex, marital status, and presence of comorbidity|
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|Figure 1: Distribution of primary care evaluation of mental disorders based psychiatric disorders between women and men, single and married participants, and patients with and without comorbid conditions. * Significantly higher prevalence|
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The comparisons of the psychiatric diagnoses between single and married participants revealed that partial remission of major depressive disorder (P = 0.002) and probable alcohol abuse/dependence (P < 0.001) were significantly higher in single participants, whereas organic disease associated depression (P < 0.001) was significantly more frequent in married patients. Other diagnoses were similar in both groups.
The patients with at least one comorbid disease had significantly higher proportions of minor depressive disorder (P = 0.010), major depressive disorder (P < 0.001), dysthymia (P < 0.001), organic disease associated depression (P = 0.011), anxiety, NOS (P = 0.006), generalized anxiety disorder (P < 0.001), panic disorder (P < 0.001), organic disease associated anxiety (P < 0.001), multisomatoform disorder (P = 0.001), and chronic pain (P = 0.002).
The risks of PRIME-MD assessments identified any mood diagnosis in 38.6%, any anxiety diagnosis in 6.5%, any somatoform diagnosis in 11.2%, and alcohol dependence in 3.3% of the patients. Comparisons between sexes revealed that the odds of a mood (OR: 1.9), anxiety (OR: 2.2) or somatoform (OR: 2.3) disorder is significantly higher in females, but males are at significantly increased risk (OR: 3.8) for alcohol dependence. Comparisons according to marital status revealed that patients that are single have a significantly higher risk for mood disorder (OR: 1.2) and alcohol dependence (OR: 2.1). Presence of a comorbid disease also increased the risk for mood (OR: 1.7), anxiety (OR: 2.2), and somatoform (OR: 1.5) disorders. The comparisons of PRIME-MD diagnoses between patient subgroups are presented in [Table 3].
|Table 3: Comparisons of primary care evaluation of mental disorders diagnoses between patient subgroups|
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Multivariate logistic regression models for determinants of the PRIME-MD-based psychiatric disorders [Table 4] showed that sex, the presence of comorbid disease, and education level were the independent determinants of mood disorders, anxiety disorders, and somatoform disorders. In general, females, patients with comorbid diseases, and patients with lower education levels had a higher risk of having a psychiatric disorder. For alcohol dependence, the independent determinants were sex, the presence of a comorbid disease, and marital status. Accordingly, males, patients with a comorbid disease, and singles had a higher risk for a potential alcohol abuse/dependence. The determinants of PRIME-MD diagnoses in multivariate models are shown in [Table 4].
|Table 4: Determinants of primary care evaluation of mental disorders diagnoses in multivariate models|
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| Discussion|| |
In this study, we have evaluated the presence of undiagnosed psychiatric disorders in non-emergent admissions to the ED. Our results suggest that 44% of the patients with non-emergent complaints had at least one undiagnosed psychiatric disturbance, and PRIME-MD was found to be useful tool to identify these patients. Previous studies on this topic have also reported that undiagnosed psychiatric disorders are of importance in ambulatory settings, and PRIME-MD can be used to disclose these disturbances.
The prevalence of psychiatric disorders reported for primary care settings or EDs likely vary according to the site-specific characteristics in each study. But as a general data, 20% to 35% of unselected patients in primary care have a psychiatric disorder, and a half to three-fourths of the patients with non-emergent complaints in EDs potentially have an occult psychiatric illness that is never diagnosed. This is accounted as a major component of repeated admissions for medical care, which represent a significant burden on health services. In the best-case scenario that these patients are identified and diagnosed, favorable outcomes can be anticipated by effective treatment for these illnesses. PRIME-MD can be used to identify these patients because it overcomes many shortcomings of patient assessment in ED setting, including the limited time for psychiatric assessment, fear of patients against stigmatization, and absence of a preexisting physician-patient relationship.
In our study, the most frequent psychiatric disorders identified by PRIME-MD were minor and major depression, and somatoform disorder. A previous study by Downey et al. reported that the most identified mental illnesses in the EDs were major depression (24%), general anxiety (9%), drug abuse (8%), alcohol (5%), psychotic syndrome (5%), and suicide risk (4%). Another study by Larkin et al. reported that there is an increasing trend in admissions to EDs for psychiatric disorders, and most frequently identified diagnoses are substance-use disorders (22%), mood disorders (17%), and anxiety-related disorders (16%). Another study by Lee et al. reviewed a cohort of ED admissions including patients with mental disorders and substance abuse and reported that the most frequent diagnoses were mood disorder (43.9%), and self-harm (18.9%). The distribution and prevalence of psychiatric disorders vary by study, setting, and the population that each study was conducted on. Therefore, we propose that each institution should implement appropriate methods according to its own needs, resources, and characteristics for effective assessment of these cases in EDs.
PRIME-MD was found to be a valid and reliable tool to diagnose psychiatric conditions in primary care settings. Our experience with PRIME-MD also showed that it is an efficient tool for initial assessment of cases for psychiatric assessment in the green zone. Of the 44% of non-emergent cases with at least one psychiatric disorder in our sample population, mood disorders were present in 39%, somatoform disorders were present in 11%, anxiety disorders were present in 7%, and alcohol dependence was present in 3%. These prevalence rates partly comply with the previous reports and reflect the distribution of psychiatric disorders in our population. Moreover, a 44% prevalence of psychiatric disorders in non-emergent admissions to ED should also be considered as a signal for the ED staff, which shows that these patients need additional psychiatric assessment, and might have additional undiagnosed mental comorbidities.
Since this study has been conducted in the ED setting of a university hospital, our results cannot be fully generalized to all primary care settings. Also, confirmation of PRIME-MD assessments with a psychiatrist's diagnosis is absent in our study, and further studies might involve a secondary analysis regarding the sensitivity and specificity of PRIME-MD assessments with regard to a full psychiatric assessment.
| Conclusions|| |
Nearly half of the non-emergent admissions to ED have an undiagnosed psychiatric disorder. These patients can be accurately treated if reliably referred to psychiatric evaluation. PRIME-MD is an efficient and time-saving tool that ED physicians can utilize for psychiatric assessment of suspected cases in ED settings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jo S, Jeong T, Jin YH, Lee JB, Yoon J, Park B, et al.
ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: Post hoc
analysis from a retrospective study. Am J Emerg Med 2015;33:1725-31.
Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184:213-6.
Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208-12.
Vieth TL, Rhodes KV. The effect of crowding on access and quality in an academic ED. Am J Emerg Med 2006;24:787-94.
Weiss SJ, Ernst AA, Derlet R, King R, Bair A, Nick TG, et al.
Relationship between the national ED overcrowding scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med 2005;23:288-94.
Hwang JI, Chang H. Understanding non-emergency patients admitted to hospitals through the emergency department for efficient ED functions. J Emerg Nurs 2010;36:196-202.
FitzGerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department triage revisited. Emerg Med J 2010;27:86-92.
Higgins ES. A review of unrecognized mental illness in primary care. Prevalence, natural history, and efforts to change the course. Arch Fam Med 1994;3:908-17.
Zung WW, Broadhead WE, Roth ME. Prevalence of depressive symptoms in primary care. J Fam Pract 1993;37:337-44.
Schulberg HC, Burns BJ. Mental disorders in primary care: Epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiatry 1988;10:79-87.
Gold I, Baraff LJ. Psychiatric screening in the emergency department: Its effect on physician behavior. Ann Emerg Med 1989;18:875-80.
Wulsin LR, Arnold LM, Hillard JR. Axis I disorders in ER patients with atypical chest pain. Int J Psychiatry Med 1991;21:37-46.
Wulsin LR, Yingling K. Psychiatric aspects of chest pain in the emergency department. Med Clin North Am 1991;75:1175-88.
Tintinalli JE, Stapczynski JS. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 4th
ed. New York: McGraw-Hill; 2011.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44.
Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL. 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;37:132-40.
Rollman BL, Belnap BH, Mazumdar S, Zhu F, Kroenke K, Schulberg HC, et al.
Symptomatic severity of PRIME-MD diagnosed episodes of panic and generalized anxiety disorder in primary care. J Gen Intern Med 2005;20:623-8.
Krasucki C, Ryan P, Ertan T, Howard R, Lindesay J, Mann A, et al.
The FEAR: A rapid screening instrument for generalized anxiety in elderly primary care attenders. Int J Geriatr Psychiatry 1999;14:60-8.
Wittchen HU, Boyer P. Screening for anxiety disorders. Sensitivity and specificity of the anxiety screening questionnaire (ASQ-15). Br J Psychiatry Suppl 1998;34:10-7.
Parkerson GR Jr. Broadhead WE. Screening for anxiety and depression in primary care with the duke anxiety-depression scale. Fam Med 1997;29:177-81.
Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV 3rd
, et al.
Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994;3:774-9.
Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd
, Hahn SR, et al.
Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272:1749-56.
Corapcioglu A, Koroglu E, Ceyhun B. Turkish adaptation and validation of a psychiatric diagnostic scale (PRIME-MD) in primary care health services. Nöropsikiyatri Gündemi 1996;1:3-10.
Broadhead WE, Leon AC, Weissman MM, Barrett JE, Blacklow RS, Gilbert TT, et al.
Development and validation of the SDDS-PC screen for multiple mental disorders in primary care. Arch Fam Med 1995;4:211-9.
Lefevre F, Reifler D, Lee P, Sbenghe M, Nwadiaro N, Verma S, et al.
Screening for undetected mental disorders in high utilizers of primary care services. J Gen Intern Med 1999;14:425-31.
Downey LV, Zun LS, Burke T. Undiagnosed mental illness in the emergency department. J Emerg Med 2012;43:876-82.
Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. Emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv 2005;56:671-7.
Lee S, Harland KK, Swanson MB, Lawson S, Dahlstrom E, Clemson L, et al.
Safety of reassessment-and-release practice for mental health patients boarded in the emergency department. Am J Emerg Med 2018;36:1967-74.
[Table 1], [Table 2], [Table 3], [Table 4]