Emergency Psychiatry in the General HospitalMood disorder screening among adult emergency department patients: a multicenter study of prevalence, associations and interest in treatment☆,
Introduction
Depression is associated with substantial morbidity, mortality and costs [1], [2], [3]. Although safe and effective treatments exist, most depressed individuals go untreated [4], [5]. The responsiveness of depression to treatment and the cost-effectiveness of screening have led the US Preventive Services Task Force (USPSTF) to recommend broad-based screening for depression in healthcare settings that have the capacity to further assess and manage patients who screen positive [5].
Efforts to increase depression screening in primary care and outpatient settings have a long history [5], [6]. In contrast, similar efforts have only recently begun in the emergency department (ED) setting. EDs form a critical component of the nation's healthcare system with approximately 115 million visits annually [7]. The Society for Academic Emergency Medicine's Public Health Task Force concluded that the evidence was not sufficient to recommend for or against depression screening in the ED and encouraged more work to be done in this area [8]. The successes observed with depression screening in outpatient settings, combined with the ED's vital role in identifying and intervening with diseases among segments of the population who would not otherwise find care, have led to further calls for increased attention to depression in the ED [9].
Several prospective, ED-based studies have discovered very high rates of mood disorders, with approximately one-quarter to one-third of patients screening positive [10], [11], [12], [13], [14], [15]. Schriger et al. [15] studied a sample of 190 ED patients presenting with vague or longstanding somatic complaints and found that 26% of their sample screened positive for a mood disorder. High rates of depression are not restricted to patients with vague somatic complaints, however. Boudreaux et al. [10] studied a sample of 182 general ED patients using the Harvard National Depression Screening Scale [16], a 10-item, validated scale patterned after the Diagnostic and Statistical Manual–IV (DSM-IV) [17] criteria for a major depressive episode. They found that 32% of their sample screened positive for depressed mood. Others have found similar trends ranging from 27% [14] to 30% [11] using a variety of depression screens.
In addition, ED patients may be disproportionately represented by patients exhibiting symptoms of mania as well. Boudreaux et al. [18] found that nearly 7% of a sample of general adult ED patients screened positive for mania using the Mood Disorder Questionnaire (MDQ) [19], [20], a validated screen based on the DSM-IV criteria for a manic episode. This 7% point-prevalence estimate is markedly higher than the estimated 1.3% 12-month prevalence of DSM-IV diagnosed bipolar disorder in a nationally representative, community cohort [1]. The proper identification of bipolar disorders in healthcare settings is important, because of the prognostic significance associated with early identification and appropriate treatment [17], [21].
Existing studies on mood disorders in the ED have one or more significant limitations, including reliance on a single-site [10], [14], [15], [18], small sample sizes [10], [15], [18], use of screening measures lacking established psychometrics [10], [11] or exclusive focus on depressive symptoms rather than examining both depression and mania [10], [11]. Also, existing studies have not determined whether patients actually desire help for their mood disorder to be initiated in the ED, the proportion who are already in active treatment or the kinds of interventions that are preferred. This information is important for intervention planning and design. Consequently, our study sought to (1) confirm previous prevalence rates of depression and mania within a multisite sample, (2) examine variables hypothesized to be associated with depression and (3) assess patient interest in a range of possible ED-initiated interventions for mood disorders. We hypothesized that depression would be more prevalent among older patients, females, minorities, patients with a chronic medical condition, patients with a history of substance abuse, recent smokers and patients who had used the ED recently.
Section snippets
Setting, study design, participant selection
This prospective, cross-sectional study was performed in August 2004. For two 24-h periods, consecutive patients aged 18+ years presenting to four urban EDs in the Boston area were enrolled. Two of the EDs were university-affiliated urban hospitals, one a community urban hospital and one a community suburban hospital. All sites are members of the Emergency Medicine Network (http://www.emnet-usa.org). Exclusion criteria included severe medical/traumatic illness or distress (e.g., intubation,
Results
Table 1 summarizes the characteristics of the sample. Among 796 eligible patients, 476 (60%) completed the assessment. One hundred fifty-two (32%; 95% CI, 28–36%) screened positive for depression, while 17 (4%; 95% CI, 2–6%) screened positive for mania. Table 2 summarizes the interest in ED-initiated interventions for mood disorders. Table 3 summarizes the bivariate associations between the variables assessed and depressed mood. Factors independently associated with depression in the logistic
Discussion
One-third (34%) of our sample screened positive for depression using a well-validated, two-item screen assessing depressed mood and anhedonia [22]. Our data confirm published estimates using a variety of other depression screens, which have ranged from 26% [15] to 33% [14]. Because existing studies, including our own, have not administered a diagnostic interview, a conclusive statement about actual diagnostic rates cannot be made. However, using the published operating characteristics of the
Conclusion
Approximately one-third of adult patients in the ED screened positive for depression. Our findings suggest depressed mood is particularly common among patients with prior psychiatric and substance abuse histories, who are economically disadvantaged, who smoke and who have had a recent ED visit. Recent efforts to increase screening and awareness of affective disorders in medical settings (e.g., the NDSD) may be warranted in the ED as well as other outpatient settings. There are considerable
References (33)
- et al.
Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study
Lancet
(1997) - et al.
Depression in geriatric ED patients: prevalence and recognition
Ann Emerg Med
(1997) - et al.
Socioeconomic and health status differences between depressed and nondepressed ED elders
Am J Emerg Med
(2002) - et al.
Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department
Ann Emerg Med
(2001) - 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) - et al.
Sensitivity and specificity of the mood disorder questionnaire for detecting bipolar disorder
J Affect Disord
(2004) - et al.
Project ASSERT: an ED based intervention to increase access to primary care, preventative services, and the substance abuse treatment system
Ann Emerg Med.
(1997) - et al.
A conceptual model of emergency department crowding
Ann Emerg Med
(2003) - et al.
Use of the ED as a regular source of care: associated factors beyond lack of health insurance
Ann Emerg Med
(1997) - et al.
The emergency department for routine healthcare: race/ethnicity, socioeconomic status, and perceptual factors
J Emerg Med
(2007)
The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)
JAMA
The functioning and well-being of depressed patients. Results from the Medical Outcomes Study
JAMA
Natural history and preventative treatment of recurrent mood disorders
Annu Rev Med
Screening for depression: recommendations and rationale
Ann Int Med
A ten-year review of the validity and clinical utility of depression screening
Psychiatr Serv
National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Advance data from vital and health statistics; no. 386
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Funding support: EDB is supported by NIH grant DA-16698.
The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.