Schizophrenic, agitated, noncompliant with medication, possibly substance
abusing—this is the picture of the typical person who comes to the
psychiatric emergency department at St. Vincent's Charity Hospital in
Cleveland, according to chief psychiatrist Philipp Dines, M.D.
The picture is not different from that seen in emergency departments
elsewhere around the country.
A report in the February Academic Emergency Medicine confirmed a
sharp increase in the number of mentally ill persons coming to the nation's
emergency departments between 1992 and 2000.
Sara Hazlett, M.D., and colleagues at Johns Hopkins University School of
Medicine reported that approximately 4.3 million psychiatric-related ED visits
(PREDVs) occurred in the United States in 2000. The PREDV rates increased 15
percent between 1992 and 2000, and accounted for 5.4 percent of all ED visits
A PREDV was defined as any visit in which one of three diagnoses included a
psychiatric discharge diagnosis or suicide attempt coded according to the
International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM), using codes 290-312.
Substance abuse (27 percent), neuroses (26 percent), and psychoses (21
percent) were the most common conditions. (Neuroses in the ICD-9-CM
refers to anxiety, hysteria, and phobic disorders.) Other disorders included
depression, personality and conduct disorders, and suicide or self-inflicted
African Americans had significantly higher visit rates than whites, and
persons on Medicaid had double the rate of PREDVs compared with the uninsured,
and almost eight times the rate of those privately insured.
Patients with psychiatric diagnoses had a higher admission rate (22
percent) than those with nonpsychiatric diagnoses (15 percent).
The uninsured were the least likely to be admitted for all major
psychiatric conditions except suicide.
Emergency psychiatrist Michael H. Allen, M.D., believes the ED is an
untapped reservoir of information about a critical segment of mentally ill
Americans and the care they receive. While the ED does serve as a kind of
barometer for the dysfunctions of the larger system—the canary in the
health system coal mine—the picture that emerges is impressionistic and
lacking in detail.
"There are no multicenter data about who shows up in the ED, what
their problems are, and what happens after they come to the ED," Allen
said. "One of the things I would like to see is a multisite system of
psychiatric surveillance to look at agitation, aggression, use of restraints,
and suicide—these are major public health issues.
"Suicide is the thing we are most interested in, but over the years
there have been lots of things that manifested in emergency settings that
could have been studied at that level and addressed. But people have not put
the resources into understanding those problems." ▪