Psychiatric Evaluations in Emergency Departments

In the article by Drs Kunen and Mandry, “Should Emergency Medicine Physicians Screen for Psychiatric Disorders?” (Psychiatric Times, October 2006), no mention was made of formally assessing a patient's mental status to diagnose delirium.

Of all psychiatric syndromes presenting in the emergency department (ED), delirium is surely the most critical. If present, no other diagnosis can apply. The authors focus exclusively on other psychiatric diagnoses instead-as though delirium were not a priority. Taking a sound psychosocial and symptom history of a patient is crucial but not sufficient, since no diagnosis is possible without a mental status exam (MSE).

The article also exposes a larger problem. Most nonpsychiatric physicians, even in the ED, not only fail to assess patients for DSM-IV diagnoses, but they never perform an MSE. There is a cavalier notion that an experienced clinician can just “tell” whether a patient has cognitive or attention problems. This casual attitude often means that patients with fluctuating levels of consciousness get confused with being “uncooperative” or “obnoxious” and that gross organic deficits may be assumed to reflect poor education, etc.

Since delirium can be the earliest indicator of reversible medical conditions, not screening patients can lead to serious, and even fatal, errors. It also becomes a model for medical students who get little support for anything other than performing the occasional mini-MSE on geriatric patients.

Shouldn't we consider a formal MSE to be as fundamental as checking a patient's vital signs in an ED evaluation? Shouldn't delirium be the number one psychiatric diagnosis to rule out?

Ironically, Dr Ronald Pies wrote a fine article on delirium in the same issue (“Treating Delirium: When theBrain Goes Off Track,” page 74). Unfortunately, no linkage was made!

Sara Hartley, MD
Oakland, Calif

Dr Hartley is a psychiatrist in a private practice in Oakland, Calif.

Drs Kunen and Mandry respond:

We would like to thank Dr Hartley for her thoughtful comments on our article, since one purpose of the article was to stimulate discussion about the importance of screening for psychiatric disorders among ED patients.

Dr Hartley notes that we did not emphasize the importance of screening for delirium, which she considers to be the most critical psychiatric condition. We certainly do not dispute the importance of screening for delirium and agree that it should be a high priority, although we do not necessarily agree that it is the most critical of all psychiatric conditions. It seems to us that there are several psychiatric conditions, some of which are potentially lethal, that should be of higher priority. These include patients with major depression who have attempted suicide, patients with schizophrenia who have expressed homicidal intent, patients with bipolar disorder who are manic and floridly psychotic, patients with substance dependence who have overdosed and compromised their cardiopulmonary and/or renal function, and children with pica who have self-poisoned.

Dr Hartley's comment about the importance of routinely conducting MSEs stimulated us to examine the frequency of reported MSEs in the CDC's national survey of EDs (which was the basis of part of our article1), and sure enough, 91% of the sampled ED physicians had not conducted an MSE. It is our hope that emergency medicine physicians will soon recognize that it is good medicine to screen patients for psychiatric disorders and that, if they are not willing to do so, they will advocate for including mental health professionals on staff who will conduct such screenings.

Seth Kunen, PhD, PsyD
Cris V. Mandry, MD
Baton Rouge, La

Dr Kunen is clinical assistant professor of medicine and director of research at the Louisiana State University Emergency Medicine Residency Program at Earl K. Long Medical Center in Baton Rouge. Dr Mandry is clinical associate professor of medicine and program director of the Louisiana State University Emergency Medicine Residency Program at the Earl K. Long Medical Center.

Reference1. McCaig LF, Burt CW.National hospital ambulatory care survey: 2002 emergency department summary. Adv Data. 2004;340:1-34.