Dramatic evidence of how psychiatric disorders are underdiagnosed in hospital emergency departments

Feb 23 2005

New research offers dramatic evidence of how psychiatric disorders are underdiagnosed in hospital emergency departments, affecting an increasing number of Americans who rely on such facilities for much of their primary health care needs. The research appears in this month’s issue of the Journal of Consulting and Clinical Psychology, published by the American Psychological Association (APA).

In their study involving more than 33,000 Caucasian and African American patients from three hospital emergency departments in the Midwest and South, psychologist Seth Kunen, Ph.D., Psy.D., from the Earl K. Long Medical Center and the Louisiana State University Emergency Medicine Residency Program and colleagues confirm earlier reports that a significant psychiatric underdiagnosis is taking place. The researchers observed a psychiatric rate of 5.27% among the emergency department patients, a rate far below the national prevalence rate of 20% to 28%.

Comparing national rates of various psychiatric disorders versus the observed emergency department rates, the researchers found the following:

• mood disorders= 4% (national rate) versus 0.70% (emergency department rate)
• anxiety= 11-16% versus 1.19%
• substance use disorders = 7% versus 2.05%
• tobacco use disorder= 25% versus .23%
• organic psychosis (psychosis due to brain injury or disease)= diagnostic ratios ranging from 3:1 to 25:1 depending on age group and method of estimation
• schizophrenia= 1.30% versus 0.32%

Both Caucasians and African Americans were underdiagnosed in the emergency departments, but the study found a much larger underdiagnosis for African Americans. The odds of Caucasians having a psychiatric diagnosis were 1.85 times that of African Americans and almost twice as many Caucasians as African Americans received a psychiatric diagnosis as the primary diagnosis. The researchers say there are several possible reasons for this disparity, including Caucasian physicians being more familiar with the mental disorder symptoms of Caucasians, the tendency of African Americans to be less trusting and less willing to disclose emotional problems to people of different racial groups, and physician bias.

The authors say it is possible that African Americans simply have fewer psychiatric disorders than Caucasians and that is the reason for the race disparity. “However, because a much greater percentage of African Americans live in poverty than Caucasians and because there are strong correlations among variable such as poverty and illness, it would be more reasonable to expect the rate of psychiatric disorders among African Americans to be as high or higher than the rate among Caucasians,” according to the authors. The authors also note that the observed race disparity may be limited to emergency departments that have a predominantly African American census.

To get a better understanding of the underdiagnosis phenomenon, the researchers conducted informal interviews with more than 50 emergency department physicians. The physicians cited lack of psychiatric expertise, a belief that many mental disorders are relatively unimportant threats to health, and the inability to provide continuity of care for their patients as major reasons that may contribute to underdiagnosis.

As emergency medicine moves from its historical origin as a trauma specialty to its developing role as a primary care provider for millions of people each year, the researchers say it’s imperative that emergency departments expand their staffs to include mental health professionals such as psychologists because hospital-based physicians may not have the training, interest, or time to deal with mental health issues.

“The psychiatric underdiagnosing we have documented is potentially the most damaging for the more vulnerable minorities and the poor who rely on emergency departments for much of their primary health care needs,” say the authors. “This underdiagnosing contributes to needless emotional suffering because many of the more common disorders, such as depression and anxiety, respond well to psychotherapy and pharmacological interventions.”

http://www.apa.org/