Will staff restructuring improve psych diagnoses?
Will staff restructuring improve psych diagnoses?
Author urges paradigm shift’ out of trauma model
If Seth Kunen, PhD, PsyD, had his druthers, every ED manager in America would have a staff or a call panel that included a substance abuse specialist, a psychologist, a psychiatrist, and a social worker. What’s more, a "paradigm shift" in which emergency medicine abandons the trauma model that has been its foundation for some 30 years is favored by the director of research in the Louisiana State University emergency medicine residency program at the Earl K. Long Medical Center in Baton Rouge.
Why is Kunen calling for such drastic changes? Because, according to a new study of which he was lead author, psychiatric disorders are seriously under-diagnosed in our nation’s EDs. Changes such as those he recommends will go a long way toward solving the problem, Kunen says.
The article, which was published in the February 2005 issue of the Journal of Consulting and Clinical Psychology, found a psychiatric diagnosis rate of 5.27% among a total of about 33,000 patients in three EDs, a rate far below the national prevalence rate of 20% to 28% in the general population.1
Comparing national rates of various psychiatric disorders in the general population versus the observed ED rates, the researchers found the following:
- mood disorders: 4% (national rate) vs. 0.70% (ED rate);
- anxiety: 11%-16% vs. 1.19%;
- substance use disorders: 7% vs. 2.05%;
- tobacco use disorders: 25% vs. 23%;
- organic psychosis (psychosis due to brain injury or disease): diagnostic ratios ranging from 3:1 (general population vs. EDs) to 25:1 (general population vs. EDs), depending on age group and method of estimation;
- schizophrenia: 1.30% vs. 0.32%.
This under-diagnosis can have a direct impact on EDs, Kunen says. "Certainly you would expect that untreated mental disorders in themselves could create a recidivism rate increase, but there will also be repeat visits because they tend to complicate recovery from medical conditions," he says. "And results are pretty consistent in the literature that major depression is not only a predictor, but also a sequela, of cardiac events — particularly in males."
Revising the trauma model
At the heart of the problem is the model undergirding the very nature of emergency medicine, Kunen says. "Emergency medicine is roughly 30 years old as an actual specialty, and it evolved out of trauma medicine," he notes. "The model that generated it is based on the assumption that you treat people with trauma — which is great, but it also has a great deal to do with training in residency and medical school."
If all ED staff members ever saw were trauma patients, then the training would match the practice models and everything would be fine, he says. However, he notes, there about 110 million patient visits to 4,000 EDs in the United States each year, and about 20% of them are injuries as opposed to illness.
This disparity leads to Kunen’s proposed paradigm shift. "We can continue pretending emergency medicine is just a trauma specialty and assert that even if someone has depression, unless they are suicidal, it is not an emergency; or we can take action," he says.
What Kunen proposes is a multi-disciplined staff in the ED or on call. "In our ED right now, we have a single mental health person, typically a social worker, called the single point-of-entry person," he explains. "If we have a patient who is floridly psychotic or threatening to hurt someone, they come and evaluate them and try find a bed somewhere — and not in our hospital." That’s the full extent of services; there’s no therapy and no case management, he says. "The ideal would be to have a substance abuse specialist, a psychologist, a psychiatrist, and a social worker available," Kunen says. "Making the diagnosis in the ED could be of great benefit."
Sounds good, but . . .
Kunen’s proposal sounds good in theory, but he is wrong to place the onus on the ED, says Harmut Gross, MD, FACEP, associate professor at Medical College of Georgia and an ED attending physician at the Medical College of Georgia Medical Center, both in Augusta.
"First of all, I think we do a generally good job of screening for the overtly psychiatrically disturbed patients who are a danger to themselves and others," says Gross. "I appreciate that [Kunen] wants to see this done, but I’m also sure dermatologists would like us to sit down with a magnifying glass and look at every mole. But if we did, we’d really be gridlocked."
As for changing the ED staffing structure, Gross says he’s not sure why Kunen wants to shift the responsibility to the ED. "We’d welcome the help, but psychiatric specialists themselves do not think many of these cases are emergencies," he says. "We have a good relationship with ours, and when we ask them to come down, they do."
The bottom line is that it’s not financially feasible for an ED to undertake such responsibility, he says. "We should hire more staff so we can go deeper in the hole?" he asks. If the psychiatric department wants to put a team together, the ED can put in a paging system, Gross says. "A paradigm shift is fine and good, but find the resources from other departments," he says.
Reference
- Kunen S, Niederhauser R, Smith PO, et al. Race disparities in psychiatric rates in emergency departments. J Consult Clin Psychol 2005; 73:116-126.
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