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Oliveira J. e Silva L, Prakken SD, Meltzer AC, Broder JS, Gerberi DJ, Upadhye S, Carpenter CR, Bellolio F. Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline. Acad Emerg Med 2022; 29:615-629. [PMID: 34665903 DOI: 10.1111/acem.14394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/22/2021] [Accepted: 09/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. METHODS We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. RESULTS A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). CONCLUSIONS We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.
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Affiliation(s)
| | - Steven D. Prakken
- Department of Psychiatry Duke University Health System Durham North Carolina USA
| | - Andrew C. Meltzer
- Department of Emergency Medicine The George Washington University School of Medicine and Health Sciences Washington District of Columbia USA
| | - Joshua S. Broder
- Department of Surgery Division of Emergency Medicine Duke University School of Medicine Durham North Carolina USA
| | | | - Suneel Upadhye
- Department of Emergency Medicine McMaster University Hamilton Ontario Canada
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University in St. Louis School of Medicine Emergency Care Research Core St. Louis Missouri USA
| | - Fernanda Bellolio
- Department of Emergency Medicine Mayo Clinic Rochester Minnesota USA
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Beiser DG, Ward CE, Vu M, Laiteerapong N, Gibbons RD. Depression in Emergency Department Patients and Association With Health Care Utilization. Acad Emerg Med 2019; 26:878-888. [PMID: 30884035 PMCID: PMC6690783 DOI: 10.1111/acem.13726] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/07/2019] [Accepted: 03/12/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. METHODS This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. RESULTS Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates. CONCLUSIONS Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.
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Affiliation(s)
- David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, IL
| | - Charlotte E. Ward
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Milkie Vu
- Section of Emergency Medicine, Departments of Medicine, University of Chicago, Chicago, IL, presently at Rollins School of Public Health, Emory University, Atlanta, GA
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Robert D. Gibbons
- Center for Health Statistics, Departments of Medicine and Public Health Sciences, University of Chicago, Chicago, IL
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Ntountoulaki E, Guthrie E, Kotsis K, Paika V, Tatsioni A, Tomenson B, Fountoulakis KN, Carvalho AF, Hyphantis T. Double RASS cutpoint accurately diagnosed suicidal risk in females with long-term conditions attending the emergency department compared to their male counterparts. Compr Psychiatry 2016; 69:193-201. [PMID: 27423361 DOI: 10.1016/j.comppsych.2016.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/29/2016] [Accepted: 06/11/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Suicidal risk is often unrecognized in emergency department (ED). We aimed to assess its prevalence in patients with long-term conditions (LTCs) attending an ED and to test whether gender differences influence suicidal risk assessment, using the diagnostic accuracy properties of the Risk Assessment Suicidality Scale (RASS). METHODS The RASS was administered to 349 patients with diabetes, COPD and rheumatic diseases visiting an ED. The MINI interview was used as the criterion standard. ROC curve analysis was performed to determine the optimal RASS cutpoint for suicidal risk separately for males and females. Somatic (PHQ-15) and depressive (PHQ-9) symptoms were also assessed and factors associated with suicidal risk across gender were determined in hierarchical regression models. RESULTS The prevalence of suicidal risk according to the MINI was 22.9%; 16.6% of patients were at low, 5.1% at moderate, and 0.9% at high risk. At an optimal cutpoint of 270, RASS had 81.3% sensitivity and 81.8% specificity. The optimal RASS cutpoint for females (340) was double the cutpoint for males (175). Somatic symptom burden was associated with suicidal risk in both sexes but it became non-significant after depressive symptoms were taken into account; suicidal risk was also associated with history of depression in females and lower income in males. CONCLUSION There is a high prevalence of suicidal risk in patients with LTCs attending the ED. As the optimal RASS cutpoint for females was double the cutpoint for males, clinicians should bear in mind gender differences when assessing for suicidal risk in the ED.
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Affiliation(s)
- Elisavet Ntountoulaki
- Department of Psychiatry, Division of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Elspeth Guthrie
- Psychiatry Research Group, Medical School, University of Manchester, Manchester, UK
| | - Konstantinos Kotsis
- Department of Psychiatry, Division of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Vassiliki Paika
- Department of Psychiatry, Division of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Athina Tatsioni
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Barbara Tomenson
- Psychiatry Research Group, Medical School, University of Manchester, Manchester, UK
| | - Konstantinos N Fountoulakis
- Third Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andre F Carvalho
- Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil
| | - Thomas Hyphantis
- Department of Psychiatry, Division of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
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Lower PHQ-9 cutpoint accurately diagnosed depression in people with long-term conditions attending the Accident and Emergency Department. J Affect Disord 2015; 176:155-63. [PMID: 25721612 DOI: 10.1016/j.jad.2015.01.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Major Depressive Disorder (MDD) is frequent in the Accident and Emergency Department (AED) but is often unrecognized. We aimed to assess the prevalence of MDD and determine the psychometric properties of the PHQ-9 in diagnosing MDD in patients with long-term medical conditions attending an AED. METHODS The PHQ-9 was administered to 349 patients with diabetes, COPD and chronic inflammatory rheumatic diseases, mainly rheumatoid arthritis and spondyloarthropathies, visiting an AED. The MINI interview was used as the criterion standard for MDD. Receiver operator characteristic (ROC) curve analysis was performed to determine the optimal PHQ-9 cutpoint for MDD. Construct validators included psychological distress (SCL-90-R), illness perceptions (B-IPQ) and Health-Related Quality of Life (WHOQOL-BREF). RESULTS The prevalence of MDD was 27.2%. At an optimal cutpoint of 8, PHQ-9 had a sensitivity of 90.5% and specificity of 89.4%. The area under the curve (0.96) was excellent. Convergent validity was established by the strong associations between PHQ-9 scores and functional status, SCL-90-R depression, illness perceptions and AED visits during the previous year. LIMITATIONS The sample consisted of multiple rather a single disease group, preventing us from accounting for illness severity using specific disease severity indices. CONCLUSION MDD is frequent in patients with long-term medical conditions attending the AED and the PHQ-9, at a cutpoint of 8, is an accurate, reliable and valid measure for MDD screening in this patient population.
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Ranney ML, Locci N, Adams EJ, Betz M, Burmeister DB, Corbin T, Dalawari P, Jacoby JL, Linden J, Purtle J, North C, Houry DE. Gender-specific research on mental illness in the emergency department: current knowledge and future directions. Acad Emerg Med 2014; 21:1395-402. [PMID: 25413369 PMCID: PMC4271843 DOI: 10.1111/acem.12524] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/14/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.
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Affiliation(s)
- Megan L Ranney
- Injury Prevention Center, Department of Emergency Medicine, Brown University, Providence, RI; Alpert Medical School, Brown University, Providence, RI
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Ranney ML, Choo EK, Cunningham RM, Spirito A, Thorsen M, Mello MJ, Morrow K. Acceptability, language, and structure of text message-based behavioral interventions for high-risk adolescent females: a qualitative study. J Adolesc Health 2014; 55:33-40. [PMID: 24559973 PMCID: PMC4065850 DOI: 10.1016/j.jadohealth.2013.12.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/12/2013] [Accepted: 12/16/2013] [Indexed: 01/20/2023]
Abstract
PURPOSE To elucidate key elements surrounding acceptability/feasibility, language, and structure of a text message-based preventive intervention for high-risk adolescent females. METHODS We recruited high-risk 13- to 17-year-old females screening positive for past-year peer violence and depressive symptoms, during emergency department visits for any chief complaint. Participants completed semistructured interviews exploring preferences around text message preventive interventions. Interviews were conducted by trained interviewers, audio-recorded, and transcribed verbatim. A coding structure was iteratively developed using thematic and content analysis. Each transcript was double coded. NVivo 10 was used to facilitate analysis. RESULTS Saturation was reached after 20 interviews (mean age 15.4; 55% white; 40% Hispanic; 85% with cell phone access). (1) Acceptability/feasibility themes: A text-message intervention was felt to support and enhance existing coping strategies. Participants had a few concerns about privacy and cost. Peer endorsement may increase uptake. (2) Language themes: Messages should be simple and positive. Tone should be conversational but not slang filled. (3) Structural themes: Messages may be automated but must be individually tailored on a daily basis. Both predetermined (automatic) and as-needed messages are requested. Dose and timing of content should be varied according to participants' needs. Multimedia may be helpful but is not necessary. CONCLUSIONS High-risk adolescent females seeking emergency department care are enthusiastic about a text message-based preventive intervention. Incorporating thematic results on language and structure can inform development of future text messaging interventions for adolescent girls. Concerns about cost and privacy may be able to be addressed through the process of recruitment and introduction to the intervention.
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Affiliation(s)
- Megan L Ranney
- Department of Emergency Medicine, Injury Prevention Center of Rhode Island Hospital, Providence, Rhode Island; Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island.
| | - Esther K Choo
- Department of Emergency Medicine, Injury Prevention Center of Rhode Island Hospital, Providence, Rhode Island; Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Rebecca M Cunningham
- Injury Control Research Center, Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Michael J Mello
- Department of Emergency Medicine, Injury Prevention Center of Rhode Island Hospital, Providence, Rhode Island; Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kathleen Morrow
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
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Ranney ML, Walton M, Whiteside L, Epstein-Ngo Q, Patton R, Chermack S, Blow F, Cunningham RM. Correlates of depressive symptoms among at-risk youth presenting to the emergency department. Gen Hosp Psychiatry 2013; 35:537-44. [PMID: 23810465 PMCID: PMC3775848 DOI: 10.1016/j.genhosppsych.2013.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The study's objective was to identify correlates of depressive symptoms among at-risk youth in an urban emergency department (ED). METHOD A systematic sample of adolescents (ages 14-18) in the ED were recruited as part of a larger study. Participants reporting past-year alcohol use and peer aggression self-administered a survey assessing: demographics, depressive symptoms and risk/protective factors. Logistic regression identified factors associated with depressive symptoms. RESULTS Among 624 adolescents (88% response rate) meeting eligibility criteria, 22.8% (n=142) screened positive for depressive symptoms. In logistic regression, depressive symptoms were positively associated with female gender [odds ratio (OR): 2.84, 95% confidence interval (CI): 1.78-4.51], poor academic performance (OR: 1.57, 95% CI: 1.01-2.44), binge drinking (OR: 1.88, 95% CI: 1.21-2.91), community violence exposure (OR: 2.25, 95% CI: 1.59-3.18) and dating violence (OR: 2.14, 95% CI: 1.36-3.38) and were negatively associated with same-sex mentorship (OR: 0.52, 95% CI: 0.29-0.91) and older age (OR: 0.55, 95% CI 0.34-0.89). Including gender interaction terms did not significantly change findings. CONCLUSIONS Screening and intervention approaches for youth in the urban ED should address the co-occurrence of depressive symptoms with peer and dating violence, alcohol and nonmarijuana illicit drug use.
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Affiliation(s)
- Megan L. Ranney
- Injury Prevention Center, Department of Emergency Medicine, Alpert Medical School, Brown University, Ann Arbor, Michigan, USA
| | - Maureen Walton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA,Injury Control Research Center, Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren Whiteside
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Quyen Epstein-Ngo
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Rikki Patton
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen Chermack
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA,Department of Veterans Affairs, Health Services Research and Development, Ann Arbor, Michigan, USA
| | - Fred Blow
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA,Department of Veterans Affairs, Health Services Research and Development, Ann Arbor, Michigan, USA
| | - Rebecca M. Cunningham
- Injury Control Research Center, Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA,School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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