Gender-specific research on mental illness in the emergency department: current knowledge and future directions

Unplanned cancer presentation in patients with psychiatric disorders: A nationwide register-based cohort study in Denmark

Unplanned presentation in the cancer pathway is more common in patients with psychiatric disorders than in patients without. More knowledge about the risk factors for unplanned presentation could help target interventions to ensure earlier diagnosis of cancer in patients with psychiatric disorders. This study aims to estimate the association between patient characteristics (social characteristics and coexisting physical morbidity) and cancer diagnosis following unplanned presentation among cancer patients with psychiatric disorders. We conducted a population-based register study including patients diagnosed with cancer in 2014-2018 and also registered with at least one psychiatric disorder in the included Danish registers (n = 26,005). We used logistic regression to assess patient characteristics associated with an unplanned presentation. Almost one in four symptomatic patients (23.6 %) with pre-existing psychiatric disorders presented unplanned in the cancer trajectory. Unplanned presentation was most common for severe psychiatric disorders, e.g. organic disorders and schizophrenia. Old age, male sex, living alone, low education, physical comorbidity, and non-attendance in primary care were associated with increased odds of unplanned presentation. In conclusion, several characteristics of patients with pre-existing psychiatric disorders were associated with unplanned presentation in the cancer trajectory; for some groups more than 40 % had an unplanned presentation. This information could be used to design targeted interventions for patients with pre-existing psychiatric disorders to ensure earlier diagnosis of cancer in this population.

Characteristics of psychiatric comorbidities in emergency medicine setting and impact on length of hospitalization: A retrospective study

This study aims to evaluate clinical correlates of psychiatric comorbidity and length of hospitalization in patients admitted in a general hospital emergency medicine setting. Overall, 160 patients hospitalized for different acute medical pathologies were selected consecutively over 12 months. All subjects were evaluated with proper forms to collect data on medical and psychiatric diagnoses. Levels of C-reactive protein were also measured in all patients. Statistical analyses were conducted with univariate, logistic, and multiple linear regressions. Patients with psychiatric comorbidity had significantly longer hospitalization than did patients with no psychiatric diagnoses (days 10.9±9.5 vs. 6.9±4.5, p<0.005). Agitation and delirium were more frequent in the psychiatry comorbidity study group (p<0.05), as was cognitive impairment (p=0.001). These variables predicted longer hospitalisation (respectively: t=-3.27, p=0.002; t=-2.64, p=0.009; t=-2.85, p=0.006). Psychiatric comorbidity acts as an adjunct factor in determining clinical severity and predicting a more difficult recovery in patients hospitalized in an emergency medicine setting.

Social determinants of health and depression in adults presenting to the emergency department: Implications for family medicine

OBJECTIVE

To estimate the extent to which social determinants of health (SDH) predict levels of depression in adults presenting to the emergency department (ED) with an acute mental health crisis.

DESIGN

Secondary data analysis.

SETTING

St Paul's Hospital, an urban tertiary care hospital in Vancouver, BC.

PARTICIPANTS

Patients 19 years and older presenting to the ED with an acute mental health crisis.

MAIN OUTCOME MEASURES

Responses to demographic questionnaires focused on SDH and to measures of self-perceived health and depression. Relationships between depression and SDH were described using t tests and χ ² tests. The extent to which SDH variables predicted depression scores, as measured by the Patient Health Questionnaire-9 (PHQ-9), was determined using linear regression.

RESULTS

The primary study had 202 participants. Data for the 156 (77%) participants who completed the PHQ-9 were assessed in this secondary analysis. In this sample, 60% of participants identified as men, 37% as women, and 4% as other. The mean (SD) age was 39.1 (13.8) years, with most participants identifying as white (65%) or Indigenous (18%). Thirty-seven percent had a high school diploma or less education, and 72% reported being unemployed. Identifying as a woman, lack of access to clean drinking water, poor food security, feeling unsafe, little structured use of time, lack of a sense of community, and dissatisfaction with housing significantly predicted higher depression scores. Overall, 59% of respondents met the criteria for moderately severe or severe depression (PHQ-9 score ≥ 15), with 37% of those reporting thoughts of suicide nearly every day for the past 2 weeks.

CONCLUSION

This study demonstrates the importance of screening for both depression and SDH in the ED. Because the ED often does not have the capacity to address appropriate levels of follow-up for this population, this study has important implications for primary care. Developing a clear pathway of follow-up support for people with depression and SDH risk factors will be critical to optimize patient outcomes, promote patient safety, enhance patient satisfaction, and optimize the use of resources between the ED and primary care.

Trends in Depressed Mood and Suicidal Behaviors Among Female High School Students Who Engaged in Physical Fighting

The objective of this article is to identify prevalence changes in depressed mood/suicidal behaviors among female high school students reporting physical fighting. This research analyzed the national combined data set of the Youth Risk Behavior Surveillance (YRBS) cross-sectional surveys from 2001 to 2015. Logistic regression analyzed the time trends. Two multiple logistic regression models were built. A quadratic trend was present with an initial decrease followed by an increase 2009 to 2015 (p < .001). The odds and severity of depressed mood/suicidal behaviors were greater among female youths with four or more fights and for other violent events, which were even greater when accounting for electronic bullying. The odds of depressed mood/suicidal behaviors among female adolescents engaged in physical fighting has been increasing with electronic bullying contributing to polyvictimization.

Acute mental health service use is increased in rheumatoid arthritis and ankylosing spondylitis: a population-based cohort study

Background

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. Whether acute mental health (MH) service utilization (i.e. emergency visits or hospitalizations) is increased in RA or AS is not known.

Methods

Two population-based cohorts were created where individuals with RA (n = 53,240) or AS (n = 13,964) were each matched by age, sex, and year to unaffected comparators (2002-2016). Incidence rates per 1000 person-years (PY) were calculated for a first MH emergency department (ED) presentation or MH hospitalization. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated, adjusting for demographic, clinical, and health service use variables.

Results

Individuals with RA had higher rates of ED visits [6.59/1000 person-years (PY) versus 4.39/1000 PY in comparators] and hospitalizations for MH (3.11/1000 PY versus 1.80/1000 PY in comparators). Higher rates of ED visits (7.92/1000 PY versus 5.62/1000 PY in comparators) and hospitalizations (3.03/1000 PY versus 1.94/1000 PY in comparators) were also observed in AS. Overall, RA was associated with a 34% increased risk for MH hospitalization (HR 1.34, 95% CI 1.22-1.47) and AS was associated with a 36% increased risk of hospitalization (HR 1.36, 95% CI 1.12-1.63). The risk of ED presentation was attenuated, but remained significant, after adjustment in both RA (HR 1.08, 95% CI 1.01-1.15) and AS (HR 1.14, 95% CI 1.02-1.28).

Conclusions

RA and AS are both independently associated with a higher rate and risk of acute ED presentations and hospitalizations for mental health conditions. These findings underscore the need for routine evaluation of MH as part of the management of chronic inflammatory arthritis. Additional research is needed to identify the underlying individual characteristics, as well as system-level variation, which may explain these differences, and to help plan interventions to make MH service use more responsive to the needs of individuals living with RA and AS.

Emergency department presentations by older people for mental health or drug and alcohol conditions: A multicentre retrospective audit

PURPOSE

Emergency department presentations by older people associated with mental health and drug and alcohol related conditions are increasing. However, the characteristics of presentations by older people in Australia are largely unknown. The aim of this research was to explore the characteristics of older people presenting with mental health and drug and alcohol conditions.

PROCEDURES

We used a retrospective electronic medical record audit to explore all emergency department presentations by older people 65 years and over for mental health and drug and alcohol related conditions over a 12 month period. Data were described using descriptive statistics.

FINIDNGS

There were 40,093 presentations; 2% (n=900) were related to mental health or drug and alcohol related conditions. Presentations were mainly associated with primary mental or medical symptoms. The majority were female (n=471; 53%). Predominate conditions were cognitive impairment (n=234; 26%) and affective disorders (n=233; 26.0%). Sixty-three percent of patients were admitted to a hospital ward. Over the study period 106 patients (242 episodes of care) represented.

PRINCIPLE CONCLUSIONS

Given the ageing population and increasing prevalence for mental health and drug and alcohol conditions, strategies are required to better recognise these conditions to reduce the burden on the health care system and improve health for older people.

Global Health and Emergency Care: Defining Clinical Research Priorities

OBJECTIVES

Despite recent strides in the development of global emergency medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments (EDs) worldwide. Here, progress on the global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified.

METHODS

A retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined global EM research priorities utilizing consensus-based decision making.

RESULTS

Research trends in global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the ED or prehospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic noncommunicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant and refugee health.

CONCLUSIONS

Despite recent strides in global EM research and a proliferation of scholarly output in the field, further work is required to advocate for and inform research priorities in global EM. The priorities outlined in this paper aim to guide future research in the field, with the goal of advancing the development of EM worldwide.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

STUDY OBJECTIVE

To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.

METHODS

National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.

RESULTS

Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.

CONCLUSION

The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Issues related to sex differences in antipsychotic treatment

PURPOSE OF REVIEW

The effectiveness, side-effect profiles, and numerous other characteristics of antipsychotic medications have been extensively studied. However, the majority of publications do not address the many potential sex differences in efficacy and doses of medications, as well as other sex-specific considerations.

RECENT FINDINGS

Of studies that exist, some suggest that female patients respond to lower doses of antipsychotic medications than males and that side-effect profiles vary between the sexes. However, the majority of preclinical trials use only male laboratory animals, and human clinical trials consist of too few women to analyze their response as a separate group.

SUMMARY

Although changes in hormone production occurring at multiple stages throughout a women's life (such as during pregnancy, breast feeding, menopause, and postmenopausal) are presented as too complex to deal with in clinical trials, they could instead be embraced as clinical dilemmas that require additional study and consideration. We suggest that a focus should be made to reanalyze data from existing major treatment trials of antipsychotics to determine what medications specifically provide the most efficacy for female patients and at what dose range. In addition, new prospective studies are needed to specifically address appropriate adjustments in psychopharmacologic treatment for female patients during pregnancy, and when postmenopausal. More studies of the effects of antipsychotics on male and female fetuses in utero and during breast feeding are also needed to better manage women with schizophrenia and their offspring on a long-term basis in the community. There is currently too little known about sex differences in neuropharmacology. With the new USA National Institutes of Health policy to include sex in all new proposals, the time has come to close this gap in knowledge.

Gender Differences in Posttraumatic Stress Symptoms Among Participants of a Violence Intervention Program at a Pediatric Hospital: A Pilot Study

Hospital-based violence intervention programs (HVIPs) have emerged as a strategy to address posttraumatic stress (PTS) symptoms among violently injured patients and their families. HVIP research, however, has focused on males and little guidance exists about how HVIPs could be tailored to meet gender-specific needs. We analyzed pediatric HVIP data to assess gender differences in prevalence and type of PTS symptoms. Girls reported more PTS symptoms than boys (6.96 vs 5.21, P = .027), particularly hyperarousal symptoms (4.00 vs 2.82, P = .002) such as feeling upset by reminders of the event (88.9% vs 48.3%, P = .005). Gender-focused research represents a priority area for HVIPs.

The intersecting roles of violence, gender, and substance use in the emergency department: a research agenda

The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This article examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus.