*Department of Emergency Medicine and â Department of Psychiatry, The University of Texas Health Science Center at Houston, ... The Journal of Emergency Medicine, Vol. .... primary care providers before suicide: a review of the evidence.
The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 786 –789, 2012 Copyright © 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
http://dx.doi.org/10.1016/j.jemermed.2008.05.004
Original Contributions
SCREENING FOR DEPRESSION IN EMERGENCY DEPARTMENT PATIENTS David Hoyer,
MD*
and Elizabeth David,
MD†
*Department of Emergency Medicine and †Department of Psychiatry, The University of Texas Health Science Center at Houston, Houston, Texas Reprint Address: David Hoyer, MD, 2026 McDuffie Street, Houston, TX 77019
e Abstract—Background: Depression is a common disease, yet it is not commonly studied in the Emergency Medicine literature. Study Objectives: To evaluate the prevalence of emergency department (ED) patients who have the symptoms of depression. Design: This was a prospective observational study performed at two EDs over a 9-month period. Adult patients were screened for depression symptoms by Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria. Results: There were 505 patients screened from April through December, 2004. Of the 505 patients, 109 (21.6%) screened positive for the symptoms of depression. The prevalence of positive screens was similar at each ED. Conclusion: About 1 in 5 ED patients may be suffering with depression. © 2012 Elsevier Inc.
sionals in the weeks before death, often with complaints not related to their intentions (4). The health professionals who see them are often in emergency departments (EDs) (5). Studies suggest that the ED is an important location for identification of mental illness and referral for treatment, but that more work is needed to evaluate screening for depression in the ED (6). The purpose of this study was to evaluate the prevalence of patients with the symptoms of depression found in large, metropolitan EDs by screening using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-4) criteria (7).
e Keywords—depression; Emergency Department; screening; DSM-4; In SAD CAGES
Study Design, Setting, and Population
METHODS
The study was a two-stratum survey with non-random sampling. The strata were two hospitals: an urban, 723bed, private non-profit level I trauma center and a suburban county, 332-bed, public hospital affiliated with The University of Texas Health Science Center at Houston, that together see approximately 100,000 adult ED patients per year. The institutional review boards of The University of Texas Health Center at Houston and the two hospitals involved approved this study.
INTRODUCTION Depression is a common disease. More than 14 million adults in the United States suffered with depression in 2003, and 35 million have suffered at some point in their lives (1). The economic costs from depression have been estimated to be $53 billion each year in the United States (2). Prevalence rates (1 year) of depression in epidemiological surveys in the United States have been 2.7–11.6% (3). Significant numbers of successful suicides have visited health profes-
Study Protocol The sampling protocol comprised a convenience sampling of adult (aged 18 years and above) patients in the
This work was presented at the Third Mediterranean Emergency Medicine Congress, Nice, France, September 2005.
RECEIVED: 10 September 2007; FINAL ACCEPTED: 5 May 2008
SUBMISSION RECEIVED:
29 April 2008;
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Table 1. Number of Positive Depression Screens/Number of Patients Screened (% & SE) Gender Hospital
Male
Female
Total
Urban Suburban Total
20/128 (15.6% ⫾ 3.2) 29/122 (23.8% ⫾ 3.9) 49/250 (19.6% ⫾ 2.5)
36/142 (25.4 ⫾ 3.7) 24/113 (21.2 ⫾ 3.8) 60/255 (23.5 ⫾ 2.7)
56/270 (20.7 ⫾ 2.5) 53/235 (22.6 ⫾ 2.7) 109/505 (21.6 ⫾ 1.8)
EDs of each hospital from April 16 to December 17, 2004. Each investigator was assigned to one ED. The sampling times were likewise convenient but included both a.m. and p.m. (9 a.m. to 4 p.m.) and varying days of the week. On days selected for screening, each investigator would spend 2– 4 h approaching all patients present in the ED at that time. Informed consent was obtained from all study participants by the investigators who administered the screening questions. Patients were excluded if they refused consent, could not communicate for the screening, or had previously been screened. Participating patients were screened for the nine DSM-4 symptoms of depression: 1) loss of interest in activities, 2) sleep disturbance, 3) appetite change, 4) depressed mood, 5) difficulty concentrating, 6) activity level change, 7) excessive guilt, 8) loss of energy, and 9) suicidal thoughts, plan or attempt (7). A positive screen for the symptoms of depression met the DSM-4 criteria, which are an affirmative response to five or more of the nine symptoms having been present on a daily basis over at least 2 weeks, including either depressed mood or loss of interest in activities. The screen took between 30 s and 2 min to administer. Patients were also asked the chief complaint that prompted their ED visit. If the patient was suicidal, the ED attending on duty was informed. Non-suicidal patients with a positive depression screen were given a list of telephone numbers for follow-up with mental health resources.
Table 2 lists the chief complaints of patients who screened positive for the symptoms of depression.
DISCUSSION The prevalence of patients in our EDs with the symptoms of depression was 22% (95% confidence interval 18 – 25%). That compares with a population depression prevalence of 2.7–11.6% (3). The high prevalence of the symptoms of depression in our ED patients correlates to the few other similar studies that have been done. A recently published study of inner-city ED diabetics found 60% of patients with some depressive symptoms and 20% screening positive for the symptoms of depression (8). Kumar et al. found a 30% 12-month prevalence of depression among ED patients (9). They concluded that “awareness of risk factors for depression in the ED setting and use of simple screening instruments could aid in the recognition of depression, with subsequent referral to mental health services.” If the 20 –30% prevalence of the symptoms of depression holds true for EDs nationwide (110 million patients visited EDs in the United States in 2002), there is potentially a lot of undiagnosed and untreated or under-treated disease in our patients (10).
Table 2. Chief Complaints of Patients Who Screened Positive for the Symptoms of Depression
RESULTS The number of patients approached was 301 at the urban hospital and 252 at the suburban hospital. Twenty patients at the urban hospital and 10 at the suburban hospital refused consent. Ten patients at the urban hospital and 7 at the suburban hospital could not communicate for the screening. One patient at the urban hospital had previously been screened. As a result, the sample comprised 505 patients, 270 at the urban hospital and 235 at the suburban hospital. Table 1 presents counts and percentages of positive screens. The standard error is approximately 4%. Of the 505 patients screened, 109 (21.6%; SE 1.8%) screened positive for the symptoms of depression. As Table 1 shows, the results were similar at each ED.
Chest pain (20 patients) Abdominal pain (11) Back pain (7) Seizure (6) Dyspnea (5) Vomiting and diarrhea (4) Skin rash (4) HIV related (4) Diabetes (4) Headache (4) Kidney disease (3) Extremity problem, no trauma (3) Psych (depression) (3) MVA (3)
Syncope (2)
Dysuria
Sexual assault (2) Liver disease (2) Sickle cell crisis (2) Altered mental status (2) High blood pressure (2)
Fever Neck pain Paresthesia Head injury CVA
Overdose Dizzy Weight loss Pneumonia Upper extremity injury Lower extremity injury
Sore throat Ill
Anorexia Non-specific pain
CVA ⫽ cerebrovascular accident; HIV ⫽ human immunodeficiency virus; MVA ⫽ motor vehicle accident.
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Given the apparent high prevalence of the symptoms of depression in ED patients, emergency physicians should have a working knowledge of the DSM-4 criteria. If an emergency physician is seeing a patient who might be depressed based on symptoms or affect, the patient should be screened. If the patient has not had depressed mood or loss of interest in activities on a daily basis for at least 2 weeks, the emergency physician can remove depression from the patient’s differential diagnosis. However, if the patient answers affirmatively to depressed mood or loss of interest in activities, the emergency physician should screen for the remaining seven DSM-4 symptoms. It can be problematic to remember all nine symptoms of depression at the patient’s bedside. Fortunately, emergency physicians already have useful memory devices such as the mnemonic “In SAD CAGES” (loss of Interest in activities/Sleep disturbance/ Appetite change/Depressed mood/difficulty Concentrating/Activity level change/excessive Guilt/loss of Energy/ Suicidal thoughts, plan, or attempt) in our literature (11). If the patient answers affirmatively to five or more of the nine symptoms having been present on a daily basis for 2 weeks, depression should remain in the patient’s differential diagnosis. The possibility of depression should be discussed with the patient and an appropriate referral made. Of course, if a patient might be suicidal, emergent psychiatric consultation is indicated.
LIMITATIONS AND FUTURE QUESTIONS A positive depression screen by itself does not make the diagnosis of depression. The positive depression screen, of course, must be part of a history, physical examination, and pertinent laboratory tests to rule out other causes of the patient’s symptoms before making the diagnosis of depression. This study was a convenience sampling and therefore was done during daytime hours. Further studies should be done with truly random sampling to determine whether the prevalence of the symptoms of depression in ED patients varies with the time of day and to validate the results of this study. Good studies need to be done to validate the optimal way to manage depression in our patients in the ED. Specifically, two major questions need to be answered. One, does screening for depression in the ED improve outcomes for our patients? The study of inner city ED diabetics concluded that screening for depression “may reduce the burden of this undiagnosed and untreated mood disorder.” The “National Study of Emergency Department Visits for Attempted Suicide and SelfInflicted Injury, 1997–2001” concluded that the high prevalence of psychiatric . . . disorders . . . suggests these
D. Hoyer and E. David
issues should be considered during management and disposition (12). Until proven otherwise, we should assume that screening for depression would help some of our patients. After all, providing information and direction about disease to patients is what physicians are supposed to do. The second major question needing study is whether initiating treatment of depression in the ED improves outcomes for our patients. It is possible that in certain patients, earlier treatment might be better than later or no treatment. However, the studies are not currently to be found in the Emergency Medicine literature.
CONCLUSIONS In conclusion, the symptoms of depression are common in ED patients. About one in five ED patients may be suffering with the disease. Screening for depression and referral could help some of these patients. Acknowledgment—The authors wish to acknowledge Brent King, MD, Kimberly Chambers, MD, and Joseph Lucke, PhD for their support and assistance with this research project.
REFERENCES 1. Kluger J. Real men get the blues. Time. September 22, 2003:48 –9. 2. Wang PS, Kessler RC. Global burden of mood disorders. In: Stein DJ, Kupfer DJ, Schatzberg AF, eds. Textbook of mood disorders. Washington, DC: American Psychiatric Publishing, Inc.; 2006:56. 3. Goodwin RD, Jacobi F, Bittner A, Wittchen H. Epidemiology of mood disorders. In: Stein DJ, Kupfer DJ, Schatzberg AF, eds. Textbook of mood disorders. Washington, DC: American Psychiatric Publishing, Inc.; 2006:43– 4. 4. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002;159:909 –16. 5. Grafstein E, Stenstrom R, Hunte G, Harris D, Innes G. The epidemiology of suicide post emergency department visit. Acad Emerg Med 2007;14:S137. 6. Kowalenko T, Khare RK. Should we screen for depression in the emergency department? Acad Emerg Med 2004;11:177– 8. 7. Criteria for major depressive episode. In: Diagnostic and statistical manual of mental disorders, 4th edn. Washington, DC: American Psychiatric Association; 1994:327. 8. Hailpern S, Calderon Y, Ghosh R, Haughey M. The association between hemoglobin A1c and depression in an inner city diabetic population. Acad Emerg Med 2007;14:S134. 9. Kumar A, Clark S, Boudreaux ED, Camargo CA. A multicenter study of depression among emergency department patients. Acad Emerg Med 2004;11:1284 –9. 10. Ream K. CDC releases latest data on ED visits. Common Sense 2004;2:15. 11. Rund DA. Behavioral disorders: clinical features. In: Tintinalli JE, Kelen GD, Stapczynski JS, ed. Emergency medicine: a comprehensive study guide, 6th edn. Irving, TX: American College of Emergency Physicians; 2004:1810. 12. Doshi A, Boudreaux ED, Wang N, Pelletier AJ Camargo CA. National Study of US Emergency Department Visits for Attempted Suicide and Self-Inflicted Injury, 1997–2001. Ann Emerg Med 2005;46:369 –75.
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ARTICLE SUMMARY 1. Why is this topic important? Few studies have assessed the epidemiology, diagnosis, and management of depression in Emergency Department (ED) patients despite studies such as this one that indicate that it is a common disease in our patients. 2. What does this study attempt to show? This study shows that screening for depression can be quickly and easily done in ED patients. 3. What are the key findings? That 22% of patients in this study screened positive for enough depression symptoms to be diagnosed with the disease. Also, that patients’ chief complaints may not indicate that they currently have the symptoms of depression. 4. How is patient care impacted? This study shows that depression is apparently quite common in our patients and therefore, emergency physicians should be comfortable screening for the symptoms. Studies need to be done to determine how best to care for patients that may be depressed in the ED.
