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Emergency departments may often under-diagnose mental disorders in youth

October 04, 2005

CHICAGO - Young people visiting an emergency department following an episode of deliberate self-harm are diagnosed with a mental disorder about half the time, according to a study in the October issue of the Archives of General Psychiatry, one of the JAMA/Archives journals.

Deliberate self harm, such as self-poisoning and self-cutting or piercing, is an important risk factor for subsequent suicide, according to background information in the article. Although previous studies indicate that following self-poisoning young people are at extremely high risk of suicide, little is known about emergency department assessment, treatment and discharge following an act of deliberate self harm. Previous studies in Europe suggest that mental health evaluations may not be uniformly provided in emergency care of youth who deliberately harm themselves, but no information from the U.S. has been available.

Mark Olfson, M.D., M.P.H., of the Columbia University Medical Center, New York, and colleagues analyzed data from a nationally representative sample of emergency department visits from 1997 to 2002 by young people, aged seven to 24 years, after deliberate self-harm. The researchers assessed the data to determine the frequency with which young people making such emergency visits are diagnosed with mental disorders, are provided various medical and psychiatric treatments and are referred for inpatient and outpatient care.

The researchers found that between 1997 and 2002, the annual overall rate of emergency visits by persons seven to 24 years old for deliberate self-harm was 225.3 per 100,000 population. The rate was significantly higher for persons 15 to 19 and 20 to 24 years of age than for persons seven to 14. "Self-poisoning (67.2 percent) accounted for a majority of the deliberate self-harm visits followed by self-cutting/piercing (25.8 percent)," the researchers report. "Overall, roughly one-half (56.1 percent) of the patient visits resulted in a mental disorder diagnosis including 15.1 percent resulting in a depressive disorder diagnosis and 7.3 percent resulting in a substance use disorder diagnosis. Psychotropic medications [medications with psychological effects] were provided in 12.1 percent of the patient visits, most commonly anxiolytics [anti-anxiety drugs] (6.2 percent)."

"Slightly more than one-half of the patient visits (56.1 percent) resulted in inpatient admission," the authors write. "In addition, 29.0 percent of the visits resulted in outpatient care referral; 5.8 percent resulted in referral to the emergency department for continuing care, 4.9 percent resulted in no follow-up care, and follow-up care was unspecified in 3.4 percent of the visits." A diagnosis of depressive disorder, a well-known and powerful risk factor for youth suicide, was strongly associated with inpatient admission.

"Mental disorders were diagnosed in roughly one-half of emergency visits by young people treated for episodes of deliberate self-harm," the authors conclude. "This suggests substantial underrecognition of mental illness and likely inadequate referral for follow-up mental health care. Further research is clearly needed to better understand the extent and reasons for problems with the detection of mental disorders during emergency department evaluations of young people following self-harm. In the meantime, efforts should be made to fortify mental health assessments. One promising strategy involves routine administration of rapid and efficient diagnostic instruments to all young people following deliberate self-inflicted harm. Improving mental health assessment of these young people provides an important opportunity for secondary prevention."

JAMA and Archives Journals