Depression in Emergency Department Patients and Association With Health Care Utilization

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.From the

Analysis of Emergency Department Visits for All Reasons by Adults with Depression in the United States

“…Basic characteristics are described in Table 1. [11,12]. However, we must point out methodologic differences between their studies [11,12] and ours.…”

“…[11,12]. However, we must point out methodologic differences between their studies [11,12] and ours. Whereas we used NHAMCS data on ED patients' depression status, these studies [11,12] relied on self-reported depression questionnaires administered to patients in their ED.…”

“…However, we must point out methodologic differences between their studies [11,12] and ours. Whereas we used NHAMCS data on ED patients' depression status, these studies [11,12] relied on self-reported depression questionnaires administered to patients in their ED. Further, our study characterizes ED patients with depression with greater power by using three years of data from a larger, more representative sample.…”

Association of depression symptom severity with short-term risk of an initial hospital encounter in adults with major depressive disorder

“…The self-administered 9-item Patient Health Questionnaire (PHQ-9) is such an instrument; it is aligned with the DSM-5 symptom criteria for MDD and has been validated as a useful tool for the diagnosis of MDD and as a reliable and valid measure of depression symptom severity by a multitude of studies [11][12][13]. The PHQ-9 total score ranges from 0 to 27 and levels of depression symptom severity are typically categorized as the following: none/minimal (0-4), mild (5)(6)(7)(8)(9), moderate (10)(11)(12)(13)(14), moderately severe (15)(16)(17)(18)(19) and severe (20)(21)(22)(23)(24)(25)(26)(27) [11]. In 2016, the US Preventive Services Task Force (USPSTF) recommended routine screening for depression among adults in the US and the PHQ-9 as a suggested instrument [14].…”

“…A better understanding of the impact of depression symptom severity on future use of healthcare resources, speci cally that provided by hospitals, may be helpful to better determine the most appropriate targeted interventions that can be implemented earlier in the course of onset of worsening depression symptoms. A few small-scale studies conducted in the US have found depression severity to impact use of healthcare resources, including hospital encounters and mental health services [19,20]. Adekkanattu et al recently developed a natural language processing (NLP) method to extract PHQ-9 scores from unstructured data in electronic health records (EHRs) that exhibited high accuracy (97%) and sensitivity (98%) compared to a reference standard to identify patients with MDD and had utility for stratifying patients by depression severity [21].…”