Douglas A. Rund
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Schizophrenia. .and..Other.Psychoitiic. .Disorders
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Psychiatric disorders are common in the emergency department patient population. Estimates of the proportion of emergency department patients who present with a psychiatric disorder range from a few percent to more than a third. This variability is partly due to differences in patient population and utilization of alternatives for psychiatric crisis intervention. When patients are screened for mental disorders including substance abuse, many patients have unrecognized psychopathology that is relevant to their assessment and treatment in the emergency setting. Subgroups of the emergency patient population at higher risk for psychiatric disorders include those who are self-referred for nonurgent problems, patients with chest pain, and the "after midnight" group of emergency department patients, who had more psychiatric illness (56 percent) than the daytime group (20 percent). Sometimes, psychiatric disorders clearly make up the primary reason for an individual's presentation to an emergency department. In other cases, psychiatric disorders lead to injury and illness. Such conditions create the need for emergency care. As screening studies have shown, psychiatric disorders may form part of the current or past medical history of a patient, yet possess little importance for the immediate clinical condition.
In studies that report categories of psychiatric illness seen in the emergency department, the most prominent diagnoses are substance abuse, affective disorders, anxiety disorders, antisocial personality disorder, and severe cognitive impairment. Among repeat users of the emergency department, persons with schizophrenia are overrepresented.
Psychiatric disorders can cause substantial impairment in social or occupational functioning or marked distress. Patients or their families are often unwilling to seek psychiatric care because of the stigma of mental illness. Their evaluation in the emergency department is their point of entry into the health care system. Also, due to poor judgment, financial considerations, or cognitive impairment, many psychiatric patients do not regularly seek medical attention until an emergency intervenes. They then seek emergency treatment for their medical needs. The most serious manifestations of mental illness (suicide, psychosis, and violent behavior) are medical emergencies and consequently are appropriately dealt with in the emergency department. Emergency physicians require substantial knowledge and skill to be able to recognize psychiatric disorders, perform crisis intervention and stabilization, and refer the patient for psychiatric hospitalization or outpatient care as needed.
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