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Clinical and nonclinical predictors of test ordering in psychiatric emergency
Available online at www.sciencedirect.com
General Hospital Psychiatry 30 (2008) 356 – 359
Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Clinical and nonclinical predictors of test ordering in psychiatric emergency Cédric Lemogne, M.D. a,b,c,⁎, Elise Blandin, M.D. a,d , Marie-Jeanne Guedj, M.D. a b
a CPOA, Sainte-Anne Hospital, 75014 Paris, France Department of C-L Psychiatry, European Georges Pompidou Hospital, 75908 Paris Cedex 15, France c CNRS UMR 7593, IFR Neurosciences Pitié-Salpêtrière, 75013 Paris, France d INSERM U562, CEA/DSV, IFR 49, 91401 Orsay, France Received 19 January 2008; accepted 20 February 2008
Abstract Objective: This naturalistic prospective study explored the predictors of laboratory test ordering in a psychiatric emergency department. Methods: We used a standardized questionnaire to collect clinical and nonclinical features in 527 consecutive patients. Results: Test ordering was independently predicted by age, spoken language, referral by relatives, eating disorders, and somatic complaints. Having been referred by a general practitioner predicted test ordering only in the absence of a clinical report. Alcohol- and substance-related symptoms predicted test ordering only in patients older than 35 years. Age did not predict test ordering in patients consulting for anxiety or suicidal ideation. Conclusion: Clinicians should be aware of possible biases when assessing the need of laboratory tests in patients presenting with psychiatric complaints. © 2008 Elsevier Inc. All rights reserved. Keywords: Emergency; Laboratory tests; Medical Clearance; Psychiatry; Bias
1. Introduction About 15% to 90% of patients attending an emergency department with a psychiatric complaint may suffer from medical problems that have caused or contributed to their psychiatric condition [1,2]. To prevent an unsafe admission to a psychiatric department, clinicians should search for such medical problems [3]. This is critical in psychiatric emergency departments with no acute medical care facilities, in which psychiatrists frequently order laboratory tests to improve their clinical assessment. Because there is no
⁎ Corresponding author. C-L Psychiatry Department, European Georges Pompidou Hospital, 75908 Paris Cedex 15, France. Tel.: +33 1 56 09 33 71; fax: +33 1 56 09 31 46. E-mail address: [email protected] (C. Lemogne). 0163-8343/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2008.02.005
standard for ordering these tests, this decision may be biased by irrelevant features [2–4]. This prospective study aimed to explore the clinical and nonclinical predictors of test ordering in a psychiatric emergency department. More specifically, we predicted that age will moderate the weight of some clinical signs in predicting test ordering and that the absence of a clinical report will predict test ordering in patients referred by a physician. 2. Methods The study setting is a specialized psychiatric emergency department that works 24 h a day in coordination with the other emergency facilities of the area. Daytime staff encompasses at least two senior psychiatrists, two psychiatric residents, six nurses, and one head nurse. Nighttime staff
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
encompasses at least two psychiatrists (one senior and one resident) and five nurses. Tests are ordered upon the responsibility of the senior psychiatrists. We used a standardized questionnaire to collect clinical and nonclinical features for all patients who attended our psychiatric emergency department during 28 days. Patients who attended the department more than one time during these 28 consecutive days were only included once. People who were seeking an advice regarding a relative were not included. Clinical features encompassed intrinsic (i.e., clinical signs) and extrinsic (e.g., stressful life-event) consultation motives, and one or two diagnosis hypotheses according to the ICD-10 criteria. Nonclinical features encompassed demographic data (i.e., gender, age, and language), history of previous psychiatric hospitalization, and consultation context (i.e., hour, mode of referral, and previous investigations). Nature and motive of ordered test were also recorded. Every questionnaire was filled out by the consulting psychiatrist immediately after the consultation. Additionally, every questionnaire was reviewed by two psychiatrists (C.L. and E.B.) the day following the consultation to avoid missing data. In such a case, missing data were extracted from clinical records and subsequently checked together with the consulting psychiatrist. All statistical analyses were performed with the SPSS software. Regarding univariate analyses, Mann–Whitney and χ2 tests addressed the association of test ordering with age and discrete variables, respectively. We then performed two backward stepwise logistic regressions for clinical and nonclinical features, separately. We entered at the first step the variables found to predict test ordering in univariate analyses with Pb.2, as recommended by experts [5]. Age was used as a discrete variable (i.e., median age). Because the diagnosis hypotheses may have been influenced by the results of the ordered tests, they were only used in univariate analyses. Regarding clinical variables, we additionally entered the interaction between age and each intrinsic consultation motive. Regarding nonclinical variables, we additionally entered the interaction between the absence of clinical report and having been referred by a general Table 1 Nature of the ordered tests Tests performed in situ Biological tests Electrolytes Complete blood count Finger glucose test Blood alcohol level Liver function tests C-reactive protein Urine drug testing Other biological tests (lipase, TSH, urinalysis, cardiac enzymes) Electrocardiogram Brain computed tomography scan Referral to a medical emergency department for further testing
72% (n=36) 64% (n=32) 56% (n=28) 48% (n=24) 34% (n=17) 32% (n=16) 32% (n=16) 20% (n=10) 20% (n=10) 20% (n=10) 16% (n=8) 8% (n=4) 28% (n=14)
357
Table 2 Reasons of test ordering Alcohol-related problem Poor general condition Delirium Chronic medical condition (e.g., diabetes) First psychotic episode Suicide attempt by drug overdose Fever Acute neurological sign Chest pain Head injury Other reasons
30% (n=15) 20% (n=10) 18% (n=9) 14% (n=7) 14% (n=7) 6% (n=3) 4% (n=2) 4% (n=2) 2% (n=1) 2% (n=1) 12% (n=6)
practitioner, an emergency physician, or a psychiatrist, separately. We finally performed a third regression for both clinical and nonclinical variables, taking into account any predictor retained in the two first regressions.
3. Results Five hundred twenty-seven consecutive patients (297 men, 230 women, mean age: 37.3 ± 14.2 years, median age: 35 years) were included. Age was missing for one male patient. Tests were ordered for 50 patients (9.5%) (see Tables 1 and 2). Tables 3 and 4 show the results of univariate analyses. Table 5 show the results of the final regression taking into account the 537 patients. We further explored the direction of the significant interactions with post hoc χ2 tests. Having been referred by a general practitioner predicted test ordering in the absence (χ2=5.551, df=1, P=.018) but not in the presence (χ2=.533, df=1, P=.465) of a clinical report. Being older than 35 (i.e., the median age) predicted test ordering in patients presenting with a consultation motive different than anxiety (χ2 =9.374, df=1, P=.002) or suicidal ideation (χ2=11.410, df=1, P=.001). In contrast, age did not predict test ordering in patients consulting for anxiety (χ2=.362, df=1, P=.547) or suicidal ideation (χ2=.211, df=1, P=.646). Finally, alcohol-related and substance-related requests predicted test ordering in patients older than 35 (χ2=10.884, df=1, P=.001 and χ2=7.123, df=1, P=.008, respectively) but not in younger patients (χ 2 =.561, df=1, P=.454 and χ2=.001, df=1, P=.981, respectively).
4. Discussion This naturalistic prospective study explored the clinical and nonclinical predictors of test ordering among 527 consecutive patients attending a psychiatric emergency department. One should consider the present results in the context of a specialized psychiatric emergency department, with patients likely to have primary psychiatric disorders, and in the context of the French health insurance, which provides the whole population with an almost free access to
358
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
Table 3 Univariate analyses regarding clinical features
Intrinsic consultation motive Anxiety Sleep disturbance Eating disorders Somatic complaints Suicidal and self-harm behavior Depressive mood Suicidal ideation Violent behavior Psychomotor agitation Delusions and hallucinations Bizarre behavior Pathological traveling, escapade Mutism Alcohol-related request Substance-related request Extrinsic consultation motive Couple problems Family problems Job problems Accommodation problems Other nontraumatic life event Traumatic life event Treatment discontinuation Organic disease beginning or worsening Main diagnosis hypotheses (ICD-10) F00-03 dementia F04-09 other organic mental disorders F10 alcohol-related disorders F11-19 substance-related disorders F20 schizophrenia F22 persistent delusional disorders F23 acute and transient psychotic disorders F30 single manic episode F31 bipolar affective disorder F32-33 unipolar affective disorder F40-48 neurotic, stress-related and somatoform disorders F50 eating disorders F60 specific personality disorders F70-79 mental retardation F84 pervasive developmental disorders
Table 4 Univariate analyses regarding nonclinical Features
Tests ordered
No tests ordered
n=50
n=477
P
8.0% 8.0% 6.0% 8.0% 8.0% 18.0% 8.0% 8.0% 8.0% 22.0% 6.0% 6.0% 2.0% 14.0% 8.0%
23.1% 6.9% 0.8% 1.7% 9.0% 20.8% 13.6% 5.7% 5.9% 18.9% 5.5% 8.2% 0.6% 4.2% 4.4%
.014 NS .002 .004 NS NS NS NS NS NS NS NS NS .003 NS
10.0% 6.0% 4.0% 10.0% 10.0% 4.0% 16.0% 6.0%
15.5% 12.8% 9.0% 6.9% 7.8% 3.1% 18.2% 1.0%
NS .162 NS NS NS NS NS .006
10.0% 4.0%
0.6% 0.2%
b.001 .001
16.0% 14.0% 10.0% 6.0% 14.0%
6.1% 6.7% 26.4% 3.8% 6.1%
.009 .061 .011 NS .035
6.0% 2% 24% 4%
1.5% 6.5% 24.1% 9.6%
.025 NS NS .187
6.0% 14.0% 0.0% 0.0%
0.2% 26.2% 0.6% 4.4%
b.001 .058 NS .130
NS indicates not significant (P N.2).
regular medical care. Although this context may account for the rate of test ordering (9.5%), it is unlikely to have influenced more qualitative features of test ordering such as its clinical and nonclinical predictors. Among clinical predictors, we found eating disorders, somatic complaints, and the beginning or worsening of an organic disease to independently predict test ordering. Among nonclinical
Demographic data Sex ratio Age (years) French-speaking patient History of psychiatric hospitalization Emergency admittance context Night admittance (22 p.m.–6 a.m.) Referred by a general practitioner Referred by an emergency physician Referred by a psychiatrist Referred by a psychologist Referred by the police or a first-aid service Referred by relatives Self-referred Previous investigations Clinical examination considered as normal Clinical examination considered as abnormal Absence of clinical report Abnormal tests in the previous 48 h
Tests ordered
No tests ordered
P
n=50
n=477
48.0% 44.2 ± 17.0 86.0% 46.0%
57.2% 36.5 ± 13.7 93.5% 57.0%
NS .003 .051 .135
10.0% 20.0% 16.0% 8.0% 0.0% 6.0%
18.0% 9.0% 15.3% 11.3% 0.4% 8.2%
.153 .014 NS NS NS NS
24.0% 24.0%
10.9% 32.7%
.007 NS
6.0%
5.5%
NS
8.0%
6.7%
NS
86.0% 10.0%
87.8% 9.9%
NS NS
NS indicates not significant (P N.2).
predictors, age, language, and having been referred by relatives independently predicted test ordering. More precisely, test ordering was independently predicted by (1) not being a French-speaking patient, (2) having been referred by relatives, and (3) the absence of clinical report in patients referred by a general practitioner. The first finding warns clinicians against possible language-related biases while assessing the need of laboratory testing in psychiatric patients. Clinicians should consider the need of
Table 5 Clinical and nonclinical predictors of test ordering in logistic regression Predictor
P
Odds ratio
95% CI
Median age French-speaking patient Referral by relatives Referral by a GP×Absence of Clinical Report Eating disorders Somatic complaints Organic disease beginning or worsening Median age×anxiety Median age×suicidal ideation Median age×alcohol-related request Median age×substance-related request
.001 .053 .003 .016
3.397 .379 3.478 3.342
1.611–7.163 .142–1.011 1.524–7.941 1.247–8.959
.012 .006 .042
9.191 7.016 5.571
1.635–51.682 1.750–28.126 1.062–29.230
.085 .063 .001
.165 .229 6.905
.021–1.279 .048–1.081 2.225–21.429
.025
7.326
1.285–41.779
CI indicates confidence interval; GP indicates general practitioner.
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
an interpreter whenever they are not fluent in speaking the language of the patient [6]. The second finding may reflect the importance of getting a reliable medical history directly from a physician [1]. The third finding emphasizes the importance of a clinical report when referring a patient to a psychiatric facility [3,4]. Interestingly, we found that age moderated the weight of some clinical signs in predicting test ordering, even when controlling for the effect of age itself. Alcohol- and substance-related requests were associated with test ordering only in the oldest patients. This finding suggests that clinicians may have underestimated the alcohol/substancerelated medical risk among younger patients. However, age may have been associated with a longer duration of substance misuse, thus more susceptible to adverse effects. These results are also consistent with evidence, suggesting that older patients and those presenting with alcohol or substance-related disorders may benefit from a systematic medical screening [7]. Conversely, age was not associated with test ordering in patients presenting with anxiety or suicidal ideation. This finding suggests that the clinicians may have underestimated the age-related medical risk in front of typical psychiatric symptoms such as anxiety or suicidal ideation. However, anxiety may reveal an underlying medical condition and a severe medical condition, such as cancer, is a well-established risk factor of suicide among elderly patients [8]. Although these symptoms alone do not require laboratory testing, there is no compelling reason to think that they protect elderly patients from an underlying medical condition. One should have expected that agitation would have been positively associated, even slightly, with test ordering. Guidelines usually recommend a full medical assessment in the management of psychomotor agitation. However, it is usually difficult to implement laboratory tests in the context of psychomotor agitation. This difficulty may account for the lack of a significant association in the present study. Clinicians should keep in mind that agitation may cover an acute medical condition, even, if not especially, in patients
359
suffering from an actual psychiatric condition. Second, one should have expected that age would have moderated the weight of psychotic symptoms, such as delusions and hallucinations or bizarre behavior, in predicting test ordering. We found no evidence to support this prediction. Finally, although history of psychiatric hospitalization was previously found to predict a final medical diagnosis, it was not an independent predictor of test ordering in the present study [9]. In conclusion, this study suggests that clinicians should be aware of possible clinical and nonclinical biases when assessing the need of laboratory testing in patients presenting with a psychiatric complaint. References [1] Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med 2000;18:390–3. [2] Zun LS, Hernandez R, Thompson R, et al. Comparison of EPs' and psychiatrists' laboratory assessment of psychiatric patients. Am J Emerg Med 2004;22:175–80. [3] Lukens TW, Wolf SJ, Edlow JA, et al. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med 2006;47:79–99. [4] Massachusetts College of Emergency Physicians. Consensus guidelines on the medical clearance exam for the evaluation and management of the psychiatric patient in the emergency department. Available at http:// www.macep.org/practice_information/medical_clearance.htm, 1999. [5] Hosmer DW, Lemeshow S. Model-building strategies. In: Hosmer DW, Lemeshow S, editors. Applied logistic regression. New York: John Wiley & Sons; 1989. p. 82–133. [6] Zun LS, Leikin JB, Stotland NL, et al. A tool for the emergency medicine evaluation of psychiatric patients. Am J Emerg Med 1996;14: 329–33. [7] Anfinson TJ, Kathol RG. Screening laboratory evaluation in psychiatric patients: a review. Gen Hosp Psychiatry 1992;14:248–57. [8] Yousaf U, Christensen ML, Engholm G, et al. Suicides among Danish cancer patients 1971–1999. Br J Cancer 2005;92:995–1000. [9] Bazarian JJ, Stern RA, Wax P. Accuracy of ED triage of psychiatric patients. Am J Emerg Med 2004;22:249–53.
General Hospital Psychiatry 30 (2008) 356 – 359
Emergency Psychiatry in the General Hospital The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.
Clinical and nonclinical predictors of test ordering in psychiatric emergency Cédric Lemogne, M.D. a,b,c,⁎, Elise Blandin, M.D. a,d , Marie-Jeanne Guedj, M.D. a b
a CPOA, Sainte-Anne Hospital, 75014 Paris, France Department of C-L Psychiatry, European Georges Pompidou Hospital, 75908 Paris Cedex 15, France c CNRS UMR 7593, IFR Neurosciences Pitié-Salpêtrière, 75013 Paris, France d INSERM U562, CEA/DSV, IFR 49, 91401 Orsay, France Received 19 January 2008; accepted 20 February 2008
Abstract Objective: This naturalistic prospective study explored the predictors of laboratory test ordering in a psychiatric emergency department. Methods: We used a standardized questionnaire to collect clinical and nonclinical features in 527 consecutive patients. Results: Test ordering was independently predicted by age, spoken language, referral by relatives, eating disorders, and somatic complaints. Having been referred by a general practitioner predicted test ordering only in the absence of a clinical report. Alcohol- and substance-related symptoms predicted test ordering only in patients older than 35 years. Age did not predict test ordering in patients consulting for anxiety or suicidal ideation. Conclusion: Clinicians should be aware of possible biases when assessing the need of laboratory tests in patients presenting with psychiatric complaints. © 2008 Elsevier Inc. All rights reserved. Keywords: Emergency; Laboratory tests; Medical Clearance; Psychiatry; Bias
1. Introduction About 15% to 90% of patients attending an emergency department with a psychiatric complaint may suffer from medical problems that have caused or contributed to their psychiatric condition [1,2]. To prevent an unsafe admission to a psychiatric department, clinicians should search for such medical problems [3]. This is critical in psychiatric emergency departments with no acute medical care facilities, in which psychiatrists frequently order laboratory tests to improve their clinical assessment. Because there is no
⁎ Corresponding author. C-L Psychiatry Department, European Georges Pompidou Hospital, 75908 Paris Cedex 15, France. Tel.: +33 1 56 09 33 71; fax: +33 1 56 09 31 46. E-mail address: [email protected] (C. Lemogne). 0163-8343/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2008.02.005
standard for ordering these tests, this decision may be biased by irrelevant features [2–4]. This prospective study aimed to explore the clinical and nonclinical predictors of test ordering in a psychiatric emergency department. More specifically, we predicted that age will moderate the weight of some clinical signs in predicting test ordering and that the absence of a clinical report will predict test ordering in patients referred by a physician. 2. Methods The study setting is a specialized psychiatric emergency department that works 24 h a day in coordination with the other emergency facilities of the area. Daytime staff encompasses at least two senior psychiatrists, two psychiatric residents, six nurses, and one head nurse. Nighttime staff
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
encompasses at least two psychiatrists (one senior and one resident) and five nurses. Tests are ordered upon the responsibility of the senior psychiatrists. We used a standardized questionnaire to collect clinical and nonclinical features for all patients who attended our psychiatric emergency department during 28 days. Patients who attended the department more than one time during these 28 consecutive days were only included once. People who were seeking an advice regarding a relative were not included. Clinical features encompassed intrinsic (i.e., clinical signs) and extrinsic (e.g., stressful life-event) consultation motives, and one or two diagnosis hypotheses according to the ICD-10 criteria. Nonclinical features encompassed demographic data (i.e., gender, age, and language), history of previous psychiatric hospitalization, and consultation context (i.e., hour, mode of referral, and previous investigations). Nature and motive of ordered test were also recorded. Every questionnaire was filled out by the consulting psychiatrist immediately after the consultation. Additionally, every questionnaire was reviewed by two psychiatrists (C.L. and E.B.) the day following the consultation to avoid missing data. In such a case, missing data were extracted from clinical records and subsequently checked together with the consulting psychiatrist. All statistical analyses were performed with the SPSS software. Regarding univariate analyses, Mann–Whitney and χ2 tests addressed the association of test ordering with age and discrete variables, respectively. We then performed two backward stepwise logistic regressions for clinical and nonclinical features, separately. We entered at the first step the variables found to predict test ordering in univariate analyses with Pb.2, as recommended by experts [5]. Age was used as a discrete variable (i.e., median age). Because the diagnosis hypotheses may have been influenced by the results of the ordered tests, they were only used in univariate analyses. Regarding clinical variables, we additionally entered the interaction between age and each intrinsic consultation motive. Regarding nonclinical variables, we additionally entered the interaction between the absence of clinical report and having been referred by a general Table 1 Nature of the ordered tests Tests performed in situ Biological tests Electrolytes Complete blood count Finger glucose test Blood alcohol level Liver function tests C-reactive protein Urine drug testing Other biological tests (lipase, TSH, urinalysis, cardiac enzymes) Electrocardiogram Brain computed tomography scan Referral to a medical emergency department for further testing
72% (n=36) 64% (n=32) 56% (n=28) 48% (n=24) 34% (n=17) 32% (n=16) 32% (n=16) 20% (n=10) 20% (n=10) 20% (n=10) 16% (n=8) 8% (n=4) 28% (n=14)
357
Table 2 Reasons of test ordering Alcohol-related problem Poor general condition Delirium Chronic medical condition (e.g., diabetes) First psychotic episode Suicide attempt by drug overdose Fever Acute neurological sign Chest pain Head injury Other reasons
30% (n=15) 20% (n=10) 18% (n=9) 14% (n=7) 14% (n=7) 6% (n=3) 4% (n=2) 4% (n=2) 2% (n=1) 2% (n=1) 12% (n=6)
practitioner, an emergency physician, or a psychiatrist, separately. We finally performed a third regression for both clinical and nonclinical variables, taking into account any predictor retained in the two first regressions.
3. Results Five hundred twenty-seven consecutive patients (297 men, 230 women, mean age: 37.3 ± 14.2 years, median age: 35 years) were included. Age was missing for one male patient. Tests were ordered for 50 patients (9.5%) (see Tables 1 and 2). Tables 3 and 4 show the results of univariate analyses. Table 5 show the results of the final regression taking into account the 537 patients. We further explored the direction of the significant interactions with post hoc χ2 tests. Having been referred by a general practitioner predicted test ordering in the absence (χ2=5.551, df=1, P=.018) but not in the presence (χ2=.533, df=1, P=.465) of a clinical report. Being older than 35 (i.e., the median age) predicted test ordering in patients presenting with a consultation motive different than anxiety (χ2 =9.374, df=1, P=.002) or suicidal ideation (χ2=11.410, df=1, P=.001). In contrast, age did not predict test ordering in patients consulting for anxiety (χ2=.362, df=1, P=.547) or suicidal ideation (χ2=.211, df=1, P=.646). Finally, alcohol-related and substance-related requests predicted test ordering in patients older than 35 (χ2=10.884, df=1, P=.001 and χ2=7.123, df=1, P=.008, respectively) but not in younger patients (χ 2 =.561, df=1, P=.454 and χ2=.001, df=1, P=.981, respectively).
4. Discussion This naturalistic prospective study explored the clinical and nonclinical predictors of test ordering among 527 consecutive patients attending a psychiatric emergency department. One should consider the present results in the context of a specialized psychiatric emergency department, with patients likely to have primary psychiatric disorders, and in the context of the French health insurance, which provides the whole population with an almost free access to
358
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
Table 3 Univariate analyses regarding clinical features
Intrinsic consultation motive Anxiety Sleep disturbance Eating disorders Somatic complaints Suicidal and self-harm behavior Depressive mood Suicidal ideation Violent behavior Psychomotor agitation Delusions and hallucinations Bizarre behavior Pathological traveling, escapade Mutism Alcohol-related request Substance-related request Extrinsic consultation motive Couple problems Family problems Job problems Accommodation problems Other nontraumatic life event Traumatic life event Treatment discontinuation Organic disease beginning or worsening Main diagnosis hypotheses (ICD-10) F00-03 dementia F04-09 other organic mental disorders F10 alcohol-related disorders F11-19 substance-related disorders F20 schizophrenia F22 persistent delusional disorders F23 acute and transient psychotic disorders F30 single manic episode F31 bipolar affective disorder F32-33 unipolar affective disorder F40-48 neurotic, stress-related and somatoform disorders F50 eating disorders F60 specific personality disorders F70-79 mental retardation F84 pervasive developmental disorders
Table 4 Univariate analyses regarding nonclinical Features
Tests ordered
No tests ordered
n=50
n=477
P
8.0% 8.0% 6.0% 8.0% 8.0% 18.0% 8.0% 8.0% 8.0% 22.0% 6.0% 6.0% 2.0% 14.0% 8.0%
23.1% 6.9% 0.8% 1.7% 9.0% 20.8% 13.6% 5.7% 5.9% 18.9% 5.5% 8.2% 0.6% 4.2% 4.4%
.014 NS .002 .004 NS NS NS NS NS NS NS NS NS .003 NS
10.0% 6.0% 4.0% 10.0% 10.0% 4.0% 16.0% 6.0%
15.5% 12.8% 9.0% 6.9% 7.8% 3.1% 18.2% 1.0%
NS .162 NS NS NS NS NS .006
10.0% 4.0%
0.6% 0.2%
b.001 .001
16.0% 14.0% 10.0% 6.0% 14.0%
6.1% 6.7% 26.4% 3.8% 6.1%
.009 .061 .011 NS .035
6.0% 2% 24% 4%
1.5% 6.5% 24.1% 9.6%
.025 NS NS .187
6.0% 14.0% 0.0% 0.0%
0.2% 26.2% 0.6% 4.4%
b.001 .058 NS .130
NS indicates not significant (P N.2).
regular medical care. Although this context may account for the rate of test ordering (9.5%), it is unlikely to have influenced more qualitative features of test ordering such as its clinical and nonclinical predictors. Among clinical predictors, we found eating disorders, somatic complaints, and the beginning or worsening of an organic disease to independently predict test ordering. Among nonclinical
Demographic data Sex ratio Age (years) French-speaking patient History of psychiatric hospitalization Emergency admittance context Night admittance (22 p.m.–6 a.m.) Referred by a general practitioner Referred by an emergency physician Referred by a psychiatrist Referred by a psychologist Referred by the police or a first-aid service Referred by relatives Self-referred Previous investigations Clinical examination considered as normal Clinical examination considered as abnormal Absence of clinical report Abnormal tests in the previous 48 h
Tests ordered
No tests ordered
P
n=50
n=477
48.0% 44.2 ± 17.0 86.0% 46.0%
57.2% 36.5 ± 13.7 93.5% 57.0%
NS .003 .051 .135
10.0% 20.0% 16.0% 8.0% 0.0% 6.0%
18.0% 9.0% 15.3% 11.3% 0.4% 8.2%
.153 .014 NS NS NS NS
24.0% 24.0%
10.9% 32.7%
.007 NS
6.0%
5.5%
NS
8.0%
6.7%
NS
86.0% 10.0%
87.8% 9.9%
NS NS
NS indicates not significant (P N.2).
predictors, age, language, and having been referred by relatives independently predicted test ordering. More precisely, test ordering was independently predicted by (1) not being a French-speaking patient, (2) having been referred by relatives, and (3) the absence of clinical report in patients referred by a general practitioner. The first finding warns clinicians against possible language-related biases while assessing the need of laboratory testing in psychiatric patients. Clinicians should consider the need of
Table 5 Clinical and nonclinical predictors of test ordering in logistic regression Predictor
P
Odds ratio
95% CI
Median age French-speaking patient Referral by relatives Referral by a GP×Absence of Clinical Report Eating disorders Somatic complaints Organic disease beginning or worsening Median age×anxiety Median age×suicidal ideation Median age×alcohol-related request Median age×substance-related request
.001 .053 .003 .016
3.397 .379 3.478 3.342
1.611–7.163 .142–1.011 1.524–7.941 1.247–8.959
.012 .006 .042
9.191 7.016 5.571
1.635–51.682 1.750–28.126 1.062–29.230
.085 .063 .001
.165 .229 6.905
.021–1.279 .048–1.081 2.225–21.429
.025
7.326
1.285–41.779
CI indicates confidence interval; GP indicates general practitioner.
C. Lemogne et al. / General Hospital Psychiatry 30 (2008) 356–359
an interpreter whenever they are not fluent in speaking the language of the patient [6]. The second finding may reflect the importance of getting a reliable medical history directly from a physician [1]. The third finding emphasizes the importance of a clinical report when referring a patient to a psychiatric facility [3,4]. Interestingly, we found that age moderated the weight of some clinical signs in predicting test ordering, even when controlling for the effect of age itself. Alcohol- and substance-related requests were associated with test ordering only in the oldest patients. This finding suggests that clinicians may have underestimated the alcohol/substancerelated medical risk among younger patients. However, age may have been associated with a longer duration of substance misuse, thus more susceptible to adverse effects. These results are also consistent with evidence, suggesting that older patients and those presenting with alcohol or substance-related disorders may benefit from a systematic medical screening [7]. Conversely, age was not associated with test ordering in patients presenting with anxiety or suicidal ideation. This finding suggests that the clinicians may have underestimated the age-related medical risk in front of typical psychiatric symptoms such as anxiety or suicidal ideation. However, anxiety may reveal an underlying medical condition and a severe medical condition, such as cancer, is a well-established risk factor of suicide among elderly patients [8]. Although these symptoms alone do not require laboratory testing, there is no compelling reason to think that they protect elderly patients from an underlying medical condition. One should have expected that agitation would have been positively associated, even slightly, with test ordering. Guidelines usually recommend a full medical assessment in the management of psychomotor agitation. However, it is usually difficult to implement laboratory tests in the context of psychomotor agitation. This difficulty may account for the lack of a significant association in the present study. Clinicians should keep in mind that agitation may cover an acute medical condition, even, if not especially, in patients
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suffering from an actual psychiatric condition. Second, one should have expected that age would have moderated the weight of psychotic symptoms, such as delusions and hallucinations or bizarre behavior, in predicting test ordering. We found no evidence to support this prediction. Finally, although history of psychiatric hospitalization was previously found to predict a final medical diagnosis, it was not an independent predictor of test ordering in the present study [9]. In conclusion, this study suggests that clinicians should be aware of possible clinical and nonclinical biases when assessing the need of laboratory testing in patients presenting with a psychiatric complaint. References [1] Reeves RR, Pendarvis EJ, Kimble R. Unrecognized medical emergencies admitted to psychiatric units. Am J Emerg Med 2000;18:390–3. [2] Zun LS, Hernandez R, Thompson R, et al. Comparison of EPs' and psychiatrists' laboratory assessment of psychiatric patients. Am J Emerg Med 2004;22:175–80. [3] Lukens TW, Wolf SJ, Edlow JA, et al. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med 2006;47:79–99. [4] Massachusetts College of Emergency Physicians. Consensus guidelines on the medical clearance exam for the evaluation and management of the psychiatric patient in the emergency department. Available at http:// www.macep.org/practice_information/medical_clearance.htm, 1999. [5] Hosmer DW, Lemeshow S. Model-building strategies. In: Hosmer DW, Lemeshow S, editors. Applied logistic regression. New York: John Wiley & Sons; 1989. p. 82–133. [6] Zun LS, Leikin JB, Stotland NL, et al. A tool for the emergency medicine evaluation of psychiatric patients. Am J Emerg Med 1996;14: 329–33. [7] Anfinson TJ, Kathol RG. Screening laboratory evaluation in psychiatric patients: a review. Gen Hosp Psychiatry 1992;14:248–57. [8] Yousaf U, Christensen ML, Engholm G, et al. Suicides among Danish cancer patients 1971–1999. Br J Cancer 2005;92:995–1000. [9] Bazarian JJ, Stern RA, Wax P. Accuracy of ED triage of psychiatric patients. Am J Emerg Med 2004;22:249–53.