Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system

Abstract

Study objective: Undiagnosed mental illness is highly prevalent and produces needless morbidity. Emergency department patients with vague or longstanding complaints are at risk for occult mental illness, but are seldom diagnosed. We conducted this study to determine whether a previously validated, self-administered, computerized psychiatric interview (Primary Care Evaluation of Mental Disorders [PRIME-MD]) could increase the detection of occult psychiatric illness in the ED.

Methods: This was a randomized, controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000. ED house staff and attending physicians participated. Patients were those with nonspecific complaints potentially associated with occult psychiatric illness (eg, long-standing headache, abdominal or back pain). Exclusion criteria were known psychiatric illness, complaint, or medication; and straightforward reason for the ED visit. Consenting subjects completed the PRIME-MD questionnaire in the waiting room, and were randomly assigned to either the "report" (report results given to physician) or "no-report" groups. PRIME-MD results were clipped to the front of the chart of report group patients. There was no other intervention. The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis, consultation, or referral from the emergency physician.

Results: A total of 339 (5.1%) of all patients were approached; 230 consented to participate in the study, and 218 completed the PRIME-MD session and were randomly assigned to study groups. Ninety-two patients in the report group and 98 cases in the no-report group were analyzed. Patients were omitted for the following reasons: left without being seen (8), mistakenly enrolled (10), or unretrievable medical records (10). Seventy-nine (42%) patients received a psychiatric diagnosis from PRIME-MD and 9 (5%) from the physician. The frequencies of physician psychiatric diagnosis and referral did not differ between groups (diagnosis: report 9%, no report 9%, Delta 0%, 95% confidence interval [CI] -13, 14; referral: report 9%, no report 7%, Delta 2%, 95% CI -11, 16).

Conclusion: ED patients willingly completed the PRIME-MD questionnaire (in a median time of 7 minutes), which frequently diagnosed psychiatric conditions. Despite this, physicians rarely diagnosed or treated these conditions regardless of whether they were provided with the PRIME-MD diagnoses.