Medical Student Research Fellowship for Summer 2006
Mentor: Gregory Luke Larkin, MD, MS, MSPH, FACEP
Department: Surgery/Emergency Medicine
Room number: CS 02.102
Mail Code: 8579
Phone number: 8-2904
Project title: Feasibility of Rapid, Computerized Mental Health Assessment in Adult Ambulatory Emergency Department Patients
Human subjects IRB approved project number (where applicable): IRB #042006 063.
Project Type: Patient-based research
Brief Description of Project:
This IRB-approved project will evaluate the short term impact of acute mental health screening on processes of care and patient oriented outcomes in the Emergency Department (ED). This project extends our previous work identifying the feasibility, and acceptability of this particular psychosocial screening methodology in this diverse, multi-ethnic population, and builds upon our prior finding of occult mental illness in more than 40% of all ED visits.1-3 The current proposed iteration of this study will provide specific patient-tailored feedback to physicians based on novel computer-based decision support software, the QPD.
The Quick PsychoDiagnostics (QPD) Panel, which is widely used by the primary
care network of Kaiser Permanente Health System, 4 screens for 9 common Axis
I psychiatric disorders (major depression, dysthymic disorder, bipolar disorder,
generalized anxiety disorder, panic disorder, obsessive-compulsive disorder,
bulimia nervosa, alcohol and or substance abuse, somatization) and requires
no physician time to administer or score. QPD criterion validity has been established
relative to the Structured Clinical Interview for DSM-IV (SCID), and convergent
validity has been determined by correlating the QPD Panel scores with well-established
mental health measures. In patients with major depression, sensitivity and specificity
of the QPD were 81% and 96% respectively. 5 For other disorders, sensitivities
range from 69%-98%, and specificities range from 90-97%. For example, the QPD
depression severity score correlates highly with the Beck, 6 Hamilton, 7 Zung,
8 and CES-D depression scales, 9 and the QPD anxiety score is highly correlated
with the Spielberger State-Trait Anxiety Inventory10 and the anxiety subscale
of the Derogatis Symptom Checklist 90 (P<.001). 11
Consenting, ambulatory patients found in the general emergency department waiting areas during randomized time periods over the course of the study will be assessed using a QPD screening panel adapted for ED use. At the end of the assessment, patients will be asked a few brief questions about their attitudes and opinions toward this procedure in order to assess willingness and satisfaction with it. Research assistants and emergency physicians will also be surveyed qualitatively about the procedure's ease of use and any pitfalls or complications they encounter. Patients' medical records will be audited to determine correlations of the QPD with antecedent and concurrent psychiatric (DSM-IV/ ICD-9) diagnoses. ED record review will also help determine whether question prompts in the waiting room will lead patients to endorse similar symptoms during the ED Review of Symptoms and in conjunction with QPD lab test feedback, lead emergency department clinicians to endorse increased numbers of mental health diagnoses and referrals on the index ED visit. The random patient sampling will also enable us to cross-sectionally assess the relative disease burden of mental illness in non-psychiatric ED patients in general, and the prevalence of patients receiving referrals and treatment for major depression, in particular.
The student will be involved in all aspects of execution, data collection and analysis, and study dissemination. Each student will have a unique project focus for a particular paper on which they will be given an opportunity to first author a manuscript. Publishable units include a focus on mood disorders, specifically depression, polysubstance abuse and dependence, anxiety disorders, (specifically post traumatic stress disorder), and suicidal ideation and intent. Students also identified an opportunity to compare mental health profiles of patients who leave the ED without being seen compared to patients who stay. Students will be expected to help perform analysis on the data, produce an abstract for presentation and submit a first draft for publication no later than August 21, 2006.
BIOSTATISTICS: Simple quantity and frequency counts will be used to describe the prevalence of overall and specific mental illness, stratified by routine demographic characteristics. Proportions will be compared using Chi-square and Fishers Exact test, as appropriate. Significant correlates of mental illness as determined by the QPD will be entered into a stepwise multiple logistic regression model. Candidates will be entered at a significance of p=.015 and removed if greater than 0.5. Our proposed sample of 1200 patients will allow for stratification by gender, ethnicity, and age and will still allow us to detect a difference in prevalence of 10% or more between subgroups with a power of 90%.
Additionally, uni and multivariate logistic regression models will be constructed on the three following specific outcomes: 1. mental health diagnosis made in the ED, 2. mental health services referrals made and, 3. psychotropic, anxiolytic and/or antidepressant medication prescribed during the ED visits.
Lastly, the proportion of patients receiving mental health diagnosis, referrals, and medications, will be compared with the cohort of patients who received psycho social screening but no Emergency provider feedback, (Phase I). Differences of proportion will be analyzed using Fisher's Exact Test, Mann-Whitney U Test, or other non parametric methods as appropriate.
Heightened awareness among ED physicians will be evaluated using the combined endpoint of ED mental health review of systems, mental health exam, and psychiatric diagnosis documented on the ED chart, psychiatric referrals made, and treatment initiated.
1. Larkin GL, Claassen CA, Emond JA, Pelletier AJ, Camargo CA. Trends in U.S. emergency department visits for mental health conditions, 1992 to 2001. Psychiatr Serv. Jun 2005;56(6):671-677.
2. Claassen CA, Trivedi MH, Shimizu I, Stewart S, Larkin GL, Litovitz T. Epidemiology of nonfatal deliberate self-harm in the United States as described in three medical databases. Suicide Life Threat Behav. Apr 2006;36(2):192-212.
3. Claassen CA, Larkin GL. Occult suicidality in an emergency department population. Br J Psychiatry. Apr 2005;186:352-353.
4. Rask KJ WM PR, McNagny SE. Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital. JAMA. 1994;271:1931-1933.
5. Shedler J. The Shedler QPD Panel (Quick PsychoDiagnostics Panel): a psychiatric 'lab test' for primary care. In Maruish M, ed. Handbook of psychological assessment in primary care settings. 2000;Mahwah, NJ: Lawrence Erlbaum Associates.
6. Beck AT WC, Mendelson M, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.
7. Reynolds WM KK. Hamilton Depression Inventory:a self-report version of the Hamilton Depression Rating Scale. Odessa Fla: Psychological Assessment Resources. 1995.
8. Zung WWK. A self-rating depression scale. ARch Gen Psychiatry. 1965;12:63-70.
9. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385-401.
10. Spielberger CD GR, Lushene RE. Manual for the State-Trait Anxiety Inventory. Palo Alto, Calif. Consulting Psychologists. 1970.
11. Derogatis LR. The SCL-90-R. Baltimore, MD: Clinical Psychometric Research. 1975.
Previous Research Activities or Publications with Medical Students:
Larkin GL, Claassen CA, Hood A, Blanco G, Framan D, Moon D, Villareal L. Injury and Mental Health: Prevalence and Spectrum of Comorbid Psychopathology in a Cohort of Injured Emergency Department Patients. Acad Emerg Med 2004; 11(5): 451
Larkin GL, Claassen CA, Hood A, Blanco G, Framan D, Moon D, Villareal L. Psychiatric Comorbidity in Victims of Intimate Partner Violence in a Multiethnic Emergency Department Population. Acad Emerg Med 2004; 11(5): 486.
Gabriela Blanco Luis Villarreal
David Farman Daniel Moon
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