Psychological distress in medical patients 30 days following an emergency department admission: results from a prospective, observational study

Most patients presenting to an emergency department (ED) with acute somatic conditions are likely to experience this situation as stressful and associated with considerable psychological distress. Although there is no well accepted definition for psychological distress, it generally involves a diversity of affective responses such as fear, hopelessness, sadness, anxiety and frustration [1]. Prior studies have associated psychological distress mainly with the presence of depressive and anxiety symptoms. Therefore, it can be defined as a psychological state or a clinical syndrome. There is an ongoing debate in the literature in terms of the conceptualization of psychological distress [2, 3]. The prevalence rates of severe psychological distress (high or very high distress) in patients admitted to the ED are reported between 34 and 47 % [4, 5]. While most patients may cope well with the challenge of an acute physical illness [6], some may still suffer from persisting psychological distress after ED and hospital discharge. To our knowledge, only one study investigated psychological distress post admission to the ED. Shah and colleagues [7] evaluated patients in the ED and 14 days thereafter for depression and cognitive impairment. Two-weeks following ED admission, they found 6 % of older medical patients to have depression. Another study reported 12 % of patients had anxiety and 22 % had depressive symptoms one year after hospital admission [8]. Also, studies found a high percentage of patients to have psychiatric symptoms after hospital discharge [9‐12].

Several factors may play a role in patients’ psychological adaptation to an ED admission such as demographic characteristics (e.g. age, gender), clinical presentation at ED (e.g. diagnosis, severity of disease) and the illness trajectory (e.g. rehospitalisation, length of hospital stay). These possible risk factors for an adverse psychological outcome following ED admission are still not well understood. Using the Global Assessment of Functioning (GAF) and the Karnofsky Performance Status Scale (KPS), McKenzie and colleagues [12] found lower initial psychological and physical functioning in hospitalized medical patients with persistence of depressive and anxiety disorders 3 months following discharge. Other studies found that physically ill patients with a positive screening for a depressive disorder or a major depression as assessed by the DSM-IV showed a longer hospital stay [13, 14]. However, most of these studies did not control for confounding variables such as main diagnosis and comorbidity. Furthermore, the severity of a medical disease or having a diagnosis of a chronic illness were related with psychological distress [15]. Additionally, evidence suggests that prevalence rates of depressive symptoms varies among different medical diagnoses and the specialties concerned with treating them with highest rates in inpatients from the neurology department (32.1 %) followed by gastroenterology (25.5 %), cardiology (22.9 %), nephrology (20 %) and respiratory department (7.1 %) [16]. Also, female patients showed more psychological symptoms after hospital discharge compared to males [9]. Depressive symptoms were higher in patients with a lower family income or with a marital status such as divorced, widowed or separated [15, 16]. Most of these studies were limited to small sample sizes and a narrow focus on specific patient populations rather than broader patient populations. Beyond psychological consequences, a patient’s own self-rated health assessment may be adversely affected by an acute somatic condition leading up to an ED admission. Studies have shown that patients presenting to the ED report poor health quality [17, 18]. Chin and colleagues found worsening assessments of self-rated health during acute illness compared to baseline levels prior to ED admission [17].

Little is known about prospective studies assessing the extent of psychological distress present in patients following ED admission. Furthermore, there is a lack of prospective studies assessing the predictors of psychological distress and self-rated health in patients following ED admission. Our aim was to determine the proportion of medical patients identified as psychologically distressed defined by the 4-item Patient Health Questionnaire (PHQ–4) and to assess their self-reported state of health 30 days following ED discharge. We also assessed the relationship between demographic and medical variables (clinical presentation and course of illness) with psychological distress and self-reported health.

Within this large cohort of medical ED patients, at least some form of psychological distress (measured as a PHQ-4 score above 0) was found in approximately 38 % of patients 30 days after discharge from the medical ED. Similar findings have been reported by Shah and colleagues [7] as well as other researchers [8, 9]. This study was primarily focused on those demographic and clinical variables potentially associated with post hospital distress and as such we did not investigate changes in or the time course of this distress. We identified several possible risk factors for psychological distress and poor self-rated health particularly factors associated with a worsening of a medical condition after discharge. Knowledge of these variables may help to identify patients at risk in whom protective strategies may help to prevent psychological distress and deteriorated health quality. However, whether such a strategy results in improved long-term patient outcomes must be investigated by an interventional study where patients are randomized to either a control group or an intervention group where psychological distress is specifically addressed.

There is no strong agreement on how to measure and define psychological distress and which adequate screening tools can be used. We have also reviewed previous studies that used validated instruments to measure distress in ED patients in a systematic research [25]. We found that most instruments used have been focused on depressive symptoms neglecting all other affective dimensions of psychological distress. We decided to use the PHQ–4 because it assesses both depression and anxiety symptoms and the fact that it is brief makes it easy to administer within the context of a telephone interview. However, future studies should address the question which of these instruments is best able to identify patients at risk for which preventive strategies may show beneficial effects.

In regard to demographic characteristics, we found female gender to be associated with adverse psychological outcome 30 days following ED admission. This effect remained robust after controlling for several other risk factors such as initial clinical conditions and course of illness. There is empirical evidence suggesting that females report higher levels of anxiety and depression [26]. Similarly, the gender differences found in our study may be explained by the fact that female patients have more emotional difficulties to overcome the stressful event caused by ED admission.

For both outcome variables, course of illness was the strongest variable related with patients’ distress 30 days after ED admission compared to demographic characteristics and initial clinical presentation. Particularly, an unplanned GP visit was strongly associated with psychological distress and self-rated health as was unplanned rehospitalisation. For the outcome variables causality remains unclear, i.e., whether distress lead to an adverse course of illness or whether an adverse trajectory increased distress (or both). There also could be other confounders that were not included in the study. Again, only interventional research will help to answer this question. Our study has limitations. First, we did not measure baseline distress at ED admission, though 2.4 % were admitted with mainly psychiatric symptoms and 8.9 % had a psychiatric comorbidity. Thus, we do not know how many of the patients who were detected as psychologically distressed 30 days after admission were already distressed at the time of ED admission. However, patients with a comorbid psychiatric disorder were independently related with the 30 day distress controlling for several other risk factors such as initial clinical conditions and course of illness. Thus, medical patients coming to the ED with comorbid psychiatric symptoms are at high risk being distressed 30 days later. Second, the potential clinical relevance of the significant effects should be interpreted with caution. The explained variances of the multiple regression analyses were only between 5 and 14 % indicating that other factors besides course of illness, clinical presentation and demographic characteristics are likely to be important for psychological distress and health quality 30 days after ED presentation, e.g. other clinical variables or psychosocial factors. Third, there may be other confounders that were not measured in the study and thus causality cannot be proven. Finally, the study sample is based on one single institution and needs external validation.

We found a moderate amount of psychological distress as well as low self-rated health in a significant number of patients 30 days after an ED visit. Several related factors, particularly variables in terms of a deteriorated course of illness, were found to be potentially helpful identifying patients at risk early. Future studies should investigate whether these conditions have a negative influence on patient outcomes and can be prevented.