EDs May Miss Mental Disorders
Young people who present to the emergency department following intentional self-harm are diagnosed with a mental disorder about half the time, according to an article published in the October issue of the Archives of General Psychiatry.
“This suggests substantial under-recognition of mental illness and likely inadequate referral for follow-up mental health care,” wrote the authors, led by Mark Olfson, MD, MPH, of the New York State Psychiatric Institute/Department of Psychiatry at Columbia University College of Physicians & Surgeons.
Previous European studies have suggested that emergency departments may not uniformly provide mental health evaluations for youth who intentionally hurt themselves, but comparable information for the United States was lacking. Dr. Olfson and colleagues used information from the 1997–2002 National Hospital Ambulatory Medical Care Survey and national census data.
Among young people between ages 7 and 24, the annual rate of emergency department visits for self-harm was 225.3 per 100,000. This rate was significantly higher in those 15 to 19 and those 20 to 24, compared with those 7 to14. Self-poisoning accounted for the majority of visits (67.2%), followed by self-cutting or piercing (25.8%).
A mental disorder was diagnosed in 56 percent of these visits for self-harm, including depressive disorders (15.1%) and substance use disorders (7.3%). Psychotropic medications were provided in 12.1 percent of the patient visits, and 41.3 percent of visits involved treatment for ingestion.
About one-half of the visits (56.1%) led to hospital admission. Also, 29 percent of the visits resulted in referral for outpatient care, 5.8 percent led to referral to the emergency department for continuing care, 4.9 percent resulted in no follow-up care, and follow-up care was unspecified in 3.4 percent of the visits.
Visits resulting in admission were significantly more likely to involve a mental disorder diagnosis, medical treatment for ingestion, and psychotropic medication in the emergency department, compared with visits resulting in discharge. Conversely, wound care was slightly more common in visits that resulted in discharge rather than admission.
Women and Warfarin
Among people with atrial fibrillation who are not taking warfarin, women face a higher risk of thromboembolism than men, according to a study published in the Sept. 20 issue of Circulation. Women benefit just as much if not more from warfarin therapy.
When not taking warfarin, women had a 3.5 percent annual rate of thromboembolism, while men had a 1.8 percent annual rate, wrote the researchers, led by Margaret C. Fang, MD, of the University of California, San Francisco. Earlier studies of the relationship between sex and thromboembolism risk in patients with thromboembolism have produced conflicting results, Dr. Fang and colleagues wrote.
To study this relationship, the researchers used the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study cohort, which included 13,559 adults with diagnosed nonvalvular atrial fibrillation who received care from Kaiser Permanente of Northern California. The cohort, assembled between July 1, 1996 and Dec. 31, 1997, was followed up through Aug. 31, 1999, a median follow-up of 2.4 years.
Analyzing data from 5,795 women and 7,764 men, the researchers found 394 incidents of ischemic stroke and peripheral embolism in patients not taking warfarin. They adjusted for clinical risk factors for stroke such as age, prior stroke, diagnosed hypertension, congestive heart failure, coronary artery disease, diabetes mellitus, and estrogen replacement therapy.
Men and women had approximately the same 30-day mortality after thromboembolism, 23 percent, and warfarin use was associated with significantly lower adjusted thromboembolism rates for men and women and similar annual rates of major hemorrhage. Women, though, were less likely than men to have intracranial hemorrhage while on warfarin (0.36% vs. 0.55%).
In multivariable models that included patients taking and not taking warfarin, women taking warfarin had a larger reduction in thromboembolism rates, compared with men taking the anticoagulant. Exposure to oral estrogen replacement therapy was not associated in multivariable analyses with a significantly increased risk of thromboembolism in women.