An estimated 20%–30% of emergency department patients may be experiencing depression. Given its known morbidity and mortality, one emergency physician advocates screening for depression in the ED, and, in some cases, jumpstarting antidepressant treatment.

David Hoyer, MD, FAAEM
Clinical Assistant Professor of Emergency Medicine, The University of Texas Health Science Center, Houston, TX


The emergency department (ED) is not an ideal place for patients with depression to seek help. Waiting times, busy staff, and a greater likelihood of a fleeting interaction with a physician coincide with the reality that many emergency physicians do not receive training for depression screening.

“By and large, patients don’t typically come into the ED saying ‘I’m depressed and I need help.’ Instead, many patients complain of depression’s symptoms, like trouble sleeping” says Dr. David Hoyer. “If the emergency physician is not familiar with screening for depression, the patient may get an incomplete evaluation and then be discharged from the ED with a diagnosis that does not fully represent the problems that the patient is having.”

Several studies, including one of Dr. Hoyer’s, show that prevalence rates of depression in ED patients may range from 20%–30%. Dr. Hoyer therefore advocates quick, simple depression screening in the ED (a longstanding practice of his own) when adult patients present with depressed affect, vague complaints, and/or there is a uniformly positive review of systems.

DEPRESSION SCREENING IN THE ED

Most screens for depression were developed by psychiatrists or researchers and are impractical for the bedside use of emergency physicians. When seeing patients he suspects may be depressed, Dr. Hoyer prefers to evaluate them with a straightforward up-or-down checklist of the 9 DSM-IV criteria for depression using the mnemonic “In SAD CAGES.” Douglas A. Rund, an emergency physician, developed this mnemonic for bedside depression screening. (Table) To screen positive for depression, the patient must have at least 5 of the 9 criteria on a daily basis for at least 2 weeks, including either loss of interest in activities or depressed mood.

In SAD CAGES

“If you’re a busy emergency physician, screening with ‘In SAD CAGES,’ which takes 30 seconds to 2 minutes, may be all the time you can allot to the consideration of depression in a patient,” says Dr. Hoyer.

That emergency physicians have precious little time to devote to patients is not disputed. The debate revolves around not only whether emergency physicians ought to screen their patients for depression in the first place, but also around what exactly they should do with patients who screen positive for depression. Dr. Hoyer believes firmly that emergency physicians should consider initiating antidepressant treatment (such as fluoxetine) for ED patients, a practice he has followed for the past 20 years.

“After I screen someone and rule out other potential causes of the patient’s symptoms, thereby arriving at a tentative diagnosis of depression, I think it is in the patient’s best interest to consider initiating an antidepressant (unless they are suicidal, psychotic, or manic, which would necessitate a psychiatric consultation),” says Dr. Hoyer. “People with depression may have diminished motivation to seek help, but if you make a tentative diagnosis in the ED and give them a prescription, there is a greater likelihood that the patient will follow up on a referral for further care. Many people receive early benefits from antidepressants, and by the time they go for follow-up in 7–10 days they may already be improving.

“Of course, I am an exception to the status quo,” continues Dr. Hoyer, “and this issue goes back to training and experience—if you haven’t been trained to evaluate for psychiatric problems then you certainly won’t prescribe a medication for those problems. Emergency medicine is still a new specialty, however, so there are emergency physicians who were trained in different specialties, especially family medicine. (Of course, family doctors prescribe the majority of antidepressants in the US today.) Still other emergency physicians might feel comfortable restarting antidepressants for patients with past depressive episodes treated with an antidepressant.”

Dr. Hoyer encourages emergency physicians who are not comfortable initiating medication to at least become familiar with screening for depression using “In SAD CAGES.” Many patients suspect that they are depressed and are grateful to know they can seek help when an emergency physician informs them that they meet the criteria for depression. Patients who screen positive could be discharged from the ED with a diagnosis of depression as long as they are not suicidal and have a reasonable follow-up plan.

CONCLUSION

“In terms of the evidence base, this subject is still greatly under-discussed and under-researched,” concludes Dr. Hoyer. “There is a great need for research on the best way to deal with depression in the ED. Meanwhile, depression has a known morbidity and mortality, and we owe it to our patients to at least screen those at risk for this disease.”

Published in Psychiatry Weekly, November 21, 2011

References:

1. Hoyer D, David E. Screening for depression in emergency department patients. J Emerg Med. 2008 Nov 18. [Epub ahead of print]

2. Kumar A, Clark S, Boudreaux ED, Camargo CA. A multicenter study of depression among emergency department patients. Acad Emerg Med. 2004;11:1284-1289.

Disclosure: Dr. Hoyer reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.