Emergency Psychiatry in the General Hospital1Influence of psychiatric comorbidities in migraineurs in the emergency department☆,
Introduction
Migraine, an episodic headache disorder with intensely disabling attacks, affects 18% of American women and 6% of American men [1], [2]. Migraine ranks eighth among the top 10 most disabling medical conditions and is a significant public health problem with substantial medical and economic consequences [3]. Migraine accounts for the majority of the five million headache visits to US emergency departments (EDs) annually [4]. The mean cost for a migraine-related ED visit in the US is US$775. This amounts to a total national annual cost of US$700 million [5].
Migraine is strongly associated with many psychiatric comorbidities [6], [7], [8], [9], [10], [11], [12], [13], [14]. The majority (51–58%) of migraineurs will meet criteria for at least one anxiety disorder in their lifetime, [6] and over 40% have depression [8], [11]. Psychiatric comorbidities are associated with a 1.55 times increase in total migraine costs in the USA [15]. Physicians should have awareness of the psychiatric comorbidities of migraine because the psychiatric comorbidities may complicate the diagnosis, affect quality of life, affect compliance with treatment and change the course of migraine [6], [16], [17], [18], [19], [20]. Psychiatric diagnosis is associated with conversion of episodic migraine to chronic migraine, [21] which in turn is associated with almost three times higher healthcare expenditures compared to total mean episodic migraine costs [15]. Because of the high prevalence of migraine and the substantial proportion of migraine sufferers who have psychiatric comorbidity, psychiatrists, ED physicians and other healthcare providers are very likely to encounter patients with migraine and psychiatric comorbidity. There is likely a shared underlying biology, as serotonergic mechanisms seem to be implicated in both conditions [6]. Thus, the study of migraine is very relevant for the field of psychiatry.
There are few large, high-quality studies that specifically examine migraineurs who present to the ED. The American Migraine Prevalence and Prevention (AMPP) study, a population-based study, showed that a small proportion of the migraine patient population accounts for almost half of all ED visits for migraine. The AMPP researchers also found that patients who visited the ED were more likely to have depression and to be of lower socioeconomic status [22]. Few studies examine the psychiatric comorbidity of migraine patients who use the ED for treatment of their headaches. Given this paucity of information, it would be useful to better understand how psychiatric comorbidities (such as affective disorders, psychotic disorders, anxiety disorders and personality disorders) are associated with ED use in migraine patients with both conditions. Different patterns of healthcare use or treatment in this group of patients might suggest ways in which their care is deficient or could be improved.
We sought to determine whether psychiatric comorbidities in migraine patients in the ED were associated with increased healthcare utilization, specifically visits to the ED, outpatient medical visits or inpatient hospital stays, compared to migraine patients with comorbid psychiatric diagnoses. We also sought to determine whether the presence of psychiatric comorbidities was associated with the type of treatment provided in the ED. Finally, we examined whether psychiatric comorbidity was associated with the use of head imaging over the 10-year period examined in this study.
Section snippets
Methods
This was a cross-sectional analysis of data obtained from the Partners Research Patient Data Registry (RPDR). The RPDR is a computerized database that stores administrative and clinical encounter data from hospitals and clinics in the Partners Healthcare system. Partners is a nonprofit organization of eight hospitals and other healthcare providers. It is the largest healthcare provider in Massachusetts and has a substantial share of the market in the greater Boston metropolitan area.
The RPDR
Results
Two thousand eight hundred seventy-two patients between the ages of 18–64 visited the hospital ED between January 1, 2003 and December 31, 2012 and received a principal diagnosis of migraine. Of these, 1037 had at least one psychiatric comorbidity and 1829 did not. Table 2 shows selected demographic characteristics of the overall population of patients and the two subgroups of patients with and without psychiatric comorbidity. Patients with psychiatric comorbidity were more likely to be female
Discussion
In this detailed examination of how psychiatric comorbidities affect migraineurs' healthcare utilization pattern and treatment, we identified the following themes: (a) The migraine patients with psychiatric disorders in our study had more ED visits, outpatient visits and inpatient visits than the migraine patients without psychiatric disorders; (b) Compared to migraineurs without psychiatric comorbidities, migraineurs with psychiatric comorbidities were administered narcotics more frequently;
Conclusion
Our study shows that much work needs to be done to better treat patients who are diagnosed with migraine in the ED, especially those with psychiatric comorbidities. The patients are receiving medications not recommended by consensus statements, as evidenced by the fact that narcotics comprised 28% of the medication administrations in all migraine patients queried in the study. Furthermore, the narcotics are administered more to migraineurs with psychiatric comorbidity compared to those without
Acknowledgments
We wish to acknowledge Dr. Elizabeth Loder for her critical review of the manuscript.
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There was no financial support for the research.
- 1
The emergency room is the interface between community and health care institution. Whether through outreach or in-hospital service, the psychiatrist in the general hospital must have specialized skill and knowledge to attend the increased numbers of mentally ill, substance abusers, homeless individuals, and those with greater acuity and comorbidity than previously known. This Special Section will address those overlapping aspects of psychiatric, medicine, neurology, psychopharmacology, and psychology of essential interest to the psychiatrist who provides emergency consultation and treatment to the general hospital population.