Type of study: Retrospective cohort study

The finding: The investigators examined the relationship between antipsychotic adherence and emergency department (ED) visits among Medicaid recipients with schizophrenia in a single state. Medication adherence was defined using fills rates from a pharmacy; ED visits were categorized into either medical or behavioral health visits based on diagnostic codes. The study cohort had, on average, more than 11 times as many medical visits as psychiatric ones. Poor antipsychotic adherence was strongly associated with more medical ED visits (RR: 1.61, 95%CI 1.50-1.74), but the association with psychiatric ED visits was smaller.

Strength and weaknesses: The study describes a challenging population of patients who are high utilizers and whose service use is not well understood. The authors captured varying degrees of medication adherence as well as different types of ED visits in order to demonstrate a dose-response relationship between adherence and utilization—lending stronger internal validity to their findings. This population is fairly specific—Medicaid recipients with schizophrenia in a single state—and there is not a good description of disability burden among this population but practiced clinicians can reasonably generalize these findings to their own locales. Schizophrenic patients also have high rates of medical comorbidity and substance use, which are not well-measured and may confound the results. Finally, these results do not provide clear guidance to ED providers as to how to improve adherence or reduce utilization.

Relevance: By ascertaining ED visits as psychiatric versus medical, the authors identify an interesting, valuable phenomenon: untreated mental illness is more often presenting as somatic illness in medical settings rather as behavioral visits. These patients present with injuries and non-specific somatic complaints. These findings speak to the importance of integrating behavioral health training and expertise into the ED in order to provide treatment for all patients, not simply those presenting with suicidal or violent ideations.