Journal Article Annotations
2018, 4th Quarter

Emergency Psychiatry

Annotations by Scott Simpson, MD, MPH
January 2018

Malingering in the psychiatric emergency department: prevalence, predictors, and outcomes

PUBLICATION #1 — Emergency Psychiatry

Malingering in the psychiatric emergency department: prevalence, predictors, and outcomes

Rumschik SM, Appel JM

Abstract: Psychiatr Serv 2018 Dec 10 (Epub ahead of print)

Objective: Malingering is commonly encountered in the psychiatric emergency department, yet little is known about its prevalence, objectives, or effect on patient management. This study analyzed characteristics of malingering and patient disposition in a 24/7-staffed comprehensive psychiatric emergency program (CPEP) and created predictive models to understand malingering and its effect on physician decision making.

Methods: Attending psychiatrists completed questionnaires after comprehensive assessments of 405 patients presenting to the CPEP during the 1-month study, recording suspicion of malingering, symptoms malingered, associated secondary gains, demographic characteristics, and initial disposition decision. Analyses examined characteristics associated with degree of malingering suspicion and disposition.

Results: Malingering was suspected among one-third of patients, and 20% were strongly or definitely suspected of malingering. High suspicion was associated with malingering of multiple symptoms and was likely to result in immediate discharge. Lower suspicion was associated with being held for further observation. Among patients for whom suspicion of malingering was high, malingering was most frequent for suicidal ideation (58%) and depression (39%); malingering was often used to seek hospital admission (54%) and to stay in the CPEP (35%); malingering was sometimes used to seek multiple secondary gains (25%); and malingering often involved multiple symptoms (44%). Patients for whom suspicion was high had an admission rate of 4%. Among patients suspected of malingering, three variables each independently increased the likelihood of hospital admission: seeking social work or housing services, seeking admission, and malingering of suicidal ideation.

Conclusions: Malingering was prevalent in the psychiatric emergency department, and suspicion of malingering was associated with disposition differences. Disposition was significantly influenced by both suspicion of malingering and the gains sought by patients.

On PubMed: Psychiatr Serv 2018 Dec 10 (Epub ahead of print)

Annotation

Type of study: Cohort study

The finding: The authors asked attending psychiatrists to anonymously share their suspicion of malingering for a consecutive series of patients seen in an emergency psychiatric service. The prevalence of suspected malingering was quite high—20% of patients were strongly or definitely suspected of malingering. Admission rates for malingering patients were far lower (4%) than for non-malingering patients (48%). The most commonly malingered symptom was suicidal ideation (58%) followed by depression (39%), although about half of patients (44%) malingered multiple symptoms.

Strength and weaknesses: The investigators achieved a high response rate (94% of possible patients were captured) in a real world, heterogeneous patient sample. The correlation of suspected malingering with disposition is anecdotally sensible but has never before been published and studied. The use of anonymous surveys precluded assessment of how individual clinicians might approach the assessment and management of malingering differently. Patients might have presented multiple times to the emergency department (ED) in this study; given that malingerers are probably but not certainly more likely to re-present, the study may overestimate the prevalence of malingering.

Relevance: This simple and highly valuable study demonstrates something that many emergency psychiatrists know well from experience: malingering is very common in emergency settings. More attention should be paid to determine best practices for identifying malingering, mitigating risks associated with the condition, and establishing a standard of care. Future studies should seek to clarify longitudinal outcomes among these patients.