Psychiatric patients can be challenging and frustrating for many Pediatric Emergency Physicians. We encounter daily patients brought for suicide attempts, change in behavior, destructive demeanor or other such complaints. While these symptoms rarely are a presentation of a medical condition, we regularly perform a medical screening exam and order a panel of laboratory tests requested by the receiving psychiatric department or facility. I can hardly remember any usefulness for these tests in altering the final disposition of a patient.
For example, if patient’s initial history and physical examination is normal then the patient should go to the psychiatric facility even if the labs are abnormal. Still, the patient will sit in our emergency department until we have that drug screen test result. On the other hand, if the patient is deemed unstable (intoxicated, altered mental status, etc.) we would have to stabilize and medically “fix” the patient or admit him/her for further observation.
I have encountered these scenarios multiple times at different institutions, and I expect that many Pediatric Emergency Physicians have similar stories.
In 2006, Annals of Emergency Medicine published a policy statement by the American College of Emergency Physicians (ACEP) that discourages the practice of routine laboratory testing for psychiatric patients with normal medical screening examinations. But that same policy excluded pediatric patients. The American Academy of Pediatrics (AAP) has no similar policy, so we are stuck with what psychiatrists believe an absolute necessity.
In 2007, Pediatrics published the AAP policy on suicide and suicide attempts in adolescents. This policy mentioned that no specific test is able to identify such patients and the key to management is identifying risk factors. Two years prior to that, the AAP published a statement discouraging routine drug screening of patients suspected of drug use unless indicated. Yet our daily struggle of testing continues, and the evidence is lacking to support it.
So what is the evidence?
Santillanes et al. recently published a retrospective, single center study tackling this topic. They described one in ten patients with psychiatric complaints required medical attention. Also, it would cost more than 17,000 $ to identify one patient who requires laboratory screening. They concluded that simple medical criteria (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape) can identify these patients with screening needs.
Shihabuddin et al. published another retrospective, single center study in 2013 on the role of urine drug screen testing on the final disposition of pediatric psychiatric patients. They concluded that urine drug screening did not alter the final disposition or management of these patients.
Fortu et al. published similar findings in 2009 and recommended that patients with straightforward psychiatric complaints may be medically cleared without a urine drug screen.
Donofrio et al. took it a step further by including multiple laboratory testing (CBC, CMP, thyroid function tests, RPR, pregnancy test) and the impact on disposition. They concluded that only asymptomatic positive pregnancy testing changed the disposition and their findings were consistent with ACEP adult guidelines.
I think we need more prospective large population studies to validate these findings. And if proven, we should change the common practice that is enforced by psychiatric services. I look for the day when I have no obligation to make these patients suffer testing and a wait that they rarely need. Would you like to see the same? Let me know your thoughts and experience.