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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Psychol Serv. 2021 Apr 1;19(2):353–359. doi: 10.1037/ser0000437

Psychological Distress among Medically Complex Veterans with a Recent Emergency Department Visit

Katherine Ramos 1,2,3,4,7, Megan E Shepherd-Banigan 4,5, Karen M Stechuchak 4, Cynthia Coffman 4,6, Eugene Z Oddone 4,7, Courtney Van Houtven 4,5, Cristina C Hendrix 2,8, Elizabeth P Mahanna 4, S Nicole Hastings 2,3,4,5,7
PMCID: PMC8484334  NIHMSID: NIHMS1654125  PMID: 33793285

Abstract

Medical complexity and psychological distress are associated with frequent emergency department (ED) use. Despite this known association, our understanding is limited about which patients are at risk for persistent psychological distress and what patterns of distress emerge over time. A secondary data analysis was used to examine self-reported psychological distress (defined as ≥ 14 unhealthy days due to poor mental health in the past month) at 30 days and 180 days following enrollment in a randomized control trial (RCT) of 513 medically complex Veterans after a non-psychiatric ED visit. We used a multivariable ordered logistic regression model to examine the association of a priori factors (baseline psychological distress, age, race, income, health literacy, deficits in activities of daily living [ADL], and deficits in instrumental activities of daily living) with three psychological distress classifications (no/low, intermittent, and persistent). Among 513 Veterans, 40% reported at baseline that they had experienced high psychological distress in the previous month. Older age was associated with lower odds of high psychological distress (OR=0.95; 95% CI: 0.94-0.97). Baseline factors associated with significantly higher odds of persistent psychological distress at 30 and 180 day assessments, included having inadequate income (OR=1.61; 95% CI: 1.02-2.55), having low health literacy (OR=1.63; 95% CI: 1.01-2.62), and reporting at least one ADL deficit (OR=1.94; 95% CI 1.13-3.33). Psychological distress at follow-up was common among medically complex Veterans with a recent ED visit. Future research should explore interventions that integrate distress information into treatment plans and/or link to mental health referral services.

Keywords: Medical complexity, psychological distress, mental health, emergency department

Medically complex patients (e.g., frail patients with multiple chronic health conditions) account for about half of health care spending (Cohen & Yu, 2012) and for a disproportionate amount of total emergency department (ED) visits and hospital stays (Hayes et al., 2016; Miller et al., 2013). U.S. Veterans are a well-recognized, medically complex population known to have high prevalence rates of multiple medical diagnoses, and frequent ED use. Of the two million U.S. Veterans who receive care in the Department of Veterans Affairs (VA) EDs (Kessler et al., 2010), approximately 20% of these Veterans have a repeat ED visit within 30 days of their initial visit (Hastings et al., 2011). Prior studies have observed that among patients admitted to the ED, 35% report high to very high psychological distress in the context of coping with chronic and medically complex conditions (Forero et al., 2016). Among frequent ED users for physical conditions, close to 47% report very high psychological distress following completion of the general health questionnaire measure (Marchesi et al., 2004). Many of these individuals also experience multiple physical health issues including limitations in their functioning (e.g., activities of daily living) and social stressors that complicate their health care and self-management (Doran et al., 2013). Studying distress in this context may help elucidate initiatives to decrease the risk of repeat ED visits and enhance current ED care and care coordination for Veterans.

Psychological distress involves multiple and varying affective responses such as worry, hopelessness, sadness, concern, anxiety, and irritability (Kemeny, 2011). Distress is distinct from a mental health disorder in that symptoms may be misconstrued as normative, the course of treatment may be unclear, and treatment-seeking behaviors tend to be low (Mojtabai & Jorm, 2015). Although psychological distress is common among ED patients (Forero et al., 2006; Marchesi et al., 2004), most patients tend to cope well with the challenges presented when facing an acute physical illness (Moos, 2012). Therefore, it is unknown whether patients continue to experience persistent psychological distress well beyond their ED visit which can lead to repeat ED readmissions.

Frequent ED users typically have numerous chronic, severe illnesses; there is also a high prevalence of mental illness, social needs, and substance use (Doran et al., 2013). Like frequent ED users, Veterans too experience high psychological distress and social needs, thus allowing researchers to study psychological distress in medically complex populations using Veteran data. For example, administrative data suggest that Veterans with high levels of social needs (i.e., homelessness), co-morbid psychiatric conditions, and substance use are at highest risk for frequent ED visits despite available integrated outpatient and specialty care provided within the VA (Doran et al., 2013). Importantly, increasing levels of psychological distress are associated with increased symptom severity (e.g., subjective experience of pain, fatigue) (Shih & Simon, 2008), presence of chronic health conditions, lower levels of physical health-related quality of life, and a higher likelihood of mental illness (Andrews & Slade, 2001; Shih & Simon, 2008; Stockbridge et al., 2014).

State of the Research Literature and Study Focus

Most existing literature on distress has been obtained from data captured during or immediately after an ED visit. Despite known associations between multiple chronic health conditions and mental health diagnoses with increased rates of ED visits and hospitalizations (Dahlén, & Janson C, 2002; Hayes et al., 2016; Himelhoch et al., 2004), little is known about persistent and continued distress post 30-days of an index ED visit and associated patient characteristics. Characterizing the frequency and determinants of persistent distress is important for understanding potential impacts of systematically assessing for distress in the ED. As such, for this secondary data analysis and descriptive study we focus our attention on the characteristics related to persistent and continued distress after an index visit and explore whether these data can elucidate patients at-risk for persistent distress that may potentially benefit from additional support. This focus will help generate hypothesis testing for future studies. Greater recognition of distress could lead to novel interventions in ED settings, potentially buffering frequent ED use among medically complex populations. Moreover, information gathered about patient demographics associated with persisting psychological distress can help clinicians identify ED patient populations that require greater oversight and follow-up post-ED visits.

Purpose of the Present Study

The goal of our study was two-fold; 1) to assess Veteran characteristics associated with psychological distress after an ED visit at 30 and 180 days; and 2) to categorize distress as “low distress,” “intermittent distress group,” and “persistent distress group” to explore the types of patients that may benefit from mental health follow-up or other interventions after an ED visit.

Method

Study Design, Setting, and Participants

We examined data from a randomized controlled trial (RCT), “Discharge Information and Support for Patients Receiving Outpatient Care in the ED” (DISPO ED) (Hastings et al., 2014; Hastings et al., 2020), a nurse-delivered care management intervention for medically complex Veterans after an ED visit in the Durham Veterans Affairs Health Care System. Veterans who visited the ED between 3/2014 and 1/2016 and met the study inclusion criteria were randomized to either the DISPO ED intervention (n=257) or to usual care (n=256).

Briefly, the DISPO ED intervention was a nurse-led telephone support intervention designed to improve transitions of care from ED to primary care, improve chronic disease self-management, and provide Veterans and their families with information regarding care services within and outside the Veterans Health Administration (VHA). The intervention consisted of two primary calls within the first seven days after discharge from an ED visit. Optional calls were available for up to 30 days following the index ED visit. A full description of the intervention is provided elsewhere (Hastings et al., 2014).

Selection of Participants

The DISPO ED trial targeted medically complex Veterans because they are known to be at increased risk of repeat ED visits (Hastings et al., 2007). Veterans were considered medically complex if they had at least one ED visit or hospitalization during a 6-month period prior to their index ED visit and two or more chronic health conditions. An index ED visit was defined as one in which a Veteran received treatment from the ED and was released. At the time of discharge, the Veteran was offered a pre-printed opt-out letter to gain exclusion from being contacted about the DISPO ED study. Other eligibility criteria included ≥1 visit to a VA-affiliated primary care clinic within the previous 12 months and receiving care in main primary clinics at the [Durham Veterans Affairs Health Care System]. Veterans were excluded if they were enrolled in a study that prohibited participation in another study, lacked the capacity to participate in the study (unless they had a legally authorized representative), were unable to communicate by phone, resided in a nursing home, long-term care, or assisted living facility, were flagged as “high-risk” for suicide in their medical chart, or had returned to the ED clinic within 24 hours of their index ED visit. Of note, Veterans who were reporting to the VA psychiatric emergency clinic for mental health evaluation (i.e., with or without medical ED care) were not included in the study.

Measures

Primary Outcome

For this analysis the primary outcome was a 3-level ordered variable, where 1= “low distress” indicating low psychological distress at both the 30 and 180 day assessments, 2= “intermittent distress group” indicating high psychological distress at either the 30 or 180 day assessment, but not both, 3=“persistent distress group” indicating high psychological distress at both the 30 and 180 day assessments. Distress at each timepoint was captured by using the Center for Disease Control (CDC) Healthy Days measure (2000). The measure is an assessment used by respondents, providers, and researchers to index perceived physical and mental health. The suggested cutoff to measure frequent distress is defined as ≥ 14 unhealthy days due to mental health in the past month. The Healthy Days measure demonstrates good construct validity and has been used in national population-based surveys for more than a decade (CDC, 2000; Hennessy et al., 1994).

Baseline characteristics

Baseline self-report data was collected via telephone survey 1-3 days following the index ED visit. Demographic items included age at index ED visit, race, and income; these items were captured via self-report. Missing data related to age and race were supplemented by medical chart review. Income was assessed with the following survey question: “Which one of the following statements best describes your own personal economic situation?” Participants responding: “I am barely getting by. I have to budget carefully, and I am not able to plan for the future.”, “I am falling behind. I have to use savings or go further into debt to pay my bills.”, or “I am in serious financial trouble, and can’t quite see how I am going to make it.” were classified as having inadequate income. Conversely, participants responding “I am in good shape. I am able to save and plan for the future.” and “I am okay. I am saving a little and I am able to provide for my needs.” were classified as having adequate income.

Self-rated health, physically healthy days, and psychological distress over the past month were collected using the Healthy Days measure. Activities of daily living (ADLs) items queried how much assistance the patient perceived needing no help, some help, or be unable to bathe oneself, dress oneself, feed oneself, get from a bed to chair by oneself, and use the toilet by oneself. Instrumental activities of daily living (IADLs) queried how much assistance the patient perceived needing for using the telephone, driving a car or using a taxi or bus, shopping for groceries or clothes, preparing meals, housework, taking medicine, and handling one’s own money. Health literacy was assessed using a single self-report item previously validated from a short test of functional health literacy in a Veteran population (Chew et al., 2008).

As a study team we reviewed independent variables that, as informed by the ED research literature and stress process theory (Pearlin, 2009; a framework for understanding mechanisms by which stressors lead to health outcomes), has been associated with distress. Lead author (KR) is a clinical psychologist who also offered her mental health expertise in VA healthcare settings to further inform variables of interest. Our selection of independent variables includes baseline psychological distress, age, race, health literacy, income, perceptions of health, and functioning. We also examined randomization arm as an explanatory variable in this secondary analysis.

Analysis

We conducted a multivariable ordered logistic regression model to examine the outcome of interest, a 3-level ordered variable of psychological distress defined above. Explanatory variables included in the ordered logistic model were selected a priori, and consisted of the following: randomization arm, baseline psychological distress (< 14 unhealthy days in past month due to mental health vs. ≥ 14 days), age (continuous variable), race (Black or African-American vs. other), self-rated health, health literacy, baseline number of physically unhealthy days, inadequate income, at least one ADL deficit (unable to do or need some help), and at least one IADL deficit (unable to do or need some help). The proportional odds assumption for the ordered logistic model was assessed. Missing data was handled using case-wise deletion. All statistical analyses were performed using SAS for Windows version 9.4 (SAS Institute, Cary, NC).

Sensitivity Analysis

To further assess the robustness of any observed differences in the main model, a sensitivity analysis was conducted to account for missing values in psychological distress at baseline and follow-up. We examined 6 different models that adopted various imputations of psychological distress at the most extreme values; the 30 and 180 day mental health distress were imputed to either be high or low in all cases and then each of those models were fit with missing baseline mental health as either low or high. Each sensitivity model was fit following the specifications of the main model.

Results

Among 513 randomized participants in the main trial the mean age was 59.1 (SD = 12.1), 22% were female, and 50% identified as Black or African American. At the time of enrollment (1-3 days following an ED visit), 40% reported high psychological distress in the previous month.

Demographic and clinical characteristics of the subset of 377 subjects with complete data entered in the model were similar to the overall sample (n=513; see Table 1). Across all variables, missing data at baseline was less than 4%. Among the Veteran sample, close to half (46%) had a mental health coordinator assigned (i.e., a coordinator that serves as a point of contact for behavioral health care, usually for Veterans who receive or have received specialty mental health care). Moreover, 46% had a major depression diagnosis and 29% had a post-traumatic stress disorder diagnosis recorded in their electronic medical health records at baseline.

Table 1.

Baseline Characteristics of Veteran Sample including Mental Health Data

Characteristics Overall Complete case sample from multivariable modelb
N = 513 N=377
Randomized to DISPO study arm 257 (50.1) 190 (50.4)
Age, mean (SD) 59.1 (12.1) 58.8 (12.2)
Black or African American racea 249 (49.6) 196 (52.0)
Inadequate incomea 228 (46.2) 178 (47.2)
Health Literacy (e.g., Less confident in filling out medical forms by oneself)a 183 (36.9) 140 (37.1)
At least one IADL deficita 306 (60.0) 224 (59.4)
At least one ADL deficita 149 (29.3) 108 (28.6)
Fair/poor self-rated healtha 297 (58.6) 215 (57.0)
Frequent (≥ 14 unhealthy days in past 30 days) physical healtha 268 (53.2) 194 (51.5)
Frequent (≥ 14 unhealthy days in past 30 days) psychological distressa 198 (40.2) 148 (39.3)
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Note. n (%) unless otherwise noted; SD = standard deviation; IADL = Instrumental Activities of Daily Living; ADL = Activities of Daily Living. Health Related Quality of Life measures include self-rated health, and the derived measures of number of unhealthy days and frequent psychological distress.

a

Missing data (n) in sample of 513: race (11); income (20); medical forms (17); IADL deficit (3); ADL deficit (4); self-rated health (6); unhealthy physical days (9); poor mental health days (20).

b

Number of observations = 377 after case-wise deletion in ordered multivariable logistic regression model; outcome is a 3-level ordered variable of psychological distress: no or low distress at 30 day and 180 day assessments, psychological distress at 30 days or 180 days (but not both), and psychological distress at both assessments. Explanatory variables include all variables in the above table.

Among 377 individuals with complete baseline and follow-up data (30 and 180 days following the index visit), 51% of the sample were classified as low distress, 22% in the intermittent distress group, and 27% in the persistent distress group. Descriptive characteristics across distress trends of low, intermittent, and persistent distress are shown in Table 2. From the ordered logistic regression model (see Table 3), baseline psychological distress was associated with higher odds of psychological distress at follow-up (Odds ratio [OR]= 8.48, 95% Confidence interval [CI] = 5.14, 14.01). From the ordered logistic regression, the specific interpretation is that the odds of being in a higher distressed category (persistent or intermittent distress) versus a lower distressed category (intermittent or low distress, respectively) is 8.14 times higher for those with baseline psychological distress compared to those with no baseline psychological distress.

Table 2.

Descriptive characteristics across distress trends of low, intermittent, and persistent distress

Low distress group
N=222		 Intermittent distress group
N=89		 Persistent distress group
N=116
Randomization arm
 DISPO ED intervention 110 39 69
 Usual care 112 50 47
Age, mean (SD) 63.7 (10.7) 56.7 (11.0) 52.9 (12.0)
Race, n (%)
 Black or African American race 95 44 71
 Not Black or African American race 125 42 42
Income
 Inadequate 77 42 71
 Adequate 135 43 43
Health literacy (e.g., confidence in filling out medical forms by oneself)
 Less confident 61 38 52
 More confident 154 51 59
IADL deficit
 At least one 107 58 86
 None 114 31 29
ADL deficit
 At least one 43 23 55
 None 178 66 60
Self-rated health
 Fair/poor 103 50 88
 Good/very good/excellent 114 39 28
Physically unhealthy days in past 30 days
 ≥ 14 unhealthy days 89 41 89
 < 14 unhealthy days 130 48 27
Days in past 30 days with psychological distress
 ≥ 14 days 25 42 93
 < 14 days 188 45 20
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Note. n (%) unless otherwise noted; SD = standard deviation; IADL = Instrumental Activities of Daily Living; ADL = Activities of Daily Living. Percentages may not add to 100% due to rounding.

Missing data: 86 patients had missing data for the outcome variable (distress at follow-up). In addition, the following numbers of patients had observed data for the outcome but had missing data on the following baseline variables: race – 8, income – 16, health literacy – 12, IADL deficit – 2 , ADL deficit – 2, self-rated health – 5, unhealthy physical health days – 3, unhealthy psychological distress days – 14.

Table 3.

Results of multivariable ordered logistic regression model for psychological distress outcome at follow-up assessments

Adjusted Model,a Odds Ratio Estimates
Effect Odds Ratio 95% Wald Confidence Limits
Randomized to DISPO ED Intervention 1.20 0.76 1.89
Age 0.95 0.94 0.97
Black or African American race 1.14 0.72 1.81
Inadequate income 1.61 1.02 2.55
Less confident in filling out medical forms 1.63 1.01 2.62
At least one IADL deficit 1.07 0.63 1.82
At least one ADL deficit 1.94 1.13 3.33
Fair/Poor self-rated health 1.39 0.84 2.28
≥14 days of psychological distress at baseline assessment 8.48 5.14 14.01
14 or more physically unhealthy days in past 30 days 1.45 0.89 2.36
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Note. IADL = Instrumental Activities of Daily Living; ADL = Activities of Daily Living

a

Adjusted model number of observations after case-wise deletion of 136 observations due to missing response and/or explanatory variables: 377. P-value for the score test for proportional odds assumption = 0.34.C-statistic = 0.84 (a measure of goodness of fit for in a logistic regression model). Generalized r-square = 0.42

Older age was associated with lower odds of being in a higher distressed category versus a lower distressed category at follow-up (OR=0.95; 95% CI 0.94-0.97). Additional baseline factors that were associated with higher odds of being in a higher distressed category versus a lower distressed category at follow-up included having inadequate income (OR=1.61; 95% CI: 1.02-2.55), having low health literacy (OR=1.63; 95% CI: 1.01-2.62), and reporting having at least one ADL deficit (OR=1.94; 95% CI 1.13-3.33). The C-statistic for the full model was 0.84, and there was no evidence that the proportional odds assumption was violated or of collinearity issues.

Sensitivity Analyses

The various imputations for those with missing psychological distress at baseline, 30 day, and 180-day assessments yielded number of observations in the model of 442 or 453. Baseline psychological distress and younger age were consistently associated with higher odds of psychological distress at follow-up in all sensitivity models.

Discussion

Our study examined patient characteristics associated with psychological distress after an ED visit (at 30 and 180 days) among a sample of medically complex Veterans to identify factors that can be targeted as part of improved care models for this population. In our study, high psychological distress was common (e.g., 40%) at the time of study enrollment among medically complex Veterans with a recent ED visit who were participating in an RCT. Of note, psychological distress at baseline was associated with distress at follow-up points of 30 days and 180 days. Veterans with increased risk for subsequent psychological distress were younger, had low health literacy, lower income, and more functional deficits. Although the existing ED literature has shown that most medical patients adapt quite well over time (Faessler et al., 2019), our analysis shows that for many, psychological distress persists.

Our study results suggest that recognizing distress in the ED may offer an opportunity for case-finding and referral to mental health support programs for higher utilizers with persistent mental health distress. One potential strategy to assess distress in the ED may involve using brief measures such as the Patient Health Questionnaire-4 (PHQ-4; Kroenke, Spitzerm Williams, & Lowe, 2009) to capture anxiety and depressive symptoms, or using a distress thermometer on a 1- 10 scale as used in oncology clinics (Cutillo et al., 2017). The VHA does already use the Patient Health Questionnaire with annual screening recommendations for Veterans seen in primary care. This practice could potentially be expanded to ED and urgent care settings in and outside of VA settings. There is some empirical evidence (Faessler et al., 2016) supporting the use of validated instruments embedded in the ED to measure distress. The PHQ-4, for example, has been implemented successfully with ED medical patients who were later contacted by phone 30-days following an index ED visit (Faessler, Perrig-Chiello, Mueller, & Schuetz, 2016). However, it is unclear whether screening and linking patients to mental health support occurs, and whether when there is a linkage if mental health support directly leads to future decreases in psychological distress. Greater research around the implementation of distress screening, links to mental health support, and sustained reductions in distress at multiple follow-up points is needed.

Formal mental health assessments and interviews with patients with varying levels of psychological distress while in the ED (by trained mental health professionals) is yet another area for future research. Investigators may test whether embedding health psychologists, case managers, or other qualified behavioral health interventionists in the ED to address distress in patients may lead to personalized care and circumvent future ED utilization costs. Lastly, assessments and interviews could potentially be further incorporated as post-hospital follow-ups and, when possible, include the Veteran’s family, immediate caregivers, and health care providers for additional perspectives.

In sum, the lack of continuity of care for ED patients with mental health symptoms, combined with limited mental illness training among ED health care professionals (Fernando & Bhat, 2017; Goode et al., 2014), warrants alternative strategies to address the immediate needs of psychologically distressed patients. Thus, the ED may be an appropriate venue to identify and support distressed patients and connect them to the mental health care most appropriate for their needs. Specifically, we should look for and test for interventions that integrate distress information into treatment protocols to enhance overall health care needs. As our analysis also shows, individuals with inadequate income are at higher risk for persistent distress, and the ED can be a window into treating social determinants of health (and potential mechanisms such as health behaviors) in this community. Examples of addressing social determinants of health within this community may include a) linking patients to social service sector agencies, b) partnering with community-based programs and practices to offer warm hand-offs and referrals, and c) maximize opportunities for collaboration among federal and state-level partners.

LIMITATIONS

This study only includes Veteran patients from one VA medical center, and thus our results may not be generalizable to other VAs, other health care systems, or, more broadly, the general population. However, trends in patient-level characteristics among frequent ED users were similar in VA and non-VA EDs (Doran et al., 2013). In this study we only used one index to measure high psychological distress. More refined measures of distress that go beyond whether there is the presence or absence of distress is needed. One way to address this limitation is to make use of a more sensitive measure of psychological distress with recommended clinical cut-off scores (e.g., Kessler Psychological Distress Scale [K6]), to capture the frequency of distress symptoms (Kessler et al., 2010; Prochaska et al., 2012). The utilization of other measures that assess depression, anxiety, and worry, in addition to diagnostic data on specific mental illnesses, may provide more detailed information about factors associated with significant psychological distress. The use of additional measures can also help tailor strategies to address distress.

Another limitation to our study is missing data. To address this issue, we examined the characteristics of the full randomized sample versus those with complete-case data and found the groups to be similar. In addition, we ran a series of sensitivity models and found in all models that baseline psychological distress and younger age were consistently associated with increased psychological distress at follow-up. Also, the use of a Veteran sample, of which nearly 80% of participants were male, limited our evaluation of possible gender-related determinants of distress.

CONCLUSION

In conclusion, we found that psychological distress was common among medically complex Veterans with a recent ED visit, and this distress often persisted at follow-up. Our findings imply that ED-related service delivery interventions may need to address psychological distress among high-cost, high-need users. Relevant to clinical care, ED clinics may consider sustainable approaches of integrating psychological distress measures to identify and support distressed patients and connect them to appropriate mental health care resources.

Acknowledgments

This work was supported by the United States (U.S.) Department of Veterans Affairs, Health Services Research and Development Service (IIR 12-052; HX000976A) and by the Center of Innovation to Accelerate Discovery and Practice Change (CIN 13-410) at the Durham VA Health Care System. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. ClinicalTrials.gov Identifier: NCT01717976

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