Malingering in the Psychiatric Emergency Department: Prevalence, Predictors, and Outcomes

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.

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.

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.

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.