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Objectives  To determine the role of previous psychiatric disorders including substance use disorders on emergency department (ED) patients on involuntary holds and compare presentations, treatment, and outcomes based on cause.    Methods  We conducted a retrospective study of patients ≥ 18 years old on involuntary holds in the ED of a tertiary care center from January 1, 2013, to November 30, 2015. Demographic and clinical information were collected. Those with and without prior psychiatric disorder including substance use disorder were compared.    Results  We identified 251 patients of which 129 (51.4%) had a psychiatric disorder, 23 (9.2%) had a substance use disorder, and 86 (34.3%) had both. Thirteen patients (5.2%) had no psychiatric disorder or substance use disorder and the majority 10 (76.9%) were on involuntary holds due to suicidal threats related to pain or another medical problem. Patients without a psychiatric or substance use disorder were older (55 years [17.8] vs 42 [19];  P  = 0.01), more likely to be married (10 [76.9%] vs 64 [26.9%];  P  < 0.001), and had more medical comorbidities (10 [76.9%] vs 114 [47.9%];  P  = 0.049) compared with those without a psychiatric or substance use disorder.    Conclusion  Patients on involuntary holds most commonly have pre-existing psychiatric disorder including substance use disorder. Patients on involuntary holds without history of psychiatric disorder often have severe pain or other active medical conditions which may contribute to suicidal thoughts. Addressing these underlying medical issues may be crucial in preventing further psychiatric decompensation.

Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department?