I began eagerly to read the article in the January 7 issue titled "Psychiatrists’ ER Involvement Improves Care for Distressed Individuals" because I believe the quality as well as the cost-effectiveness of primary patient care, whether in the emergency room or clinic, may by enhanced by routine psychiatric screening and prompt on-site treatment when indicated.

I was disappointed, however, to find the headline was misleading. In the first place, there was no further mention of psychiatrists in the body of the article, which described an experimental intervention in the ER with patients exhibiting panic symptoms. Instead, a nonpsychiatrist did the ER consultation and referral, while the only follow-up care provided at the psychiatric clinic seemingly consisted of cognitive-behavioral treatment. Nothing was said about medication use.

In the second place, I was not convinced that the "intervention" patients did any better than the "usual care" group. Although they attended the psychiatric clinic more often and returned less often to the ER, their total continued use of all nonpsychiatric medical facilities (a number that included ER visits) rose at the same rate as the controls. Therefore, the treated patients were actually attending other medical clinics more.

To me that suggests that they may have been somatizing more and turning to other medical specialists because their panic disorder was being inadequately treated. Further fruitless testing and ineffective medications dispensed through those alternate venues would reduce any cost savings achieved by cutting ER visits.

Perhaps the goals of the intervention would have been achieved better by sending a psychiatrist to the ER to do a rapid assessment, initiating a trial of appropriate medication then and there (in addition to psychoeducation and instruction in simple behavioral techniques), to be continued with psychotherapy at the psychiatric clinic. Underuse of psychiatrists in situations such as this may be a case of "penny-wise and pound-foolish."

Nancy T. Block, M.D.

Scotch Plains, N.J.