DISCUSSION

This case study highlights the repeated presentations to a local emergency department. The available data details at least 38 encounters for acute MSK-related pain or injury, for a seven year period ending in Feb 2021; remarkably, 28 of which were within one calendar year (2015). Upper limb pain and persistent MSK pain involving an extremity were the main reasons for ED presentation. However, no further mental health presentations for the ED or specialist care were identified which may be due to the type of data captured (or not) in the retrospective records. The final mental health diagnosis provided in April 2017 reports a first-time diagnosis of Anorexia Nervosa. It is important to note that up to 40% of people diagnosed with Anorexia Nervosa have comorbid personality disorders across the Cluster B traits, which are defined by the DSM as including impulsive behavioural patterns along with compulsive traits (13). Existing evidence suggests that pain is implicated in higher rates of generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) substance misuse and other comorbid disorders (14) resulting in a further reduction in functionality, recalcitrant treatment response and increased health care costs. It appears that people living with mental health conditions receiving inadequate treatment remain at risk of experiencing other comorbid health conditions and it remains plausible that the repeated acute pain/ MSK presentations observed may be due to an unrecognised eating disorder phenotype. An improved understanding of pre-existing vulnerabilities/resiliencies associated with repeated acute care presentations and triage processes may inform healthcare redesign to streamline more bespoke care pathways for people with acute MSK injury. It is acknowledged that people living with a mental illness experiencing concomitant physical symptoms, which in turn results in a shortened life span, increased comorbidities, a lowering in their quality of life due to a mix of disparity in healthcare access and utilisation (15). Unfortunately, these physical symptoms have been largely attributed to underlying psychiatric conditions (16). It is our belief that living with a mental illness may lead to a delay in establishing the correct diagnosis and intervention required to adequately address the physical and mental signs/symptoms, which could result in an inappropriate plan of care on discharge from the ED. Early onset mental health disorders have shown to increase risk for lifelong adversity (17), contributing to health inequity. There are several studies on the observations of, and reporting on, an increasing number of young people presenting to the ED with mental health disorders (18). The intensely stimulating environment of the ED may prove a therapeutic challenge for an acutely injured person with or without history of previous mental health disorders. The trauma, distress, pain, and expectations around recovery are complex for people living with a mental illness. Adding to this complexity are pre-existing stress, pain, mental ill-health, and early life adversity as all could influence the clinical course on a patient-by-patient basis following acute injury. Such complexity can, and likely does, place further demands on the resources within an ED workforce and resources (19). Limitations The retrospective data collection is limited over the time period captured between 1 January 2015 to 31 July 2021 at the single ED location looking for only acute MSK pain presentations with limited information gathering about any triggers prior to presentation and existing supports and services. We do not have further available information on the young person attending other hospital EDs in addition to the district hospital ED within the catchment area, largely, if not completely, due to a lack of communication between hospital EMRs. Our retrospective record review data interrogated set points in time and does not capture all the information from specific presentations. Further, a lack of information around the methods of classification of the data obtained at the time of presentation also hampers the interpretation of the data collected from the retrospective record review. This is a case report based on the retrospective study of de-identified data and it was not possible to provide the patient’s perspective.