Behind “Rise of Malingering” in ER Psychiatry: Why Better Patient Classification Matters

With increasing numbers of patients presenting at our nation’s already oversubscribed emergency departments (EDs) for mental healthcare, the Psychiatric Times recently posed a pointed question: Just how many patients have real psychiatric illness? It’s not rhetorical. Recent research suggests that up to 20% of psychiatric ED patients are “strongly or definitely” suspected of malingering, deliberately feigning or exaggerating symptoms, while suspicion exists for roughly one-third of all visits.

That’s a staggering proportion, and the trend appears to be rising. This shift brings with it a tangled web of clinical, operational, and ethical challenges that affect not only providers but also the patients most in need of timely, effective care.

The human and operational toll

When malingering is suspected, the impact extends far beyond the individual encounter. Clinicians are caught in a difficult balancing act to preserve empathy and patient dignity while assessing the possibility that someone is intentionally misrepresenting their condition. This is not merely a matter of annoyance or inconvenience. It can lead to moral injury in the form of the deep emotional distress that occurs when clinical professionals feel unable to provide the care they believe is right.

From an operational standpoint, suspected malingering consumes scarce resources. In already overburdened EDs, time spent on a suspected psychiatric malingerer can mean longer waits for patients in true crisis. Often, these patients require more labor resources due to the nature of their complaint, and this can both delay care of other patients as well as present significant safety risks. The risk for violence and adverse events increases if staffing is being consumed and concentrated on a few of these patients. Additionally, many ED’s do not have readily available psychiatric resources, i.e., psychiatric consultants, placing further burdens on the ED clinicians to safely make a diagnosis and disposition. 

Staffing models are already under strain by nationwide clinician shortages as well as constrained hospital budgets, yet must still account for the unpredictable demands of such encounters. The uncertainty inherent in these cases frequently requires longer evaluation periods, additional testing, and consultations across multiple departments, further stretching capacity.

The limitations of current screening

The ability to obtain precise clinical data that may aid another clinician in ruling out an acute heart attack is not readily available in such a succinct form to the behavioral clinician. This further complicates the ability to identify a patient as truly malingering at an earlier point in the visit. Commonly used instruments, such as the Structured Interview of Reported Symptoms (SIRS) or the Structured Inventory of Malingered Symptomatology (SIMS), are designed to identify inconsistencies or improbable symptom patterns. Yet, even these tools can misfire.

SIMS, for example, has been reported to have misclassification rates exceeding 70%. In other words, it may label genuine patients as feigning symptoms at alarmingly high rates. Such false positives can do real harm, undermining trust, delaying appropriate treatment, and stigmatizing individuals already in distress. These tools also work best when used in conjunction with skilled clinical judgment. Over-reliance on automated or checklist-based approaches risks reducing nuanced human experiences to binary outcomes: “genuine” or “faking.” Mental illness is not that tidy.

The ethics of suspicion

The ethics of malingering in psychiatry are also complicated. On one hand, deliberately fabricating symptoms can divert limited resources away from those in acute crisis and erode public trust in behavioral health systems. On the other hand, even when malingering is suspected, the underlying motivations often point to real and pressing needs, including homelessness, substance use disorder, escape from interpersonal violence, or untreated medical conditions.

In the ED setting, clinicians are well aware that even the repeat medical malingerer who constantly comes in complaining of chest pain, may actually present at one point with a real heart attack. This is also true of the patient who repeatedly comes in with a complaint of suicidality.

For many, the ED is the only accessible point of entry into the healthcare system. If an individual presents with fabricated symptoms as a means to secure shelter or safety, it raises the question: is the behavior a calculated manipulation, or a desperate adaptation? The answer often lies somewhere in between.

Regardless, clinicians face the dual obligation to safeguard their resources and to treat each patient with respect and compassion. This means suspicion should never translate into dismissal without a thorough and fair assessment.

Why better patient classification matters

Addressing the rise of malingering in ED psychiatry doesn’t start and end with detection. It begins with more comprehensive patient classification. In this context, classification means understanding and documenting who the patient is in relation to the system. For instance, has the ED seen this patient before, for how long, what was the diagnosis, how they were discharged in the past, why they are presenting now, what interventions will have the most impact, and do  they meet the diagnostic criteria for  psychiatric illness? Better classification systems and more rapid access to historical patient data as a part of these systems can help clinicians:

• Distinguish urgent psychiatric crises from non-psychiatric drivers of ED visits: Recognizing when underlying social, medical, or legal issues are the real drivers allows for appropriate routing of patients to social services, case management, or medical care.
• Streamline throughput without compromising care: Classifying patients accurately on arrival can help prioritize those at highest clinical risk while still ensuring others receive the support they need in more appropriate settings. Inpatient psychiatric beds are indeed scarce and must be used wisely.
  Reduce reliance on low-specificity screening tools: Integrating comprehensive patient classification into the triage process provides a more complete picture of the patient’s history and circumstances, rather than relying solely on symptom checklists.
• Protect patient dignity and trust: Even in cases of suspected malingering, patient classification done well ensures the patient is heard, their needs are documented, and their interaction with the system is respectful.
  

Moving toward a balanced approach

The discussion about suspected malingering should not lead to cynicism in psychiatric care. Rather, it’s a claxon call for more thoughtful, systematic approaches to account for the full complexity of patient presentations. This means investing in:

• Training for staff to recognize patterns without prematurely labeling patients.
• Interdisciplinary collaboration and better workflows between psychiatry, social work, nursing, and medical teams.
• Policies that safeguard against risk of misclassification while still enabling timely identification and interventions for those in true psychiatric crisis.
• Thoughtful use of AI and data-driven analysis for necessary feedback loops to more rapidly identify and inform trends in patient presentations, helping facilities more precisely refine triage protocols over time.
  

Better classification improves efficiency and fosters equity. It ensures that the patient in psychosis waiting for an inpatient bed isn’t competing for resources with someone who needs detox, housing support, or protection from domestic violence. All deserve care, but the pathways should differ.

Looking ahead

The reality is that malingering will continue to exist in some form. But rising rates of suspicion in EDs should not translate into eroded trust or diminished care. By focusing on accurate classification from the outset, we will create systems that respond more effectively to the full spectrum of patient needs, reduce clinician burnout, and protect scarce behavioral health resources.

Behind every ED patient presentation there is a human story. Better classification ensures those stories are heard and addressed in the right setting, at the right time, with the right resources, period.

Photo: Bigstock

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