To examine clinical and sociodemographic differences between psychiatric patients suspected of malingering and non-malingering controls in an urban emergency department (ED) setting.

We used retrospective chart review to compare 57 psychiatric patients suspected of malingering with 195 date-matched controls. We examined evidence used for malingering and documented secondary gains.

The prevalence of malingering was 5.6-7.1%, with documented evidence consistent with DSM-V guidelines. Malingering patients were more likely to be male (p <  .001), > 45 years old (p = .002), Black (p = .049), unhoused (p <  .001), and frequent users of ED (p <  .001). Psychiatric diagnoses were found in ~75% of malingerers. Diagnosis of antisocial personality (OR = 8.03, p = .013) and substance use disorder (OR = 2.05, p = .018) predicted increased probability of malingering. Malingering encounters were more likely to result in discharges (p <  .001). The most common secondary gains were unmet clinical needs.

Results support adaptational models of malingering. Malingering patients are more likely to have sociodemographic vulnerabilities. A disproportionate number of malingering patients have unmet needs for psychiatric treatment and resources. The study provides further evidence for inequities that may be related to social and structural determinants of health.