1. Contact: Allan Abbass 902473-2514, allan.abbass@dal.ca
Emotion-based Assessment and Treatment of Patients with Repeat Unexplained ED Visits Quality Award Winner 2010 Accreditation Canada Leading Practice
An Emergency Department and Centre for Emotions and Health Collaboration
Contact: Allan Abbass ,

2. Impact of Emotional factors in Capital Health
Hospital Days
Emergency use
Medical Visits
Tests + Procedures
Excess Medications
Poor Outcomes
Disability
Morbidity
Mortality
Physical Symptoms
Physical Illnesses
Low self care
Self Injury
Relationships
Low Compliance
Complaints
Emotion
Dysregulation

3. Great Overlap Between Common Problems
Headache
Confusion
Irritable Bowel
Dyspepsia
Abdominal pain
Bladder dysfunction
Pelvic Pain
Chemical
Sensitivity
Fibromyalgia
Fatigue
Hypertension
Chest pain
Psoriasis
Dermatitis
Conversion
Pseudoneurological
Phenomena
Depression
Anxiety
Panic

4. Great Overlap Between Common Problems
Headache
Confusion
Irritable Bowel
Dyspepsia
Abdominal pain
Emotion
Dysregulation
Bladder dysfunction
Pelvic Pain
Chemical
Sensitivity
Fibromyalgia
Fatigue
Hypertension
Chest pain
Psoriasis
Dermatitis
Conversion
Pseudoneurological
Phenomena
Depression
Anxiety
Panic

5. Unexplained Symptoms: Consecutive Referrals Nimnuan et al, 2001
Specialty
% with 1 or more unexplained symptoms
Gynecology 66
Neurology 62
Gastroenterology 58
Chest Clinic 51
Rheumatology 45
Total 52

6. Capital Health Excess Burden of Emotion-linked Medical Disorders
Emergency use: ~15-20,000 visits/yr
Hospital Days: ~13,000 days per year
Medical Visits: 25-50% of all new consults
Excess Tests + Procedures: ?
Excess Medications: ~$150,000/yr in Hospital
Suboptimal Outcomes: ? Cost
Excess Side effects: ? Cost: many admissions
Disability: ~$6,000,000/ year in Capital Health
Mortality: a measurable excess in reviews
Info from Emergency Database, Decision Support, Occupational Health and Pharmacy

7. Emergency Data
Unexplained Chest Pain, Headache, Panic, Abdominal Pain account for 16% of all CDHA ED Visits each year
75% of all Chest Pain complaints come out with no diagnosis: 9000 visits
88% of all Abdominal Pain complaints come out with no diagnosis: 7000 visits
   Wait Times

8. What is Intensive Short-term Dynamic Psychotherapy-ISTDP
A method based on videotaped research to diagnose and address problems handling emotions
Effective with broad range of physical and psychological problems
Actively researched and taught in our Centre
More information

9. Physical Problems treatable with ISTDP
Voluntary Muscle Tension
 Fibromyalgia, chest pain, abdominal pain, hyperventilation, panic attacks
Involuntary Muscle Tension
 Hypertension, IBS, Dyspepsia, Urinary symptoms, pelvic pain, migraine

10. Cognitive-perceptual Disruption
 dizziness, fainting, weakness, memory problems, accidents, injury, psychotic features
Motor Conversion
 Falling, loss of speech, spasm, weakness

11. How Effective is ISTDP 21 published outcome studies
Effective with multiple medical conditions and physical symptom syndromes
Marked drop in Dr and Hospital costs
Majority stop psychiatric medications
Around 85% of treated patients return to work from disabilities (several studies)
Single session brings 25% symptom reduction on average
Saves approximately 10 times what it costs each year through service use and disability reduction.

12. Medication Related Mixed office sample in BC Abbass, 2002

13. Health Care Utilization Abbass, Am J Psychotherapy, 2002

14. ISTDP reduced Repeat Emergency Visits for Medically Unexplained Symptoms Abbass, Campbell et al, Can J Emerg Med, 2009, 2010a, 2010b
Control
ISTDP
 Innovation Grant to staff ED with Diagnostic Clinicians

15. Implementation
Established long term relationship between CEH and ED
Provided videotape based education sessions to the emergency staff
Developed an information pamphlet for patients.
Introduced rapid access referrals to the service where emergency patients were seen in less than 2 weeks when possible.
Showed videotape of the emergency-referred cases we had seen.
Provided literature to emergency physician and other staff.
Provided a month of on-site consultation and liaison with emergency physicians.

16. Results Abbass, Campbell et al, 2009
3.8 sessions average
Significant Improvement on symptom measure (BSI)
High Patient Satisfaction ratings (~8/10)
Marked increase in referral rates by more Emergency Doctors
Major reduction in repeat Emergency Use (65-70% reduction)
“Net Cost saving” of 500 per patient
Funding received for 1.2 FTE Psychologists to staff the ED
Named Canadian Leading Practice by Accreditation Canada 2010
Nova Scotia expected to roll this program out to other emergency departments

17. Results (cont’d)
Simply understanding that emotional factors were responsible for symptoms was enough to reduce symptoms and ED use. Only 2 returned to ED, after assessment and during course of clinic.
Almost all patients were suitable referrals for service. Only 2 or 3 did not fit the service.
More complex patients needed coordinated Tx
While all had multiple issues, at the core of the problem was some form of attachment trauma in early life.
Nearly all were moderate resistant, highly resistant or fragile

18. Conclusions The service is widely acceptable and well used
Patients benefit with reduced ED visits
Service use reduction can help to reduce wait times
This service matches meeting the patient at point of entry, and
Exemplifies patient-centred care at Capital Health

19. More information
Canadian Journal of Emergency Medicine article:
Journal of Academy of Medical Psychology articles on Cost Effectiveness and Implementation
D%20Treatment.pdf
TDP%20in%20the%20ED.pdf