Early Detection Saves Lives
After 50 it's time to get tested-for everything.
Here's a statistic that may surprise you: At least one in six visits to an emergency department in the Halifax area involves a physical complaint with no discernable cause. Seventy-five per cent of chest pain complaints and roughly 88 per cent of abdominal pain cases have causes that cannot be determined by emergency physicians.
Now, two doctors at the QEII Health Sciences Centre in Halifax have begun a collaboration designed to get to the root of these unexplained symptoms, and to help ease the burden created by repeat visits to emergency rooms. Award-winning psychiatrist and former emergency physician, Dr. Allan Abbass, and his colleague, Dr. Sam Campbell, chief of emergency medicine at the QEII, contend that high numbers of emergency room patients who have medically unexplained symptoms may be experiencing physical manifestations which are actually related to difficulties in handling emotion.
There is a way to diagnose and treat these patients. The treatment, called Intensive Short-Term Dynamic Psychotherapy, or ISTDP, allows for a rapid diagnosis of emotional factors, and in emergency cases, requires a very short course of treatment, averaging four sessions.
Making a connection between a patient's painful physical symptoms and strong emotions is one of the main objectives of the therapy. Many patients are unaware that their emotions are contributing to or driving these symptoms.
"The treatment we use is very effective with panic," says Dr. Abbass. He notes that people can completely stop having panic attacks after just a few sessions. "It is significantly better than medication alone," he says, adding that antidepressants, antipsychotics, and anti-anxiety medications, which are often prescribed for panic and anxiety disorders, are often not needed once a patient has had the treatment. Those medications are also sedatives, which Abbass says make it harder for patients to access their emotions.
"The standard way we do these interviews allows us to see how a person responds physically when emotions are mobilized," he says. "It's a physical event when a person has an emotion like anger-it's in the body. If a person is frightened of intense feelings, such as rage, being triggered from some old event, then they become anxious. Instead of feeling the emotion, their body responds with physical symptoms, and they get sick," says Abbass, who lists muscle tightening or weakness, bowel symptoms, confusion, visual and hearing problems and faintness as some of the possible symptoms of repressed emotion.
Physicians in emergency departments around Halifax are beginning to make these connections. According to Abbass, the mandate for emergency doctors has always been to treat the most urgent, life-threatening cases and move on, often leaving these patients with no explanation for their frightening chest pain, shortness of breath or abdominal pain. With these potentially dangerous symptoms, the patients may receive a costly medical workup each time they return to the emergency room.
"The emergency department expertise is medical and not psychological," says Dr. Abbass. "They have to deal with emergencies that are life-threatening, so there's a training gap. People aren't trained to evaluate these things, and (approaching illness from a psychological perspective) hasn't historically been a significant focus of emergency medicine."
Abbass and several colleagues from other medical specialties have formed a working group to take these ideas to the medical school curriculum at Dalhousie University in Halifax and to its campus in Saint John, NB.
"Second-year medical students now have a whole week of curriculum on emotions and health, which is teaching them to be aware of their own reactions, their own behavioural responses, what's happening with the patient, and how the patient physically responds to his or her own emotions. This new curriculum focus is going to help shift the philosophy of care," says Dr. Abbass. "Over the last 10 years, I've been providing annual videotaped workshops to surgery residents, family medicine residents and several other groups and medical specialties. Dalhousie is leading the way in this. We don't know of another place in the country which has this content built into their curriculum. It is really good news for people in the Maritimes," he says.
It is his hope that ISTDP will eventually reach more patients outside the city and the province. Currently, about 15 per cent of users come from outside Nova Scotia. "Because it is short, it is a lot more cost-effective, so we have many people from out of the province, and even some from out of the country flying in for the treatment," he says. "We have already had contact from other Canadian provinces and from several other countries about this service."
The emergency department at the QEII now has on-site psychologists six days a week, and more change may be on the way. Dr. John Ross's recent report on emergency care in the province of Nova Scotia recommended that ERs employ Abbass' progressive, cost-cutting techniques across the province.
With eight per cent of hospital admissions at the QEII Health Sciences Centre attributed to unexplained symptoms, the costly problem extends beyond the emergency department. Abbass also provides ongoing outpatient care through his Centre for Emotions and Health.
"In a study we are doing right now of 890 patients, we have seen a sustained 50 per cent drop in hospital use in people we treated. These people have all sorts of problems, from eating disorders, to depression, to personality disorders, psychosis and bipolar disorder. We provide a brief course of treatment, averaging seven sessions, and it seems to make a big dent in their hospital and physician use," says Dr. Abbass.
"The difference in the cost of these patients, in terms of physician use and hospital is $4.3 million. The treatment only costs $1,000, and it saves $5,000 per patient within the medical system," he says. "Although it is not a panacea, about three-quarters of patients make and maintain gains-not bad for a short treatment."