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Three Part Question

In [patients with medically unexplained symptoms] is there [an effective intervention] to [reduce rates of re-attendance]?

Clinical Scenario

40 year old gentleman presents to your emergency department complaining of chest pain. After a full work up, there is no evidence of cardiac pathology, but the patient remains very anxious and distressed. Looking through the notes, you see that this is the third time this month he has visited your ED for chest pain, despite having had angiography some months ago which was reported as normal. You wonder if you can offer anything to this patient to help him understand his symptoms.

Search Strategy

MEDLINE, EMBASE and PsycINFO were searched from earliest available data to March 2018
(Unexplain*.mp OR ((somatoform OR functional) adj5 (symptom* OR disorder* OR complaint*)).mp OR ((frequent adj1 attend*) OR (high adj1 utili*) OR hypochondri*).mp OR ((Headache OR 'chest pain' OR 'pelvic pain' OR 'benign pain' or 'back pain' OR gastrointest* OR seizure* OR fatigue OR 'irritable bowel' OR fibromyalgia) adj3 (psycholog* OR psychogen* OR psychosom* OR psychophysiol* OR functional OR non-cardiac OR noncardiac OR tension))
AND
(Treatment* or intervention* or therapy* or manage* or strateg* or communicat* or CBT or reattribution or ISTDP or psychotherap*).mp
AND
"emergency department".mp OR exp Emergency Service, Hospital/

Search Outcome

461 papers identified in MEDLINE, 949 in EMBASE, 598 in PsycINFO.
Of 1612 unique citations, 6 were identified for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Esler et al. 2003 USA	59 patients presenting to ED with NCCP given 60 mins of CBT involving psychoeducation about physical symptoms and breathing exercises.	Controlled pre-post intervention study	Chest pain frequency	Greater reduction of -10.47 episodes with CBT vs -7.94 without	Small sample, limited 3 month follow up period, self-reported outcome measures. Improvements seen may not be specific to the CBT intervention, could be due to spending time with a therapist (the placebo-attention effect) Issue with 'regression to the mean' - patients first presenting when symptoms are most severe so they will improve regardless of intervention.
			Chest pain severity	No significant reduction at 3 months
			Health anxiety and fear of cardiac symptoms	No significant reduction at 3 months
Mulder R. et al. 2017 New Zealand	424 patients with non-cardiac chest pain were randomised to either 3-4 sessions of CBT or treatment as usual and reassessed at 3 and 12 months	Pragmatic RCT	ED presentations	Reduced reattendance at 3 months but then no difference at 12 months	Published only as an abstract, unclear methods, inclusion criteria, and results
			Health anxiety	Reduced at 3 months but not significant at 12 months
Baker M. et al. 2013 England	20 patients with Medically Unexplained Symptoms who attended >12 times per year were identified offered weekly CBT with individualised care plans	Pre-post intervention	ED presentations	Reduced from average of 16.2 to 5 ED visits per patient per year	Published only as an abstract, small sample size, no control group
Abbass A. et al. 2009 Canada	50 patients identified with MUS or 'somatisation' in the ED were offered Intensive Short-Term Dynamic Psychotherapy (ISTDP) and reassessed at 1 year	Pre-post intervention	ED presentations	Reduced from 4.6 to 1.4 visits per year	Uncontrolled study, regression to the mean of symptom intensity, selection biases of referring doctors who may choose patients more likely to respond, and high loss to followup
			Brief Symptom Inventory ratings at first assessment and end of contact	Reduced from 1.21 to 0.86
Price P. et al. 2016 Australia	95 patients with non-cardiac chest pain were given phone based coaching sessions for self-management of their chest pain, then compared at 6 months with retrospectively matched controls	Controlled pre-post intervention	ED presentations (likelihood of representation over 30 days)	Intervention group two times less likely to attend ED (14.1% vs 27.7%)	Published only as an abstract, no randomisation, and short follow up period
			Inpatient admissions	No significant difference
Jirsch J. et al 2011 Canada	23 patients who had been diagnosed with psychogenic non-epileptic seizures and attended the ED frequently were retrospectively assessed to see if delivering the diagnosis of a psychogenic illness (confirmed by video/EEG telemetry) reduced the number of ED attendances over the following 2 years	Retrospective chart review	ED presentations	Reduced from 6.5 to 4 visits over 2 years	Weak study design of retrospective chart review, small sample size with no controls.
			ED visits classified as neurological	Reuced from 2.6 to 1.3 visits for neurological complaints

Comment(s)

Despite the fact that MUS is a huge problem for emergency departments, representing 4% of ED visits, we have found very little evidence for interventions against this problem. The six articles we found were of generally low quality. Whilst they potentially suggest that a moderate benefit, in terms of ED attendance and symptom severity, could be derived from offering brief CBT to these patients the evidence is contradictory and sparse. This conclusion is in keeping with the findings of larger systematic reviews of psychological interventions in other healthcare settings. A 2014 Cochrane review found low to moderate evidence of a small benefit of CBT over usual care for MUS patients in outpatient and primary care settings, although this may not be comparable in terms of treatment duration with a brief ED intervention

Clinical Bottom Line

Brief CBT may be promising for patients with MUS but more research is required.

References

1. Esler J. et al. A brief cognitive-behavioral intervention for patients with noncardiac chest pain Behaviour Therapy 2003; Volume 34 (2), 129-148
2. Mulder R. et al. Managing non-cardiac chest pain: An RCT comparing brief CBT with treatment as usual Australian and New Zealand Journal of Psychiatry 2017; Volume 51 (Supplement 1), 9-10
3. Baker M. et al. A Pilot Project Targeting Frequent Attenders At The Emergency Department With Medically Unexplained Symptomss Emergency Medicine Journal 2013; Volume 30 (10), 866
4. Abbass A. et al. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention stu Canadian Journal of Emergency Medicine 2009; Volume 11 (6), 529–534
5. Price P. et al. Effectiveness of a phone-based care coordination pilot on reducing hospital utilisation and costs for patients with chest pain Heart Lung and Circulation 2016; Volume 25 (Supplement 2), S7
6. Jirsch J. et al. Recognition of psychogenic non-epileptic seizures diminishes acute care utilization Epilepsy and Behaviour 2011; Volume 22 (2), 304-307