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Meyer B, Betz LT, Brückner K, Holtkamp M. Enhancing quality of life in epilepsy with a digital intervention (emyna): Results of the ELAINE randomized controlled trial. Epilepsia Open 2024; 9:1758-1771. [PMID: 39167060 PMCID: PMC11450619 DOI: 10.1002/epi4.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/23/2024] [Accepted: 06/17/2024] [Indexed: 08/23/2024] Open
Abstract
OBJECTIVE Despite the availability of pharmacological treatment for seizures, people with epilepsy (PwE) commonly experience impairments in quality of life (QoL). Given the limited access to psychosocial treatments for PwE, digital interventions could bridge treatment gaps and help improve QoL. The objective of this study was to examine the effectiveness of emyna, a fully automated digital intervention based on cognitive behavioral therapy (CBT) techniques, in improving health-related QoL among PwE who reported impairments in QoL. A previous trial showed that emyna was effective in improving depressive symptoms among PwE with a comorbid depressive disorder, but its effects on QoL among PwE without comorbid depression remain unknown. METHODS A pragmatic randomized controlled trial was conducted with N = 438 PwE (mean age = 37.5, 70.3% women, physician-verified diagnoses) who were assigned to the intervention group (n = 216), which used emyna alongside treatment as usual (TAU), or the control group (n = 222), which received TAU only. QoL and secondary outcomes such as general self-efficacy, medication adherence, general distress, and epilepsy-related work and social adjustment were assessed at baseline, 3 months, and 6 months. The primary outcome was QoL assessed with the Quality of Life in Epilepsy [QOLIE-31] total score at 3 months post-randomization. RESULTS Findings from the intent-to-treat analyses showed that after 3 months, participants in the intervention group experienced significant and clinically relevant improvements in health-related QoL compared to the control group (baseline-adjusted group difference = 4.5; 95% CI = [2.0, 6.9], p < 0.001; Cohen's d = 0.32). Effects on secondary outcomes did not reach statistical significance. SIGNIFICANCE This study extends previous research by demonstrating that emyna facilitates improvements in QoL in a diverse group of PwE treated in routine care settings. This CBT-based digital intervention therefore presents a convenient and cost-effective addition to healthcare providers' treatment repertoire. PLAIN LANGUAGE SUMMARY In our study, we tested a digital program called emyna, which conveys cognitive behavioral therapy (CBT) techniques to help improve the quality of life for people living with epilepsy. We found that those who used emyna alongside their usual treatments felt better about their quality of life compared to those who did not use the program. Emyna offers a new, convenient way for people with epilepsy to manage their condition, which can be used alongside currently available treatments.
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Affiliation(s)
- Björn Meyer
- Research & Development DepartmentGAIA GroupHamburgGermany
| | - Linda T. Betz
- Research & Development DepartmentGAIA GroupHamburgGermany
| | - Katja Brückner
- Department of Neurology and Epileptology, Epilepsy Center HamburgEvangelical Hospital AlsterdorfHamburgGermany
| | - Martin Holtkamp
- Department of Neurology, Epilepsy‐Center Berlin‐BrandenburgCharité‐Universitätsmedizin BerlinBerlinGermany
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Munger Clary HM, Snively BM, Kumi-Ansu Y, Alexander HB, Kimball J, Duncan P, Conner K, Christopher J, Lohana P, Brenes GA. Quality of life during usual epilepsy care for anxiety or depression symptoms: Secondary patient-reported outcomes in a randomized trial of remote assessment methods. Epilepsy Res 2024; 204:107396. [PMID: 38908323 PMCID: PMC11457121 DOI: 10.1016/j.eplepsyres.2024.107396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/28/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND AND OBJECTIVES Anxiety and depression are highly prevalent and impactful in epilepsy. American Academy of Neurology quality measures emphasize anxiety and depression screening and quality of life (QOL) measurement, yet usual epilepsy care QOL and anxiety/depression outcomes are poorly characterized. The main objective was to assess 6-month QOL, anxiety and depression during routine care among adults with epilepsy and baseline anxiety or depression symptoms; these were prespecified secondary outcomes within a pragmatic randomized trial of remote assessment methods. METHODS Adults with anxiety or depression symptoms and no suicidal ideation were recruited from a tertiary epilepsy clinic via an electronic health record (EHR)-embedded process. Participants were randomized 1:1 to 6 month outcome collection via patient portal EHR questionnaires vs. telephone interview. This report focuses on an a priori secondary outcomes of the overall trial, focused on patient-reported health outcomes in the full sample. Quality of life, (primary health outcome), anxiety, and depression measures were collected at 3 and 6 months (Quality of Life in Epilepsy-10, QOLIE-10, Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory-Epilepsy). Change values and 95 % confidence intervals were calculated. In post-hoc exploratory analyses, patient-reported anxiety/depression management plans at baseline clinic visit and healthcare utilization were compared with EHR-documentation, and agreement was calculated using the kappa statistic. RESULTS Overall, 30 participants (15 per group) were recruited and analyzed, of mean age 42.5 years, with 60 % women. Mean 6-month change in QOLIE-10 overall was 2.0(95 % CI -6.8, 10.9), and there were no significant differences in outcomes between the EHR and telephone groups. Mean anxiety and depression scores were stable across follow-up (all 95 % CI included zero). Outcomes were similar regardless of whether an anxiety or depression action plan was documented. During the baseline interview, most participants with clinic visit EHR documentation indicating action to address anxiety and/or depression reported not being offered a treatment(7 of 12 with action plan, 58 %), and there was poor agreement between patient report and EHR documentation (kappa=0.22). Healthcare utilization was high: 40 % had at least one hospitalization or emergency/urgent care visit reported and/or identified via EHR, but a third (4/12) failed to self-report an EHR-identified hospitalization/urgent visit. DISCUSSION Over 6 months of usual care among adults with epilepsy and anxiety or depression symptoms, there was no significant average improvement in quality of life or anxiety/depression, suggesting a need for interventions to enhance routine neurology care and achieve quality of life improvement for this group.
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Affiliation(s)
- Heidi M Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Beverly M Snively
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Yaw Kumi-Ansu
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Halley B Alexander
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - James Kimball
- Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Pamela Duncan
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kelly Conner
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Physician Assistant Studies, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jerryl Christopher
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Paneeni Lohana
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Gretchen A Brenes
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Lim KS, Wong KY, Chee YC, Fong SL, Yu X, Ng CG, Tang V, Lai ST, Audrey C, Shauna A, Tan CT. Feasibility of psychological screening in a tertiary epilepsy clinic. Epilepsy Behav 2023; 148:109455. [PMID: 37774547 DOI: 10.1016/j.yebeh.2023.109455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/16/2023] [Accepted: 09/17/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE People with epilepsy (PWE) have a high prevalence of developing depression and anxiety. The objective is to determine the feasibility of brief screening tools to screen for depression and anxiety in epilepsy, and the predictive factors. METHOD This is a cross-sectional study in the neurology clinic in a tertiary teaching hospital in Kuala Lumpur. The screening tools used were the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and the General Anxiety Disorder Form (GAD-7). RESULTS Five hundred and eighty-five patients were recruited in this study, and 50.8% of them were male, predominantly Chinese (46.7%), with a mean age of seizure onset of 21.8 ± 16.1 years. The majority had focal seizures (75.0%), and 41.9% had seizure remission. There were 15.5% who scored ≥15 in the NDDI-E, and 17.0% had moderate or severe anxiety (scored ≥10 in the GAD-7). In a regression model to predict the NDDI-E score, the age of seizure onset recorded a higher beta value (β = -0.265, p =< 0.001), followed by the duration of epilepsy (β = -0.213, p =< 0.001), use of levetiracetam (LEV) (β = 0.147, p = 0.002), clonazepam (CLZ) (β = 0.127, p = 0.011), and lamotrigine (LTG) (β = 0.125, p = 0.011), number of current antiseizure medications (β = -0.124, p = 0.049), seizure remission for ≥1 year (β = -0.108, p = 0.011), and female (β = 0.082, p = 0.049). For the GAD-7 score, the predictors included current age (β = -0.152, p = 0.001), the use of LEV (β = 0.122, p = 0.011), Indian ethnicity (β = 0.114, p = 0.006), and the use of carbamazepine (β = -0.090, p = 0.043). CONCLUSION Implementation of simple psychological screening using self-administered questionnaires was feasible in a busy tertiary epilepsy clinic.
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Affiliation(s)
- Kheng-Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Kian-Yong Wong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong-Chuan Chee
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Si-Lei Fong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Xuen Yu
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong-Guan Ng
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Venus Tang
- Department of Clinical Psychology, Prince of Wales Hospital, Hospital Authority, Hong Kong; Division of Neurosurgery, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Siew-Tim Lai
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Christine Audrey
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Aminath Shauna
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chong-Tin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Xu ZYR, Shen CH, Cai MT, Zhang GF, Ding MP, Guo Y. Managing depression and anxiety in patients with epilepsy in eastern China: A survey of epilepsy health professionals in Zhejiang Province. Epilepsy Behav 2022; 127:108516. [PMID: 34991055 DOI: 10.1016/j.yebeh.2021.108516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/12/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We aimed to evaluate the assessment and management of epilepsy with anxiety and depression, and their clinical practice based on a survey. METHODS A cross-sectional survey of epilepsy health professionals was undertaken in Zhejiang Province using the modified International League Against Epilepsy (ILAE) Psychology Task Force questionnaire. We recorded the characteristics of participants and the practice of screening, referral, and treatment for depression and anxiety disorders. A total of 146 participants joined in the survey, of which 76.0% were neurologists, and 69 participants were the member of the Zhejiang Association Against Epilepsy (ZAAE). RESULTS This survey revealed that almost all participants (87.7%) agreed that screening for depression and anxiety in patients with epilepsy (PWEs) was very important; however, the frequency of screening was very low (41.1% of participants screened less than 10% of patients, and 34.2% participants screened between 10% and 30% of patients). A higher frequency of screening was reported in the member group and compared with that in the non-member group (P = 0.025). The main barrier to screening was the lack of time during clinic visits: 81.5% participants included screening questions as part of their clinical review. When anxiety/depression was diagnosed, the next step should be to refer patients to a psychiatrist (78.1%). No standardized procedures and lack of mental health specialists trained to assess and/or manage PWEs, were the main barriers to follow-up assessment and management. Lack of appropriately trained mental health specialists was also the main barrier to psychological treatment for depression and anxiety. CONCLUSION This survey highlighted that epilepsy healthcare professionals in Zhejiang province agreed on the importance of screening for psychiatric comorbidities in PWEs; however, the screening and management were actually insufficient. Certain barriers to screening, referral, and treatment were presented and improvements were recommended.
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Affiliation(s)
- Zheng-Yan-Ran Xu
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chun-Hong Shen
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meng-Ting Cai
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Gui-Fen Zhang
- Department of General Practice, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mei-Ping Ding
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Guo
- Department of Neurology, Epilepsy Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Department of General Practice, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Ongchuan Martin S, Sadeghifar F, Snively BM, Alexander H, Kimball J, Conner K, O'Donovan CA, Munger Clary HM. Positive anxiety or depression screen despite ongoing antidepressant prescription in people with epilepsy: A large cross-sectional analysis. Epilepsy Behav Rep 2022; 20:100572. [PMID: 36411879 PMCID: PMC9674492 DOI: 10.1016/j.ebr.2022.100572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/30/2022] [Accepted: 11/05/2022] [Indexed: 11/09/2022] Open
Abstract
Purpose While antidepressants are recommended to manage anxiety or depression in epilepsy, limited effectiveness data exist in real-world epilepsy samples, and prior work indicated frequent positive screens despite antidepressant prescription. In response, this study evaluates factors associated with positive anxiety or depression screen during ongoing antidepressant prescription. Methods Clinical and sociodemographic characteristics were collected among consecutive adult epilepsy clinic patients completing validated anxiety and depression instruments. The sample was divided by presence vs absence of existing antidepressant prescription at time of screening. Among those on an antidepressant, multivariable logistic regression was performed on pre-selected characteristics to evaluate for association with positive anxiety and/or depression screen. Pre-selected characteristics included: antidepressant dose, antidepressant prescriber specialty, antiseizure medications (number, potential psychotropic effects), seizure frequency, employment, visit no-shows, and medical insurance. Results Of 563 people with epilepsy, 152 had evidence of antidepressant prescription at time of screening and 73/152(48%) had positive anxiety and/or depression screen. Multivariable modeling demonstrated low antidepressant dose and no-show visit(s) were associated with positive screens (adjusted OR 2.29, CI 1.00-5.48 and 3.11, 1.26-8.22 respectively). Conclusion Low antidepressant dose and factors potentially associated with adherence (visit no-shows) may contribute to persistent anxiety and/or depression among epilepsy patients on an antidepressant.
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Affiliation(s)
| | - Fatemeh Sadeghifar
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Beverly M Snively
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Halley Alexander
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - James Kimball
- Department of Psychiatry, Wake Forest Unversity School of Medicine, Winston-Salem, NC, USA
| | - Kelly Conner
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Cormac A O'Donovan
- Department of Neurology and Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Heidi M Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Bermeo-Ovalle A. What Matters to You? Looking Beyond Seizure Freedom Following Epilepsy Surgery. Epilepsy Curr 2021; 21:339-340. [PMID: 34924829 PMCID: PMC8655247 DOI: 10.1177/15357597211030755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gandy M, Modi AC, Wagner JL, LaFrance WC, Reuber M, Tang V, Valente KD, Goldstein LH, Donald KA, Rayner G, Michaelis R. Managing depression and anxiety in people with epilepsy: A survey of epilepsy health professionals by the ILAE Psychology Task Force. Epilepsia Open 2021; 6:127-139. [PMID: 33681656 PMCID: PMC7918327 DOI: 10.1002/epi4.12455] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/09/2020] [Accepted: 11/23/2020] [Indexed: 01/19/2023] Open
Abstract
Objectives The Psychology Task Force of the Medical Therapies Commission of the International League Against Epilepsy (ILAE) has been charged with taking steps to improve global mental health care for people with epilepsy. This study aimed to inform the direction and priorities of the Task Force by examining epilepsy healthcare providers' current practical experiences, barriers, and unmet needs around addressing depression and anxiety in their patients. Methods A voluntary 27-item online survey was distributed via ILAE chapters and networks. It assessed practices in the areas of screening, referral, management, and psychological care for depression and anxiety. A total of 445 participants, from 67 countries (68% high income), commenced the survey, with 87% completing all components. Most respondents (80%) were either neurologists or epileptologists. Results Less than half of respondents felt adequately resourced to manage depression and anxiety. There was a lack of consensus about which health professionals were responsible for screening and management of these comorbidities. About a third only assessed for depression and anxiety following spontaneous report and lack of time was a common barrier (>50%). Routine referrals to psychiatrists (>55%) and psychologists (>41%) were common, but approximately one third relied on watchful waiting. A lack of both trained mental health specialists (>55%) and standardized procedures (>38%) was common barriers to referral practices. The majority (>75%) of respondents' patients identified with depression or anxiety had previously accessed psychotropic medications or psychological treatments. However, multiple barriers to psychological treatments were endorsed, including accessibility difficulties (52%). Significance The findings suggest that while the importance of managing depression and anxiety in patients with epilepsy is being recognized, there are ongoing barriers to effective mental health care. Key future directions include the need for updated protocols in this area and the integration of mental health professionals within epilepsy settings.
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Affiliation(s)
- Milena Gandy
- The eCentreClinicDepartment of PsychologyFaculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyAustralia
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical PsychologyCincinnati Children’s Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Janelle L. Wagner
- College of NursingMedical University of South CarolinaCharlestonSCUSA
| | - W. Curt LaFrance
- Departments of Psychiatry and NeurologyRhode Island HospitalBrown UniversityProvidenceRIUSA
| | - Markus Reuber
- Academic Neurology UnitRoyal Hallamshire HospitalUniversity of SheffieldSheffieldUK
| | - Venus Tang
- Department of Clinical PsychologyPrince of Wales Hospital, Hospital AuthoritySha TinHong Kong
- Division of NeurosurgeryDepartment of SurgeryFaculty of MedicineChinese University of Hong KongShatinHong Kong
| | - Kette D. Valente
- Department of PsychiatryFaculty of MedicineUniversity of Sao Paulo (HCFMUSP)Sao PauloBrazil
| | - Laura H. Goldstein
- Department of PsychologyInstitute of Psychiatry, Psychology and NeuroscienceKing’s College LondonLondonUK
| | - Kirsten A. Donald
- Division of Developmental PaediatricsDepartment of Paediatrics and Child HealthRed Cross War Memorial Children’s Hospital and the Neuroscience InstituteUniversity of Cape TownCape TownSouth Africa
| | - Genevieve Rayner
- Melbourne School of Psychological SciencesUniversity of MelbourneMelbourneVictoriaAustralia
| | - Rosa Michaelis
- Department of NeurologyGemeinschaftskrankenhaus HerdeckeUniversity of Witten/HerdeckeHerdeckeGermany
- Department of NeurologyUniversity Hospital Knappschaftskrankenhaus BochumRuhr‐University BochumBochumGermany
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Munger Clary HM, Croxton RD, Snively BM, Brenes GA, Lovato J, Sadeghifar F, Kimball J, O'Donovan C, Conner K, Kim E, Allan J, Duncan P. Neurologist prescribing versus psychiatry referral: Examining patient preferences for anxiety and depression management in a symptomatic epilepsy clinic sample. Epilepsy Behav 2021; 114:107543. [PMID: 33246893 PMCID: PMC7855561 DOI: 10.1016/j.yebeh.2020.107543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Anxiety and depression symptoms in epilepsy are common, impactful and under-recognized and undertreated. While prior survey data suggests equipoise among epileptologists for managing anxiety and/or depression via prescribing in the epilepsy clinic versus psychiatry referral, patient preferences are unknown and should potentially influence practice habits among epileptologists. Thus, the primary objective of this study was to determine patient preference for anxiety and/or depression prescribing by neurologists versus psychiatry referral among an adult epilepsy clinic sample of symptomatic patients. METHODS Management preferences for anxiety and/or depression were surveyed in an adult tertiary care epilepsy clinic. Individuals who screened positive for anxiety and/or depression symptoms on validated instruments during a routine care-embedded learning health system study were recruited. Demographics, social variables, psychiatric treatment history, and treatment priorities and preferences were surveyed. Preference was defined as a slightly greater than 2:1 ratio in favor neurology prescribing or psychiatry referral. The study was powered to assess this primary objective using a two-sample binomial test. Multinomial logistic regression examined an a priori multivariable model of treatment preference (secondary objective). RESULTS The study sample included N = 63 symptomatic adults, with 64% women and mean age 42.2 years. Most reported past or current treatment for anxiety and/or depression, and treatment for these symptoms was a high or moderate priority among 65.1% of the sample. Neurologist prescribing was preferred in 83.0% (nearly 5:1) over psychiatry referral among those who chose neurology or psychiatry (as opposed to neither of the two; p < 0.001, 95% CI 0.702-0.919). Overall, 69.8% of the total study sample preferred neurology prescribing. Multivariable modeling indicated preference for neither management option (compared with neurologist prescribing) was associated with low overall treatment prioritization and having never received neurologist medication management. None of the factors examined in the a priori multivariable model were associated with selecting psychiatry referral (compared to neurologist prescribing). CONCLUSION In this sample, most patients indicated a preference for neurologists to prescribe for anxiety or depression symptoms in the epilepsy clinic. Care models involving neurologist prescribing for anxiety and depression symptoms merit further investigation and potential adoption in clinical practice.
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Affiliation(s)
- Heidi M Munger Clary
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Rachel D Croxton
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Beverly M Snively
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Gretchen A Brenes
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - James Lovato
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Fatemeh Sadeghifar
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - James Kimball
- Department of Psychiatry, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Cormac O'Donovan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Kelly Conner
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Esther Kim
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Jonathan Allan
- Department of Psychiatry, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Pamela Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Munger Clary HM, Kimball J, Brenes G, O’Donovan C, Snively BM, Duncan P. Reply to Braillon. Epilepsy Behav 2020; 107:107049. [PMID: 32253146 PMCID: PMC9396821 DOI: 10.1016/j.yebeh.2020.107049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Heidi M. Munger Clary
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - James Kimball
- Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Gretchen Brenes
- Department of Internal Medicine, Section of Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Cormac O’Donovan
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Beverly M. Snively
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Pamela Duncan
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Who is willing to participate in research? A screening model for an anxiety and depression trial in the epilepsy clinic. Epilepsy Behav 2020; 104:106907. [PMID: 32000099 PMCID: PMC7282472 DOI: 10.1016/j.yebeh.2020.106907] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Anxiety and depression in epilepsy are prevalent, associated with poor outcomes, underrecognized, undertreated, and thus a key area of need for treatment research. The objective of this study was to assess factors associated with research participation among epilepsy clinic patients who screened positive for anxiety or depression. This was accomplished by characterizing clinical and psychiatric factors among patients seen in an epilepsy clinic and evaluating which factors were associated with consent for potential research participation, via a combined clinical and research screening model. METHODS In a pragmatic trial of anxiety and depression treatment in epilepsy, individuals with a positive screen for anxiety and/or depression at a routine epilepsy clinic visit were invited to opt-in (via brief electronic consent) to further eligibility assessment for a randomized treatment study. Information on psychiatric symptoms and treatment characteristics were collected for dual clinical care and research screening purposes. Cross-sectional association of demographic, clinical, and psychiatric factors with opting-in to research was analyzed by multiple logistic regression. RESULTS Among N = 199 unique adults with a first positive screen for anxiety and/or depression among 786 total screening events, 154 (77.4%) opted-in to further potential research assessment. Higher depression scores and current treatment with an antidepressant were independently associated with opting-in to research (depression odds ratio (OR) = 1.13 per 1-point increase in Neurological Disorders Depression Inventory-Epilepsy (NDDI-E) score, p = 0.028, 95% confidence interval (CI): 1.01-1.26; antidepressant OR = 2.37, p = 0.041, CI: 1.04-5.41). Nearly half of the 199 individuals (43.7%) with anxiety and/or depression symptoms were already being treated with an antidepressant, and 46.7% were receiving neither antidepressant therapy nor mental health specialty care. One-quarter (24.1%) reported a past psychiatric hospitalization, yet only half of these individuals were receiving mental health specialty care. SIGNIFICANCE Our results demonstrate a high willingness to participate in research using a brief electronic consent approach at a routine clinic visit. Adults with persistent anxiety or depression symptoms despite antidepressant therapy and those with higher depression scores were more willing to consider a randomized treatment study. This has implications for future study design, as individuals already on treatment or those with more severe symptoms are often excluded from traditional research designs. We also found a high burden of psychiatric disease and high prevalence of persistent symptoms despite ongoing antidepressant treatment.
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Scott AJ, Sharpe L, Thayer Z, Miller LA, Hunt C, MacCann C, Parratt K, Nikpour A, Wong T, Gandy M. Design and validation of two measures to detect anxiety disorders in epilepsy: The Epilepsy Anxiety Survey Instrument and its brief counterpart. Epilepsia 2019; 60:2068-2077. [PMID: 31560136 DOI: 10.1111/epi.16348] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The study objective was to develop and validate the first epilepsy-specific anxiety survey instrument (Epilepsy Anxiety Survey Instrument [EASI]) alongside a briefer screening instrument to detect anxiety disorders in routine clinical practice (brEASI). METHODS The instruments were developed utilizing a mixed-methods approach in four related studies. Pilot items were developed following qualitative interviews with people with epilepsy (PWE; Study 1) and consultation with multidisciplinary experts in anxiety and epilepsy (Study 2). PWE (n = 314) then completed pilot items alongside existing measures of anxiety and depression (Study 3). Factor analysis was conducted to refine the scale and select well-performing items for a briefer diagnostic screener (brEASI). The brEASI was validated against a gold standard diagnostic interview in 106 PWE recruited from an outpatient epilepsy service (Study 4). Receiver operating characteristic analysis was conducted to determine the brEASI's diagnostic performance. RESULTS Twenty-six pilot items were generated based on the findings of Studies 1 and 2. Analyses in Study 3 resulted in an 18-item EASI, and eight well-performing items were selected for the brEASI. The area under the curve (AUC) of brEASI was excellent (AUC = 0.89, 95% confidence interval = 0.82-0.94). At a cutoff of 7, it demonstrated a sensitivity of 76% and specificity of 84% for identifying Diagnostic and Statistical Manual of Mental Disorders, 5th edition anxiety disorders. SIGNIFICANCE The EASI and brEASI represent the first valid and reliable epilepsy-specific anxiety instruments. The EASI has been designed to comprehensively assess anxiety in PWE, whereas the brEASI may be used within busy neurology settings to provide rapid information to aid diagnoses of anxiety disorders. Given the significant prevalence and burden of anxiety in PWE, these tools are important potential solutions to improve the understanding and detection of anxiety in epilepsy.
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Affiliation(s)
- Amelia J Scott
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Louise Sharpe
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Zoe Thayer
- Comprehensive Epilepsy Service, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Australian Research Council Centre of Excellence in Cognition and Its Disorders, Sydney, New South Wales, Australia
| | - Laurie A Miller
- Comprehensive Epilepsy Service, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Australian Research Council Centre of Excellence in Cognition and Its Disorders, Sydney, New South Wales, Australia
| | - Caroline Hunt
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Carolyn MacCann
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Kaitlyn Parratt
- Comprehensive Epilepsy Service, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Armin Nikpour
- Comprehensive Epilepsy Service, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Australian Research Council Centre of Excellence in Cognition and Its Disorders, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Toh Wong
- Comprehensive Epilepsy Service, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Milena Gandy
- Department of Psychology, eCentreClinic, Macquarie University, Sydney, New South Wales, Australia
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Munger Clary HM, Salpekar JA. Should adult neurologists play a role in the management of the most common psychiatric comorbidities? Practical considerations. Epilepsy Behav 2019; 98:309-313. [PMID: 30471892 PMCID: PMC6614011 DOI: 10.1016/j.yebeh.2018.10.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/10/2018] [Accepted: 10/13/2018] [Indexed: 11/17/2022]
Abstract
Despite the high prevalence and negative impact of psychiatric comorbidities on the life of adults with epilepsy, significant unmet mental health care need exists because of a variety of factors, including poor access to mental health care providers. A potential solution to address access barriers is neurologist-driven diagnosis and management of common psychiatric conditions in epilepsy, of which mood and anxiety disorders are the most common. In this manuscript, patient selection criteria and practical treatment strategies are outlined for common mood and anxiety disorders that can be safely managed by neurologists. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".
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Affiliation(s)
- Heidi M Munger Clary
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America.
| | - Jay A Salpekar
- Departments of Psychiatry and Neurology, Johns Hopkins University, Baltimore, MD, United States of America
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13
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Bermeo-Ovalle A. Psychiatric comorbidities go untreated in patients with epilepsy: Ignorance or denial? Epilepsy Behav 2019; 98:306-308. [PMID: 30600177 DOI: 10.1016/j.yebeh.2018.11.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 11/21/2018] [Indexed: 01/16/2023]
Abstract
Psychiatric comorbidities are common in patients with epilepsy (PWE). Depression and anxiety are the most prevalent of these comorbidities and are associated with worse quality of life. Several screening tools are available to identify and follow up these conditions. However, time constrains in outpatient clinic visits and limited access to mental healthcare professionals discourage clinicians to use them. This paper discusses the advantage and limitations of screening tools and makes a compelling argument for neurologists to take an active role in the diagnosis and treatment of common psychiatric comorbidities in PWE. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".
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Affiliation(s)
- Adriana Bermeo-Ovalle
- Rush University Medical Center, Department of Neurological Sciences, 1725 West Harrison Street, Suite 885, Chicago, IL 60612, United States of America; Laboratory of Electroencephalography, 1725 West Harrison Street, Suite 885, Chicago, IL 60612, United States of America.
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Meyer B, Weiss M, Holtkamp M, Arnold S, Brückner K, Schröder J, Scheibe F, Nestoriuc Y. Effects of an epilepsy-specific Internet intervention (Emyna) on depression: Results of the ENCODE randomized controlled trial. Epilepsia 2019; 60:656-668. [PMID: 30802941 DOI: 10.1111/epi.14673] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Depression and anxiety are highly prevalent among people with epilepsy (PwE) but often remain unrecognized and treated inadequately. Effective psychosocial treatments such as cognitive behavioral therapy (CBT) are rarely available to most PwE, which is one reason electronically delivered CBT (eCBT) is regarded as promising. This study examined an eCBT intervention, termed Emyna, that was tailored to suit the needs of PwE. It includes CBT-related content on depression, stress and anxiety, seizure triggers and auras, and lifestyle habits. The trial examined the efficacy of Emyna in reducing symptoms of depression (primary outcome) and anxiety as well as improving quality of life. METHODS Participants (N = 200) with epilepsy, a diagnosis of a depressive disorder, and at least moderate depressive symptoms were randomized to Emyna or care as usual. At baseline and after 3, 6, and 9 months, participants were invited to complete online questionnaires. The primary outcome was improvement of depressive symptoms at 3 months. RESULTS Relative to the control group, intervention group participants experienced significantly greater improvements in depression, anxiety, stress, social-occupational impairment, and epilepsy-related quality of life, in both intention-to-treat (ITT) and per-protocol analyses. In ITT analyses, effects of medium magnitude were observed, as measured by the Patient Health Questionnaire-9 items (Cohen d = 0.54, 95% confidence interval [CI] = 0.25-0.82, P < 0.001) and the Neurological Disorders Depression Inventory for Epilepsy (d = 0.51, 95% CI = 0.23-0.79, P < 0.01). At 3 months, intervention group participants also reported fewer illness-related days off work and fewer days hospitalized over the preceding months, compared to control group participants (P ≤ 0.05), whereas no such differences were present at baseline (P > 0.30). SIGNIFICANCE These findings showed that Emyna, used adjunctively to usual care, could help improve mental health, social-occupational functioning, and quality of life among PwE. The program provides an additional treatment option that could produce clinically relevant symptom reductions and reduce key cost drivers (ie, hospitalization rates and illness-related inability to work).
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Affiliation(s)
- Björn Meyer
- Research Department, Gaia Group, Hamburg, Germany.,Department of Psychology, City, University of London, London, UK
| | - Mario Weiss
- Research Department, Gaia Group, Hamburg, Germany
| | - Martin Holtkamp
- Department of Neurology, Epilepsy Center Berlin-Brandenburg, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Arnold
- Clinic for Epilepsy, Schön Clinic Vogtareuth, Vogtareuth, Germany
| | - Katja Brückner
- Department of Neurology and Epileptology, Epilepsy Center Hamburg, Evangelical Hospital Alsterdorf, Hamburg, Germany
| | - Johanna Schröder
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Yvonne Nestoriuc
- Department of Clinical Psychology, Helmut Schmidt University, Hamburg, Germany
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Michaelis R, Schöller H, Höller Y, Kalss G, Kirschner M, Schmid E, Trinka E, Schiepek G. Integrating the systematic assessment of psychological states in the epilepsy monitoring unit: Concept and compliance. Epilepsy Behav 2018; 88:5-14. [PMID: 30212726 DOI: 10.1016/j.yebeh.2018.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Admission to the epilepsy monitoring unit (EMU) for long-term video-electroencephalography (EEG) monitoring (VEEG) constitutes the gold standard for seizure diagnosis and presurgical evaluation. This study applied the concept of a high-frequency systematic monitoring of psychological states and tested patients' compliance in order to evaluate if its integration in the EMU is feasible and if patients benefit from the graphically underpinned discussion of their EMU stay-related cognitions and emotions. METHODS The process-monitoring is technically realized by an internet-based device for data collection and data analysis, the Synergetic Navigation System (SNS). A convenient sample was enrolled: All eligible patients who were admitted to the EMU of the Department of Neurology, Christian Doppler Medical Center, Salzburg, Austria, between November 6th 2017 and January 26th 2018 were approached and recruited upon consent. After a short resource-oriented interview, each enrolled patient was provided with a tablet. The daily questionnaire included eight standardized and up to three personalized items. Self-assessments were collected every 5 h prior to meal times (6:30 am, 11:30 am, and 4:30 pm) and at 9:30 pm. The detailed visualizations of the patients' replies were discussed with the participants during a feedback session at the end of the EMU stay. RESULTS Twenty-one patients (12 women/9 men, median age 29 years [range 18-74 years]) were consecutively recruited (72% of all eligible patients). Compliance rates were high (median: 82%, range 60%-100%) among the respondents. Mood correlated strongly with hopefulness (r = 0.71) and moderately with energy (r = 0.63) in all patients. When correlating the intraindividual medians of the process questionnaire time series with the pretest total scores, energy correlated moderately and negatively with the Perceived Stress Scale (PSS) (r = -0.45), while self-efficacy correlated moderately and negatively with the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) total scores in all patients (r = -0.5). Nine patients (43%) reported that they learned something meaningful about themselves after the feedback discussion of their individual time series. CONCLUSION The results support the feasibility of high-frequency monitoring of psychological states and processes in routine EMU settings. Repeated daily collections four times per day of psychological surveys allow for the assessment of highly resolved, equidistant time series data, which gives insight into psychological states and processes during EMU admission.
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Affiliation(s)
- Rosa Michaelis
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany; Integrated Curriculum for Anthroposophical Medicine (ICURAM), Witten/Herdecke University, Herdecke, Germany.
| | - Helmut Schöller
- Institute of Synergetics and Psychotherapy Research, Paracelsus Medical University, Salzburg, Austria; Department of Psychiatry, Psychotherapy and Psychosomatics, Paracelsus Medical University, Salzburg, Austria
| | - Yvonne Höller
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Margarita Kirschner
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Elisabeth Schmid
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Centre for Cognitive Neuroscience, Paracelsus Medical University, Salzburg, Austria
| | - Günter Schiepek
- Institute of Synergetics and Psychotherapy Research, Paracelsus Medical University, Salzburg, Austria; Department of Psychiatry, Psychotherapy and Psychosomatics, Paracelsus Medical University, Salzburg, Austria
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Munger Clary HM, Snively BM, Hamberger MJ. Anxiety is common and independently associated with clinical features of epilepsy. Epilepsy Behav 2018; 85:64-71. [PMID: 29908386 PMCID: PMC6093217 DOI: 10.1016/j.yebeh.2018.05.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/12/2018] [Accepted: 05/12/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to assess for independent association of anxiety symptoms with epilepsy localization and other epilepsy-related and demographic factors in a large tertiary care adult epilepsy population. METHODS Among 540 adults, anxiety was measured by the Symptom Checklist 90-R (SCL-90R) anxiety subscale, and detailed demographics, epilepsy localization, and depression scores (SCL-90R) were collected. High anxiety was defined by SCL-90R anxiety T-score ≥ 60. Stepwise multiple logistic regression was carried out to assess for independent association of high anxiety scores with demographic and clinical factors. RESULTS High anxiety symptoms were present in 46.1% of participants (N = 250). Focal or unknown epilepsy type and depression scores were independently associated with high anxiety (adjusted odds ratios (OR): 2.89 (95% confidence interval [CI] = 1.33-6.29, p = 0.007) and 2.12 (95% CI = 1.83-2.45, p < 0.001), respectively; depression odds per 5-point increase in scale). Among the focal epilepsy subpopulation, mesial temporal sclerosis was also independently associated with high anxiety, with adjusted OR: 2.12 (95% CI = 1.11-4.04, p = 0.023). Lower education, non-white race/ethnicity, Spanish native language, prior head trauma, antiseizure drug polytherapy, and left focus or bilateral foci (in focal epilepsy) were associated with high anxiety in simple logistic regression, but these associations were not independent. A total of 46 individuals (18.4% of those with high anxiety) scored high for anxiety but not depression. Only 26% of those with high anxiety symptoms were taking a potentially anxiolytic medication. CONCLUSION Anxiety symptoms, often without concomitant depression, were highly prevalent in this epilepsy sample and independently associated with focal/unknown epilepsy and mesial temporal sclerosis. These results strongly support the value of screening specifically for anxiety in the epilepsy clinic, to direct patients to appropriate treatment.
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Affiliation(s)
- Heidi M. Munger Clary
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Beverly M. Snively
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Marla J. Hamberger
- Department of Neurology, Columbia University Medical Center, New York, New York, U.S.A
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