AT AES 2016
HOUSTON (FRONTLINE MEDICAL NEWS) – Patients with psychogenic nonepileptic seizures who stick with evidence-based treatment have significantly fewer seizures and have less associated disability than do those who don’t make it to therapy and psychiatry visits, a study showed.
Reporting preliminary data from 59 patients in a 123-patient study , Benjamin Tolchin, MD, and his colleagues said that patients who adhered to their treatment plans were significantly more likely to experience a reduction in seizure frequency of more than 50%, compared with nonadherent patients (P = .018). Treatment dropout was positively associated with having a prior psychogenic nonepileptic seizure (PNES) diagnosis and with having less concern about the illness.
Speaking during a podium session at the annual meeting of the American Epilepsy Society, Dr. Tolchin , a fellow in clinical neurophysiology and epilepsy at Brigham and Women’s Hospital, Boston, said that “adherence with psychiatric treatment declines steadily over time.” Although 80% of the 123 patients he studied made it to their first postdiagnosis appointment, adherence dwindled to 14% by 18 months.
These figures, he said, are consistent with what’s been reported in the PNES literature. Others have found that after diagnosis, 20%-30% of patients don’t attend their first appointment, although psychiatric treatment and therapy constitute evidence-based care that is effective in treating PNES.
Dr. Tolchin said previous studies have found that “over 71% of patients were found to have seizures and associated disability at the 4-year follow-up mark.”
In addition to tracking adherence, Dr. Tolchin and his coinvestigators attempted to identify risk factors for nonadherence among their patient cohort, all of whom had documented PNES. Study participants provided general demographic data, and investigators also gathered information about PNES event frequency; any prior diagnosis of PNES or other psychiatric comorbidities; history of physical, emotional, or sexual abuse; and health care resource utilization. Patients also were asked about their quality of life and time from symptom onset to receiving the PNES diagnosis.
Finally, patients filled out the Brief Illness Perception Questionnaire (BIPQ) . This instrument measures various aspects of patients’ cognitive and emotional representations of illness, using a nine-item questionnaire. Higher scores indicate that the patient sees the illness as more concerning.
All patients were referred for both psychotherapy and four follow-up visits with a psychiatrist. The first psychiatric visit was to occur within 1-2 months after receiving the PNES diagnosis, with the next two visits occurring at 1.5- to 3-month intervals following the first visit. The final scheduled follow-up visit was to occur 6-9 months after the third visit.
Most patients (85%) were female and non-Hispanic white (77%), with a mean age of 38 years (range, 18-80). About one-third of patients were single, and another third were married. The remainder were evenly split between having a live-in partner and being separated or divorced, with just 2% being widowed.
By self-report, more than one-third of patients (37%) were on disability, and nearly one-quarter (24%) were unemployed. Just 18% were working full time; another 11% worked part time, and 8% were students.
The median weekly number of PNES episodes per patient was two, although reported events per week ranged from 0 to 350.
Psychiatric comorbidities were very frequent: 94% of patients reported some variety of psychiatric disorder. Depressive disorders were reported by 78% of patients, anxiety disorders by 61%, and posttraumatic stress disorder by 54%. Other commonly reported psychiatric diagnoses included panic disorder (40%), phobias (38%), and personality disorders (31%).
Almost a quarter of patients (23%) had attempted suicide in the past, and the same percentage reported a history of substance abuse. Patient reports of emotional (57%), physical (45%), and sexual (42%) abuse were also common.
Having a prior diagnosis of PNES was identified as a significant risk factor for dropping out of treatment (hazard ratio, 1.57; 95% confidence interval, 1.01-2.46; P = .046]. Patients with a higher concern for their illness, as evidenced by a higher BIPQ score, were less likely to drop out of treatment (HR, 0.77 for 10-point increment; 95% CI, 0.64-0.93; P = .008).
“Neurologists and behavioral health specialists need new interventions to improve adherence with treatment and prevent long-term disability,” Dr. Tolchin said.
The study, which won the Kaufman Honor for the highest-ranking abstract in the comorbidities topic category at the meeting, was supported by a practice research training fellowship from the American Academy of Neurology and the American Brain Foundation. Dr. Tolchin reported no other disclosures.
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