The effectiveness of psychological interventions for patients with relatively well-controlled epilepsy

Previous reviews about psychological interventions focused on refractory epilepsy patients and were inconclusive; this review investigates what the contribution of the psychologist can be for the large group of patients with relatively well-controlled epilepsy. This review was restricted to the literature reporting on adult patients with relatively well-controlled epilepsy. A literature search on the effect of psychological interventions was conducted using Medline and PsychInfo, including those studies published through March 2002. Applying strict inclusion criteria, a total of seven studies were identified. Four studies incorporated a waiting-list control group. Of these, one study addressing cognitive rehabilitation reported positive results on psychological outcome and one intervention based on comprehensive care led to seizure reduction, whereas all other studies were plagued too much by methodological inadequacies to allow firm conclusions to be drawn. Recommendations for future intervention studies, such as standardized interventions, controlling for positive attention, outcome measures without overlap with the intervention, and a follow-up measurement, are given. It is concluded that a concerted effort to assemble larger patient groups in randomized-controlled studies is a prerequisite to acquiring well-founded knowledge about psychological interventions in patients with relatively well-controlled epilepsy.     

癫患者心理治疗临床观察

目的 观察癫癎患者心理干预的效果.方法 应用格瑞思<症状自评量表SCL-90>,对317例癫癎患者的心理状态进行评估,在抗癫癎药物治疗的同时,以多种心理咨询方式对患者进行心理干预.结果 317例患者经心理干预后,干预组治疗前后疗效显著(P<0.01),对照组前后比较差别无统计学意义(P＞0.05),干预组追踪测试结果 与治疗后相比无明显差别,干预效果比较稳定(P＞0.05).结论 多数患者因心理障碍影响生活质量.心理干预是消除或减轻患者心理障碍的有效治疗方法 ,应成为癫癎综合治疗不可缺少的组成部分.     

Juvenile myoclonic epilepsy: Psychiatric comorbidity and impact on outcome

Juvenile myoclonic epilepsy (JME) is a well-defined age-related idiopathic epilepsy syndrome. Past studies have emphasized the difficulties in the treatment of patients with JME, which have been attributed to some specific psychiatric, psychological, and psychosocial characteristics. These aspects have aroused a significant amount of interest in the last two decades. In this article, the available studies that investigated the prevalence of psychiatric disorders (PDs) in JME and its impact on seizure outcome were reviewed in order to provide an update to clinicians about these two important aspects associated with this common epilepsy syndrome. The review disclosed a high prevalence of PDs in patients with JME, particularly mood, anxiety, and personality disorders. In addition, most recent studies have also observed that overall prevalence of PDs in JME has not shown statistically significant differences when compared with TLE, an epilepsy syndrome where the psychiatric aspects are most frequently studied. Taken together, data regarding the prevalence of PDs and their possible consequences on seizure outcome on JME indicate that special attention should be directed to psychological disturbances and psychiatric symptoms in this epilepsy syndrome. The early recognition and treatment of psychiatric symptoms, as well as psychological disturbances and psychosocial difficulties, should be considered fundamental to JME prognosis.This article is part of a supplemental special issue entitled Juvenile Myoclonic Epilepsy: What is it Really?     

Psychoeducation in bipolar patients with comorbid personality disorders

BACKGROUND: The co-occurrence of personality and bipolar disorders is quite common. Bipolar patients with personality disorders have been described as having poorer outcome than 'pure' bipolar patients. However, from a combined-approach point of view, a little has been done to improve the course of these patients. Psychoeducation has shown its efficacy in the prevention of relapses in the bipolar population but, to date, no data is available on its efficacy in the management of bipolar patients with personality disorders. METHOD: The present study shows a subanalysis from a single-blind randomized prospective clinical trial on the efficacy of group psychoeducation in bipolar I patients. Bipolar patients fulfilling DSM-IV criteria for any personality disorder were randomized to either psychoeducational treatment or a non-structured intervention. There were 22 patients in the control group and 15 in the psychoeducation group. All patients received naturalistic pharmacological treatment as well. The follow-up phase comprised 2 years where all patients continued receiving naturalistic treatment without psychological intervention and were assessed monthly for several outcome measures. RESULTS: At the end of the follow-up phase (2 years), a 100% of control group patients fulfilled criteria for recurrence versus a 67% in the psychoeducation group (p < 0.005). Patients included in the psychoeducation group had a higher time-to-relapse and a significantly lower mean number of total, manic and depressive relapses. No significant differences regarding the number of patients who required hospitalization were found but the mean duration of days spent in the hospitalization room was significantly higher for the patients included in the control group. CONCLUSION: Psychoeducation may be a useful intervention for bipolar patients with comorbid personality disorders. Further studies should address the efficacy of specifically tailored interventions for this common type of patients.     

A randomized, controlled, clinical trial of activity therapy for apathy in patients with dementia residing in long-term care

BACKGROUND: Apathy is a common symptom in patients with dementia and has adverse consequences for patients and caregivers. Most treatments for apathy, particularly non-pharmacologic interventions, have not been evaluated in controlled trials. OBJECTIVES: This study evaluated the efficacy of a kit-based activity intervention, compared to a time and attention control (one-on-one meetings with an activity therapist) in reducing apathy and improving quality of life in 37 patients with dementia. METHODS: The design was a randomized, controlled, partially masked clinical trial. All outcome measures were administered at baseline and follow-up. The primary outcome measure was the apathy score of the Neuropsychiatric Inventory (NPI). Other outcome measures were the NPI total score, the Alzheimer Disease Related Quality of Life scale(ADQRL), and the Copper Ridge Activity Index (CRAI). RESULTS: There was a significant reduction in NPI apathy scores in both treatment groups. The only significant difference between the two treatment groups was a modest advantage for the control intervention on the CRAI cueing subscale (p = 0.027), but not on the other CRAI subscales. There was also a greater within group improvement in quality of life ratings in the control intervention (p=0.03). CONCLUSIONS: Despite the substantial improvement in apathy scores during the course of the study, there was no clear advantage to the reminiscence-based intervention over the time and attention, one-on-one control intervention. More research is needed to develop specific behavioral interventions for apathy in patients with dementia.     

心理干预对癫患者焦虑抑郁情绪的影响

目的:探讨心理干预对癫患者焦虑抑郁情绪的影响。方法:对163例成人癫患者在抗癫治疗的同时实施为期3个月的心理干预;采用中文版Zung焦虑自评量表(SAS)及抑郁自评量表(SDS)分别于干预前、干预后1个月和3个月进行评定。结果:163例癫患者实施心理干预后焦虑和抑郁情绪改善显著,并随干预时间延长而显著下降。与干预前比较,干预1周,SAS及SDS评分与干预前差异无统计学意义(P=0.469、0.272);干预1个月和3个月,SAS及SDS评分与干预前比较差异有显著统计学意义(F=15.196、16.207,P均<0.001)。结论:癫患者焦虑抑郁情绪明显;心理干预能够显著改善患者焦虑抑郁情绪;干预时间越长,效果越好。     

Refractory Epilepsy: An Evaluation of Psychological Methods in Outpatient Management

Two groups of adult outpatients (n = 19 and n = 21) with poorly controlled epilepsy and significant psychological disorder, assessed in terms of rating scales, received two psychological treatments in a balanced cross-over design after stable baseline seizure frequency had been established. A third group (n = 19), who had poorly controlled epilepsy but no significant psychological disturbance received one type of psychological treatment after a stable baseline. The treatments were educational and were designed to improve coping skills. Weekly seizure frequency was monitored for 42 weeks, and self-rating measures of anxiety and depression were obtained before treatment and at the end of follow-up. All three groups showed a significant reduction in seizure frequency that was maintained at 6-month follow-up. The two groups with psychological symptoms showed a significant improvement in scores on the self-rating scales. We concluded that routine use of psychological intervention may be helpful in outpatient management of epilepsy.     

Comprehensive Care of the Epilepsy Patient—Control, Comorbidity, and Cost

Summary:  Traditionally, control of seizures in patients with epilepsy is viewed as the most important clinical outcome. Yet, current antiepileptic drugs (AEDs) do not always achieve this. Around 30–40% of patients remain uncontrolled despite pharmacological intervention. Poor tolerability of AEDs is a large part of the problem and contributes as much to the overall effectiveness of therapy as efficacy. Comorbid conditions are present in many patients, and appropriate management of these can further improve seizure control and quality of life. Patients with epilepsy often experience—among other disorders—neuropsychological effects, migraines, and psychological problems (especially anxiety and depression). Sleep disturbances are also common and have been shown to contribute to the intractability of seizures in some patients. Many anticonvulsant treatments have the potential to improve—or in some cases worsen—these concurrent conditions, and these properties should therefore be considered in the total care of the patient. Finally, the costs of uncontrolled epilepsy are measured not only in terms of direct healthcare-related costs, but also in terms of lost productivity and opportunity. The indirect costs of epilepsy are substantial and account for 70–85% of total disease-related costs. Patients with uncontrolled seizures contribute disproportionately to healthcare costs, reinforcing the need for the development of newer AEDs with improved profiles of efficacy and tolerability, but with minimal adverse effects on behavior, cognition, and sleep.     

Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers

OBJECTIVES. It has been convincingly demonstrated that in dementia, psychoeducative group intervention with caregivers positively impacts on motivation for care and satisfaction of the caregivers. It has, however, been neglected to examine the effect of psychoeducative group intervention on the behavioural and psychological symptoms of the demented patients. METHODS. In a 3-month, expert-based and conceptualized group intervention with caregiving relatives of demented patients we investigated whether behavioural and psychological symptoms may improve and which of a set of independent variables may predict improvement. RESULTS. The 3-month group intervention yielded a significant improvement in agitation and anxiety of the demented patients. The presence of an additional somatic disease in the patients and male gender predicted a less positive outcome of the intervention related to the presence of agitation. CONCLUSIONS. This study demonstrated that psychoeducative group intervention with the caregivers of demented patients is helpful for the demented patients themselves. This evidence of a positive mediator effect of the group intervention on the behavioural and psychological symptoms of the patients underscores the importance of nonpharmacological strategies in the treatment of dementia.     

Clobazam

Catastrophic childhood epilepsies such as infantile spasms (IS), progressive myoclonic epilepsy, and Lennox-Gastaut syndrome (LGS) are rare but debilitating and frequently persist into adulthood. Early, targeted use of medications that have demonstrated efficacy in the management of LGS or its associated epilepsies may simplify the patient’s treatment regimen and reduce the incidence of adverse events. Key to the overall benefit to the patient is to maximize seizure control while minimizing adverse effects, especially behavioral and cognitive problems. Clobazam has demonstrated clinical benefit and has been administered safely in more than 50 European studies in which data were reported on greater than 3000 pediatric and adult patients with epilepsy, 300 of whom were diagnosed with LGS; therefore, its use is now being investigated in the U.S. This review will explore the use of clobazam in the treatment of epilepsy, particularly with regard to its potential benefit in LGS. Though not currently approved for use in the U.S., a program is underway to gain Food and Drug Administration approval for the treatment of pediatric and adult patients with refractory epilepsy, specifically in LGS. A phase 2 study will be completed in late 2006 to investigate the safety and efficacy of clobazam as adjunctive therapy in 68 pediatric and adult patients with LGS.     

The use of Well-Being Therapy in childhood: clinical cases

Anxiety, mood and somatoform disorders are among the most prevalent forms of psychological suffering during childhood and adolescence. If untreated, these problems can be predictors of more severe disorders in adulthood. New trends in clinical psychology suggest the relevance of focusing on child's competencies and developing optimal functioning in youth. A specific psychotherapeutic strategy for enhancing well-being (Well-Being Therapy; WBT) has been developed for adult patients and it was found to be effective in determining remission from affective symptoms, in improving psychological well-being and in preventing relapses. In this article we describe a modified form of WBT which has been applied for the first time to children suffering from emotional and behavioral disorders in order to test its feasibility and potential effects in reducing symptoms and in improving new skills. Four cases particularly interesting by a clinical point of view are reported. This new therapeutic approach, based on the promotion of psychological well-being seems to be a very promising intervention: children improved at post treatment and during 1 year follow-up, both in symptomatology and in social skills. The promotion of psychological well-being and optimal functioning is an innovative and relevant ingredient and could play an important role in the treatment of somatic and psychosocial symptoms in paediatric settings.     

Treatment issues for children with epilepsy transitioning to adult care

This is the third of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper focuses on treatment issues that arise during the course of childhood epilepsy and make the process of transition to adult care more complicated. Some AEDs used during childhood, such as stiripentol, vigabatrin, and cannabidiol, are unfamiliar to adult epilepsy specialists. In addition, new drugs are being developed for treatment of specific childhood onset epilepsy syndromes and have no indication yet for adults. The ketogenic diet may be effective during childhood but is difficult to continue in adult care. Regional adult epilepsy diet clinics could be helpful. Polytherapy is common for patients transitioning to adult care. Although these complex AED regimes are difficult, they are often possible to simplify. AEDs used in childhood may need to be reconsidered in adulthood. Rescue medications to stop prolonged seizures and clusters of seizures are in wide home use in children and can be continued in adulthood.Adherence/compliance is notoriously difficult for adolescents, but there are simple clinical approaches that should be helpful. Mental health issues including depression and anxiety are not always diagnosed and treated in children and young adults even though effective treatments are available. Attention deficit hyperactivity disorder and aggressive behavior disorders may interfere with transition and successful adulthood but these can be treated. For the majority, the adult social outcome of children with epilepsy is unsatisfactory with few proven interventions.The interface between pediatric and adult care for children with epilepsy is becoming increasingly complicated with a need for more comprehensive transition programs and adult epileptologists who are knowledgeable about special treatments that benefit this group of patients.     

A longitudinal study of psychological features in patients before and two years after epilepsy surgery

This study aimed at investigating psychological features before and two years after epilepsy surgery. Fifty patients, 39 with temporal lobe epilepsy (TLE) and 11 with frontal lobe epilepsy (FLE), were assessed at baseline and two years postoperatively with the Karolinska Scales of Personality (KSP). Baseline group level outcome was normal while individual level analyses delineated some mild to moderate degrees of psychological problems exceeding the normal range in subsets of patients. Features of hostility characterized half of the FLE and one-fourth of the TLE patients. Above 1/3 in each group had dependency features. About 1/3 of the TLE patients suffered from psychasthenia. In conclusion, even though group levels were normal, several patients had psychological problems. The main longitudinal result was that the personality features were stable and did not change after epilepsy surgery.     

Do we need any more new antiepileptic drugs?

The last decade has seen the licensing of nine new antiepileptic drugs (AEDs) with more to come. Despite this, only 58 and 63% of patients with localisation-related and newly diagnosed epilepsy, respectively, had been seizure-free for more than a year in separate prospective outcome studies undertaken at the Epilepsy Unit in Glasgow. Data will be presented to support the hypothesis that adolescent and adult epileptic patients comprise two distinct populations. Around 60% will be controlled on monotherapy with the first or second choice AED, while the majority of the remainder is difficult-to-control. It is for this latter group and the many pharmacoresistant paediatric patients with encephalopathic syndromes that we need new AEDs. For a successful clinical outcome, patients must be able to tolerate the treatment. Neurotoxic, sedative, cognitive and psychiatric symptoms, dysmorphic and other long-term side effects, and teratogenesis plague the current crop of AEDs. Pharmacokinetic and pharmacodynamic interactions complicate the situation still further. These problems may, in part, be a consequence of combining drugs with similar mechanisms of action. Unravelling the genetics of the epilepsies will provide a range of tempting targets for pharmacological intervention. We need, also, models of refractory epilepsy to help identify promising therapies. An efficient regulatory trial programme will ensure rapid availability of new AEDs for the many children and adults whose lives continue to be blighted by seizures.     

Personality Assessment Inventory among patients with psychogenic seizures and those with epilepsy

The Personality Assessment Inventory (PAI) is a widely used self-report questionnaire designed to detect and quantify dimensions of adult psychopathology. Previous studies that examined the ability of the PAI to differentiate between patients with psychogenic nonepileptic seizures (PNES) and those with epilepsy (EPIL) have yielded inconsistent results. We compared the full PAI profiles of 62 patients with PNES, 55 with EPIL, and 45 normal control (NC) participants to determine the diagnostic accuracy of the PAI. We also sought to highlight psychopathologic symptoms that may inform psychological treatment of patients with PNES or epilepsy. PNES and EPIL patients reported more somatic concerns and symptoms of anxiety and depression than did NC persons. PNES patients reported more unusual somatic symptoms, as well as greater physical symptoms of anxiety and depression than did patients with EPIL. Classification accuracy of the "NES Indicator" was not much better than chance, whereas the Conversion subscale alone had reasonable sensitivity (74%) and specificity (67%). Overall, the PAI demonstrated only moderate classification accuracy in an epilepsy monitoring unit sample. However, the inventory appears to identify specific psychopathological symptoms that may be targets of psychological/psychiatric intervention.     

Epilepsy surgery in people with intellectual disability – English Version

In patients with refractory epilepsy, evaluation of epilepsy surgery should be part of the diagnostic work-up. Epilepsy and refractory epilepsy are common in people with intellectual disability. Therefore, epilepsy surgery with its chances of success and its risks has to be discussed. The presurgical diagnostic procedures may have to be adapted to the patientʼs cognitive and emotional abilities. Whether people with intellectual disabilities experience postoperative seizure freedom less frequently, has yet to be determined. Patients with genetic epileptic encephalopathies (particularly channelopathies) as well as non-lesional patients usually are not good surgical candidates. Neurocognitive functions usually do not suffer after epilepsy surgery in patients with intellectual disability. Even nonresective epilepsy surgery may be carried out with good outcome both in children and adult patients. Therefore, epilepsy surgery is an important tool in epilepsy care for people with intellectual disability.

     

Treatment of epilepsy in adults

Epilepsy is a chronic neurological disorder in adults and requires treatment with antiepileptic medication. While the majority of patients with epilepsy can be treated with medication, about one third will fail on medical treatment. Therefore, other treatment options such as surgery, devices, and the ketogenic diet are other options to consider, in addition to medical treatment. The treatment of epilepsy requires many other factors to be taken into consideration, and these include, but are not limited to, age, gender, coexistent medical conditions, and the use of concomitant medications. The goal of treatment is to provide optimal seizure control while using the least possible number of medications, particularly for young females at reproductive age or the elderly who may suffer from other medical diseases and receive other concomitant medications. Certain conditions may co‐exist with epilepsy, such as migraine, mood disorder, and memory disturbances, therefore the decision to choose the most appropriate medication for epilepsy patients should also involve treatment of these conditions. Here, we review current clinical practice in epilepsy and focus on the most common problems and conditions that clinicians face on a daily basis to treat adult patients with epilepsy. Side effect profiles, spectrum of efficacy and optimal choices per predominant type of seizures are summarized and can be used for educational purposes.     

Newly Diagnosed Epilepsy: Can Nurse Specialists Help? A Randomized Controlled Trial

PURPOSE: To describe a group of people with newly diagnosed epilepsy and to test the effect of an epilepsy nurse specialist on patients' knowledge of epilepsy, satisfaction with the advice provided, and psychological well-being. METHODS: Neurologists in the United Kingdom (U.K.) recruited adults with newly diagnosed epilepsy. Patients were randomized to receive the offer of two appointments with an epilepsy nurse specialist or usual medical care. The main outcome measures were a questionnaire assessing patients' knowledge of epilepsy, the Hospital Anxiety and Depression Scale, and patients' reported satisfaction with the advice and explanations provided on key epilepsy-related topics. RESULTS: Ninety people with new epilepsy completed the trial. At baseline, fewer than half the patients reported having been given enough advice on epilepsy, and there were important differences in patients' knowledge of epilepsy. Lack of a U.K. school-leaving examination pass (General Certificate School Examination) was associated with lower knowledge of epilepsy (p = 0.03). At follow-up, the patients randomized to see the nurse specialist were significantly more likely to report that enough advice had been provided on most epilepsy-related topics compared with the control group. There were no significant differences in knowledge of epilepsy scores. However, there were significant differences in the group who, at baseline, had knowledge scores in the lowest quartile; those randomized to the nurse had higher knowledge scores (42.7 vs. 37.2; p < 0.01). Compared with doctors, the nurse was highly rated for providing clear explanations. CONCLUSIONS: Patients who have less general education have less knowledge of epilepsy. The introduction of a nurse specialist in epilepsy is associated with a significant increase in patient reports that enough advice has been provided. Nurse intervention appears to help those with the least knowledge of epilepsy improve their knowledge scores.     

A Pilot Study of Mood in Epilepsy Patients Treated with Vagus Nerve Stimulation

Context. Antiepileptic drugs (AEDs) are frequently used for their beneficial mood effects.Objective. We sought to determine if there was a quantifiable effect on mood of the vagus nerve stimulator (VNS) when used as an antiseizure treatment.Design. Mood was assessed before and 3 months after VNS implantation in adult epilepsy patients. A group of adult epilepsy patients on stable AED regimens were used as a comparison group. AED regimens were unchanged during the study. The change in mood scale scores across time was assessed by t test (intragroup) and two-factor repeated-measures ANOVA (intergroup).Setting. An epilepsy center in a university hospital was the setting.Subjects. Twenty consecutive adult epilepsy patients undergoing VNS implantation to improve seizure control and twenty adult seizure patients with no intervention were enrolled.Main outcome measures. The mood scales used were the Cornell Dysthymia Rating Scale (CDRS) and the Hamilton Depression (Ham-D), Hamilton Rating Scale for Anxiety (Ham-A), and Beck Depression Inventory (BDI) scales.Results. The VNS group showed a significant decrease in mood scale scores across time (t test CDRS P = 0.001, Ham-D P = 0.017, BDI P = 0.045), indicating a decrease in depressive symptoms. The Ham-A scores in the VNS group and the comparison group scores did not significantly change across time. There were no significant differences between groups across time, although the BDI approached significance at P = 0.07. The VNS group had a significant decrease in seizure frequency compared with the comparison group (P = 0.01). There was no difference in mood scales over time between the VNS treatment responders (defined by >50% decrease in seizure frequency) and nonresponders, suggesting dissociation between seizure frequency reduction and mood change.Conclusion. VNS treatment is associated with mood improvement as measured by multiple scales, but differences in mood scale scores over time between the VNS and a comparison group were not found.     

良性癫痫儿童的生活质量

目的研究良性癫痫患儿的生活质量。方法采用癫痫患者生活质量量表对７７例良性癫痫儿童的生活质量进行测查评定，并与在年龄、性别、文化程度和学习成绩等方面严格匹配的７７名正常儿童进行对比。结果患儿组的生活质量明显低于正常组，与诊断疾病本身、病程、控制发作时间长短及长期服药等因素产生的心理障碍有关。结论除合理的药物治疗外，应对患儿进行包括心理干预的综合治疗。