Comorbidities in Hispanic/Latino Veterans with epilepsy.

BACKGROUND: Hispanic/Latino people with epilepsy may be at a differential risk of medical and psychiatric comorbidities given genetic, environmental, sociocultural, and quality of care factors. In people with epilepsy, comorbidities are especially crucial to investigate given the well-known impact on quality of life and risk of adverse outcomes. Yet, Hispanic/Latino Veterans with Epilepsy (HL-VWE) remain an understudied population. The present nationwide population study sought to investigate medical and psychiatric comorbidities in this group. METHODS: Data from the Veterans Health Administration (VHA) Corporate Data Warehouse administrative data were used to identify 56,556 VWE (5.7 % HL-VWE) using a one-year cross-sectional analysis of ICD codes. Elixhauser Comorbidity Index scores and psychiatric diagnoses were calculated based on ICD-9/ICD-10-CM diagnoses using a lookback period. Comparisons were made between HL-VWE and non-HL-VWE using chi-squared and student t-tests. Regression analyses were then performed to examine group differences while accounting for age. RESULTS: HL-VWE had higher probability of being diagnosed with several psychiatric conditions when accounting for age, including depression (OR 1.21, 95 % CI 1.13-1.31) and schizophrenia (OR 1.56, 95 % CI 1.31-1.84). There were no significant differences in medical comorbidities between the HL-VWE and non-HL-VWE groups. CONCLUSIONS: We present results from the largest known study of HL people with epilepsy examining their psychiatric and medical comorbidities and one of the first to specifically study HL-VWE. Compared to non-HL-VWE, the Hispanic/Latino group had comparable medical comorbidity, but higher rates of multiple psychiatric conditions. Results indicate a need for increased screening and interventions in this population to reduce psychiatric disease burden.

Health care utilization of Hispanic/Latino veterans with epilepsy: A national population-based study.

OBJECTIVE: Hispanic/Latino people with epilepsy are a growing population that has been understudied in clinical epilepsy research. U.S. veterans are at a higher risk of epilepsy due to greater exposures including traumatic brain injury. Hispanic/Latino Veterans with Epilepsy (HL-VWEs) represent a growing population; however the treatment utilization patterns of this population have been vastly understudied. METHODS: HL-VWE were identified from administrative databases during fiscal year 2019. Variables compared between Hispanic and non-Hispanic VWEs included demographics, rurality, service era, utilization of clinical services/investigations, and service-connected injury. Chi-square and Student's t tests were used for comparisons. RESULTS: Among 56 556 VWEs, 3247 (5.7%) were HL. HL-VWEs were younger (59.2 vs 63.2 years; p < .01) and more commonly urban-dwelling (81.6% vs 63.2%, p < .01) compared to non-HL-VWEs. They were also more likely to have served in recent missions such as the Persian Gulf War and post- 9/11 wars (p < .01). HL-VWEs had a higher utilization of all neurology services examined including neurology clinic visits, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, electroencephalography (EEG), epilepsy monitoring, and comprehensive epilepsy care (p < .01 for all). HL-VWEs were more likely to visit an emergency room or have seizure-related hospitalizations (p < .01). HL-VWEs were more likely to have a service-connected disability greater or equal to 50% (p < .01). SIGNIFICANCE: This study is one of the largest cohorts examining HL-VWEs. We found higher utilization of services in neurology, epilepsy, and neuroimaging by HL-VWEs. HL-VWE are younger, more commonly urban-dwelling, and more likely to have served during recent combat periods and have higher amounts of service-connected disability. Given that the proportion of Hispanic veterans is projected to rise over time, more research is needed to provide the best interventions and mitigate the long-term impact of epilepsy on this diverse patient group.

Psychiatric Comorbidities in Women Veterans with Epilepsy.

Background: Women Veterans with epilepsy (WVE) may have unique psychiatric comorbidities that affect presentation, treatment, and outcomes. This large, nationally representative study of Veterans Health Administration (VHA) patients explores sex differences in psychiatric diagnoses and treatment to better characterize WVE. Methods: This study included a retrospective cohort design utilizing VHA Corporate Data Warehouse administrative data. Data from 58,525 Veterans with epilepsy (8.5% women) were obtained. Psychiatric diagnoses and treatment were analyzed, with comparisons between men with epilepsy and WVE. Secondary analyses included further exploration of select gynecological conditions. Results: WVE had higher psychiatric burden than men, as evidenced by higher rates of nearly all psychiatric diagnoses, including depression (59.1% vs. 38.9%; χ2 = 771.6), posttraumatic stress disorder (42.0% vs. 26.5%; χ2 = 549.1), and anxiety disorder (44.9% vs. 24.5%; χ2 = 977.7), as well as higher use of psychotropic medication prescriptions (2.3 vs. 1.4 average number of psychotropics prescribed). Furthermore, higher percentages of women versus men utilized the emergency room for psychiatric purposes (11.7% vs. 6.9%; χ2 = 153.06) and were hospitalized with psychiatric diagnoses (9.8% vs. 6.1%; χ2 = 100.95). Discussion: Veterans with epilepsy represent a unique group with high rates of psychiatric comorbidity. These results suggest that among Veterans, men and women with epilepsy have differing psychiatric comorbidities, leading to disparate health care needs. Based on this study's findings, WVE may require a different approach to care with an increased focus on specialized psychiatric treatment for WVE.

Patterns of psychotropic drug use in veterans with epilepsy: Do drug interactions matter?

RATIONALE: Patients with epilepsy are likely to suffer from psychiatric comorbidities, including depression and anxiety. They often require treatment with multiple psychotropic drugs (PDs). While it is clear that CYP-inducing ASMs (EIASMs) can increase the oral clearance of multiple medications (thus lowering systemic exposure), it is less clear that all PK interactions are clinically meaningful (e.g. lower efficacy). As a first step in addressing this issue, this study sought to quantify the potential impact of ASM choice, whether EIASM or non-inducer (NIASM), on surrogate markers of suggestive of clinical use, including resultant antidepressant (AD) or antipsychotic (AP) dose, frequency of combination use of AD & AP, and number of multiple drug switches of PDs. Our hypothesis is that because of PK interactions, EIAED treatment would be associated with higher psychotropic drug doses, more frequent Rx adjustments and poly psychotropic comedication, all in order to optimize therapeutic response. METHODS: Using VA pharmacy and national encounter databases, veterans with epilepsy were identified based on having a seizure diagnosis and being prescribed concomitantly an ASM and a psychotropic drug for at least 365 days between 10/1/2010 and 9/30/2014. Patients for whom psychotropic drugs were prescribed any time between beginning and end prescriptions dates of ASMs were considered. Among those, patients receiving both an EIASM + NEIASM concomitantly were categorized with the EIASM group. Patients were evaluated for AD only, AP only and both (AD & AP). To compute average drug doses per day, averages for each patient were computed and averaged again. Multiple drug switches were defined to be for patients who had been prescribed more than three psychotropic drugs during the observation period. Pearson's Chi-Square test was used to compare relative proportions of AD, AP and AD + AP in both groups. RESULTS: In all, 16,188 patients were identified (57.0% on EIASM, 43.0% on NIASM) with a mean age of 58.7 years (91.2% male). A larger proportion of patients on EIASM received mono treatment with any psychotropic drug, as compared to NIASM (42.0% vs 36.1%). Among all, 59.6% received AD only, 6.5% received AP only, and 33.8% received both concurrently. Of EIASM, 62.5% were on AD, 5.9% on AP, and 31.7% on both AP & AD. For NIASM, 55.9% received AD, 7.4% AP, and 36.7% on AD & AP.Chi-square showed that the distribution of PD was statistically different between EIASM and NIASM groups. Z tests showed that each difference (AD, AP and both) in proportions was statistically significant (p values (4 tests, one Chi-square, 3 Z tests <0.001) between EIASM vs NIASM. Interestingly, mean doses of AD or AP did not appear to differ between ASM groups. CONCLUSIONS: Concurrent psychotropic drug use is quite common in the VA population with epilepsy, and a large number of patients still receive enzyme-inducing ASMs that may complicate other medical therapies. Interestingly, in seeming contradiction to our hypothesis, mean daily doses of either AD or AP did not appear to differ between inducers vs non-inducers. Similarly, use of polytherapy, and/or multiple trials of various psychotropic drugs did not appear increased in the CYP-induced group. In fact, combination therapy of AD + AP was higher in NIASM than EIASM. These data suggest that perhaps these types of PK interactions may not in fact result in meaningful clinical differences. Since the present analyses did not include clinical psychiatric measures, future analyses examining direct clinical outcomes are clearly warranted.

Utilization of epilepsy care among Women Veterans: A population-based study.

OBJECTIVE: Higher healthcare utilization in epilepsy correlates with better clinical and quality of life outcomes. Women Veterans with epilepsy (WVE) have unique characteristics that may affect access and utilization of care. This study investigates epilepsy care in WVE, with respect to utilization of outpatient, inpatient, and emergency room care. METHODS: Data were collected from 58,525 Veterans with epilepsy using the Veterans Health Administration (VHA) Corporate Data Warehouse administrative data. Overall, 8.5% of the sample were women (n = 4983). Neurology visits, comprehensive epilepsy care, neuroimaging, ASM prescription and hospital and emergency care were analyzed, and comparisons were made with men Veterans with epilepsy to identify gender differences. RESULTS: Compared to men, a greater proportion of WVE utilized services including neurology (73.8% vs. 62.0%), comprehensive epilepsy care (16.1% vs. 11.7%), epilepsy monitoring unit evaluation (EMU; 6.1% vs. 2.9%), neuroimaging (CT: 39.1% vs. 36.6%; MRI: 43.7% vs. 32.5%), and electroencephalograms: (EEG: 36.5% vs. 29.1%). WVE also evidenced higher percentages of seizure-related emergency room care usage vs. men (15.2 vs. 12.6) and hospitalizations (12.3 vs. 10.0) and were prescribed a greater number of ASMs (average:2.3 vs. 1.9). Valproate was prescribed to 17.6% of WVE, despite potential teratogenic concerns. SIGNIFICANCE: WVE have greater utilization of epilepsy care within the VHA system compared to men, which could lead to better epilepsy management and quality of life. However, higher rates of emergency care, hospitalizations, and concurrent ASMs among WVE highlight the clinical complexity and raise concern for potentially comorbid conditions including psychogenic non-epileptic seizures.

An Update on the Healthy Soldier Effect in U.S. Veterans.

INTRODUCTION: The healthy soldier effect (HSE) describes a phenomenon of enduring health and lower mortality among veterans due in part to initial screening procedures and health care access. Although early data were supportive of a broad HSE among former military members, more recent investigations have suggested a possible attenuation of the effect with older age. The present study aimed to provide an update of the HSE using an expansive Veterans Health Administration (VHA)-wide sample with a particular focus on age and sex effects. MATERIALS AND METHODS: Mortality data for veterans within the VHA were obtained from the VHA Support Service Center program office and compared to mortality data from the general U.S. population spanning FY2014 to the second quarter of FY2020. The standardized mortality ratio (SMR) was calculated for the overall sample and for age- and sex-specific cohorts. Mortality rate ratios were also calculated and compared across sexes. RESULTS: Lower SMRs were observed in veterans compared to the general U.S. population (SMR 0.866). This effect was most prominent in younger and very old veterans, although a higher mortality was seen in the 55- to 64-year age cohort (SMR 1.371 for males and 1.074 for females). The HSE in females was lower than that in males in the <55-year age group but became higher in older cohorts. CONCLUSIONS: This is the largest investigation to date examining the HSE in U.S. veterans and includes younger veterans from more recent military eras. Higher mortality among the 55- to 74-year age groups merits further investigation, as does the relatively higher mortality among older female veterans. Our findings have implications for the provision of health care and preventative care to these veterans most at risk for higher mortality.

Psychiatric co-morbidity of drug-resistant epilepsy in Veterans.

OBJECTIVE: Psychiatric conditions are frequently co-morbid in epilepsy and studies examining Veterans with epilepsy suggest this population may present with unique psychiatric and clinical features Drug-resistant epilepsy (DRE) may confer a greater risk of psychiatric dysfunction; however, there is a paucity of literature documenting this. To expand our clinical understanding of Veterans with DRE, we assessed a comprehensive Veterans Health Administration (VHA)-wide sample, describing psychiatric conditions, medications, and healthcare utilization. METHODS: Psychiatric and hospitalization data were collected on 52,579 Veterans enrolled in VHA healthcare between FY2014-2ndQtr.FY2020 from the VHA Corporate Data Warehouse administrative data. Data examined include psychiatric diagnosis, psychotropic medication use, and utilization of hospital services. RESULTS: At least one psychiatric diagnosis was present in 70.2% of patients, while 49.8% had two or more diagnoses. Depression (51.7%), posttraumatic stress disorder (PTSD) (38.8%), and anxiety (38.0%) represented the most common psychiatric co-morbidities. Psychiatric medication use was present in 73.3%. Emergency room (ER) visits were highest in those with suicidality (mean 14.9 visits), followed by bipolar disorder (10.3), and schizophrenia (12.1). Psychiatric-related hospitalizations were highest for schizophrenia (mean 2.5 admissions) and bipolar disorder (2.3). Females had more psychiatric diagnoses (2.4 vs. 1.6, p < 0.001), psychiatric medications (3.4 vs. 2.3, p < 0.001), and ER utilization than males (6.9 vs. 5.5, p < 0.001). SIGNIFICANCE: A substantial psychiatric burden exists among Veterans with DRE. Compared to prior epilepsy literature, results suggest that Veterans with DRE evidence more prevalent psychiatric comorbidity, emergency care usage, and inpatient psychiatric admissions. Females were especially impacted, with greater rates of psychiatric conditions and treatment. Considering the relationship of psychiatric comorbidities in epilepsy with psychosocial functioning and quality of life, our findings highlight the need for screening and provision of services for those with DRE.

Association Between Standardized Mortality Ratio and Utilization of Care in US Veterans With Drug-Resistant Epilepsy Compared With All US Veterans and the US General Population.

Importance: Drug-resistant epilepsy (DRE) is thought to be associated with increased mortality, but larger population-based studies are lacking. Additionally, the benefit of effective management in DRE lacks evidence. Objective: To examine the association of utilization of care with mortality in US veterans with DRE. Design, Setting, and Participants: Observational cohort study conducted between October 1, 2013, and March 31, 2020. Mortality statistics in US veterans with DRE were compared to the US general population and all veterans within the Veterans Health Administration. Epilepsy was defined as use of 1 or more antiseizure medications (ASMs) for 30 days or longer with a seizure diagnosis or 1 inpatient or 2 outpatient encounters with an epilepsy diagnosis. DRE was defined as the use of 2 or more ASMs. Among 9.6 million US veterans, 164 435 (1.7%) had epilepsy, of whom 55 571 (33.8%) had DRE. Epilepsy and DRE were administratively identified based on criteria noted in design. Identified participants were included for analysis. Exposures: Veterans with DRE. Main Outcomes and Measures: Standardized mortality ratio (SMR). Results: Among US veterans with DRE, the mean (SD) age was 58.3 (15.4) years, and 49 430 individuals (88.9%) were male. Of ethnicity data gathered, 3170 individuals (5.7%) were Hispanic or Latino, 50 599 (91.1%) were not Hispanic or Latino, 842 (1.5%) declined to answer, and 960 (1.7%) were recorded as unknown. Of race data gathered, 516 individuals (0.9%) were American Indian or Alaskan Native, 270 (0.5%) were Asian, 11 316 (20.4%) were Black or African American, 587 (1.1%) were of multiple races, 453 (0.8%) were Native Hawaiian or Pacific Islander, 39 543 (71.2%) were White, 1697 (3.1%) declined to answer, and 1189 (2.1%) were recorded as unknown. SMR was 1.50 (95% CI, 1.47-1.53) compared with the US general population and 1.56 (95% CI, 1.53-1.59) compared with all veterans. Utilization rates were 81.1% (n = 45 057) for neurology clinic evaluation, 66.4% (n = 36 905) for magnetic resonance imaging (MRI), and 49.6% (n = 27 546) for electroencephalography (EEG) testing. Only 8350 individuals (15.0%) had comprehensive epilepsy evaluations and 3357 (6.0%) had epilepsy monitoring. Multivariable analysis revealed an association between lower mortality and neurology clinic evaluation, EEG, MRI, epilepsy monitoring, and the use of more than 2 ASMs after adjusting for age and comorbidities. Conclusions and Relevance: Mortality rates were significantly higher in US veterans with DRE compared to the general population. Better utilization of comprehensive epilepsy care, diagnostic services, and medications were each associated with reduced mortality. These findings indicate that appropriate management of DRE is critical in this population.

Antiepileptic Drugs and Suicidality in Veterans with Seizures.

Objectives: Veterans and patients with epilepsy are at higher risk of suicide than the general population. Some studies suggest that antiepileptic drugs (AEDs) further increase the risk of suicide. The nature of the relationship between suicidality and epilepsy treatment needs clarification. We examined this relationship in a cohort of veterans with seizures. Methods: We performed a retrospective chart analysis of patients at the Philadelphia VA Medical Center with a diagnosis of seizure disorder between January 2000 and April 2007. Patients with suicidal ideation and/or suicidal behaviors were analyzed with respect to the following risk factors: age, history of traumatic brain injury (TBI), substance abuse and AED prescription. Results: 526 charts were reviewed, 385 of which met inclusion criteria. Patients with substance abuse were more likely to have suicidal ideation (adjusted odds ratio 3.37, 95% CI 1.84 -6.18). Risk decreased with age (adjusted odds ratio 0.94, 95% CI 0.92 - 0.97 for each year). There was no statistically significant relationship between suicidality and AED use or history of TBI. Conclusion: In our population, AEDs were not associated with increased risk of suicidality, whereas substance abuse was associated with a substantial risk increase. The interactions among seizures, suicidality, substance abuse and other neuropsychiatric diseases are complex. Large-scale studies in patients with seizures are needed to understand the impact of individual drugs and other contributing factors. Providers should be cautious not to withhold potentially beneficial treatment, however patients with risk factors such as history of substance abuse should be followed closely after AED initiation or adjustment.

Implementation of an established algorithm and modifications for the identification of epilepsy patients in the veterans health administration.

Identification of epilepsy patients from administrative data in large managed healthcare organizations is a challenging task. The objectives of this report are to describe the implementation of an established algorithm and different modifications for the estimation of epilepsy prevalence in the Veterans Health Administration (VHA). For the prevalence estimation during a given time period patients prescribed anti-epileptic drugs and having seizure diagnoses on clinical encounters were identified. In contrast to the established algorithm, which required inclusion of diagnoses data from the time period of interest only, variants were tested by considering diagnoses data beyond prevalence period for improving sensitivity. One variant excluded data from diagnostic EEG and LTM clinics to improve specificity. Another modification also required documentation of seizures on the problem list (electronic list of patients' established diagnoses). Of the variants tested, the one excluding information from diagnostic clinics and extending time beyond base period of interest for clinical encounters was determined to be superior. It can be inferred that the number of patients receiving care for epilepsy in the VHA ranges between 74,000 and 87,000. In the wake of the recent implementation of ICD-10 codes in the VHA, minor tweaks are needed for future prevalence estimation due to significant efforts presented. This review is not only beneficial for researchers interested in VHA related data but can also be helpful for managed healthcare organizations involved in epilepsy care aiming at accurate identification of patients from large administrative databases.

Characteristics of Veterans diagnosed with seizures within Veterans Health Administration.

The purpose of this report is to describe the demographics of Veterans diagnosed with seizures and taking antiepileptic drugs (AEDs) within the Veterans Health Administration (VHA) during fiscal year (FY) 2011 (October 1, 2010, to September 30, 2011), particularly with regard to comorbid traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Information collected included age; sex; Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) status; and relevant encounter diagnosis codes for seizures, TBI, and PTSD. During FY11, 87,377 Veterans with seizures on AEDs were managed within the VHA. Prevalence was 15.5 per 1,000, and annual incidence was 148.2 per 100,000. The percentages of comorbid TBI and PTSD were 15.8% and 24.1%, respectively. For OIF/OEF/OND Veterans, these percentages increased to 52.6% and 70.4%, respectively. PTSD and TBI are risk factors for both epilepsy and psychogenic nonepileptic seizures. Within the VHA, many Veterans experiencing seizures cannot be successfully treated with AEDs. The VHA Epilepsy Centers of Excellence promotes a multidisciplinary approach to increase and improve access to both epilepsy and mental health specialists for the care of epileptic and nonepileptic seizures.