Depression and anxiety in caregivers of patients with functional seizures.

OBJECTIVE: Contrary to patients, the psychological impact of functional seizures to caregivers has not been adequately investigated. This study aimed to evaluate the rates and determinants of depression and anxiety in caregivers of patients with functional seizures. METHODS: Patients with functional seizures and their caregivers completed surveys about demographic, disease-related, and psychosocial characteristics. Rates and determinants of depression and anxiety were evaluated using the Beck Depression and Anxiety Inventory scores as dependent variables and patient and caregiver characteristics as independent variables. RESULTS: Twenty-nine patients (76% female, mean age of 37 years) and their caregivers (59% female, mean age of 43 years) were recruited. Symptoms of anxiety and/or depression were present in 96% of patients (96% depression, 92% anxiety) and 59% of caregivers (52% depression, 50% anxiety). Specifically, 31% of caregivers manifested mild depression, 14% moderate depression, and 7% severe depression, whereas 48% were not depressed. Similarly, 14% of caregivers manifested mild anxiety, 29% moderate anxiety, and 7% severe anxiety, whereas 50% were not anxious. Patient and caregiver depression levels strongly correlated (r = .73, p < .0001). The presence of anxiety and depression in the caregiver was associated with male patient gender (p = .02), patient depression level (p = .002), the caregiver being a parent or sibling (p = .02), and caregiver burden (p = .0009). SIGNIFICANCE: Caregivers of patients with functional seizures experience high rates of anxiety and depression, explained by specific demographic and psychosocial factors that could act as intervention targets.

Depression and Anxiety in Adult Persons With Epilepsy and Their Caregivers: A Survey-Based Study at a Tertiary Care Center.

ABSTRACT: This study evaluated the rates of depression and anxiety and their determinants in adult persons with epilepsy and their caregivers. Both completed surveys about demographic, disease-related, and psychosocial characteristics. One hundred patients and caregivers participated. A mood disorder was present in 89% of patients and 56% of caregivers. In the univariate analysis, the presence of mood disorder in the patient was associated with being unmarried, unemployed, frequent hospitalizations, side effects from polypharmacy, patient stigma, patient quality of life, caregiver anxiety, and caregiver burden. In the multivariate analysis, medication side effects sustained as an important determinant. In the univariate analysis, the presence of mood disorder in the caregiver was associated with seizure frequency, patient anxiety, patient quality of life, caregiver stigma, and caregiver burden. In the multivariate analysis, patient anxiety level and caregiver burden sustained as important determinants. Adult persons with epilepsy and their caregivers experience high rates of mood disorders, explained by certain clinical factors.

Translating Phenomenology of Psychogenic Nonepileptic Seizures Into Nosology: Insights From Patients' and Caregivers' Profiles.

BACKGROUND: Patients with psychogenic nonepileptic seizures (PNES) can be semiologically dichotomized into those with hyperkinetic and those with paucikinetic events. The objective of this study was to compare characteristics of patients with diverse phenomenology and their caregivers to evaluate for differences that could inform about disease nosology. METHODS: Patients and caregivers monitored at the Epilepsy Monitoring Unit completed surveys about sociodemographic and disease characteristics, treatment and health care utilization, physical and psychosocial impact, and epilepsy knowledge. Patients were classified into hyperkinetic versus paucikinetic based on their recorded events. Comparison of the 2 populations was performed using Student t test for continuous variables and Fischer exact test for categorical variables. RESULTS: Forty-three patients with Epilepsy Monitoring Unit confirmed PNES and 28 caregivers were enrolled. Patients with hyperkinetic events were more commonly non-White patients and necessitated greater caregiving time. Otherwise, no statistically significant differences were seen between the 2 semiologically diverse groups of patients and caregivers in their sociodemographic (age, sex, employment, income, marital, and education) and disease (age of onset, duration, seizures frequency) characteristics, treatment (number of antiseizure medications before diagnosis, side effects) and health care utilization (emergency room visits, hospitalizations, clinic visits), physical (injuries) and psychosocial (depression, anxiety, quality of life, stigma, burden) characteristics, nor in their knowledge about seizures. CONCLUSIONS: Hyperkinetic events were more frequently encountered in non-White patients and required more caregiving time. Further research is required to elucidate if phenomenological dichotomy of PNES can inform about their nosological basis, and if it can guide treatment and define prognosis.

DDESVSFS: A simple, rapid and comprehensive screening tool for the Differential Diagnosis of Epileptic Seizures VS Functional Seizures.

OBJECTIVE: Functional seizures (FS) are often misclassified as epileptic seizures (ES). This study aimed to create an easy to use but comprehensive screening tool to guide further evaluation of patients presenting with this diagnostic dilemma. MATERIALS AND METHODS: Demographic, clinical and diagnostic data were collected on patients admitted for video-EEG monitoring for clarification of their diagnosis. Upon discharge, patients were classified as having ES vs FS. Using the collected characteristics and video-EEG diagnosis, we created a multivariable logistic regression model to identify predictors of ES. Then, we trained an integer-coefficient model with the most frequently selected predictors, creating a pointing system coined DDESVSFS, with scores ranging from -17 to +8 points. RESULTS: 43 patients with FS and 165 patients with ES were recruited. In the final integer-coefficient model, 8 predictors were identified as significant in differentiating ES from FS: normal electroencephalogram (-3 points), predisposing factors for FS (-3 points), increased number of comorbidities (-3 points), semiology suggestive of FS (-4 points), increased seizure frequency (-4 points), longer disease duration (+3 points), antiepileptic polypharmacy (+2 points) and compliance with antiepileptic drugs (+3 points). Cumulative scores of ≤ -9 points carried <5% predictive value for ES, while cumulative scores of ≥ -1 points carried >95% predictive value. The model performed well (AUC: 0.923, sensitivity: 0.945, specificity: 0.698). CONCLUSIONS: We propose DDESVSFS as a simple, rapid and comprehensive prediction score for the Differential Diagnosis of Epileptic Seizures VS Functional Seizures. Large prospective studies are needed to evaluate its utility in clinical practice.

Mind the gap: health disparities in families living with epilepsy are significant and linked to socioeconomic status.

There is limited information on disparities of people with epilepsy (PWE) and, foremost, their caregivers. The objective of this study was to comprehensively compare between PWE and caregivers with low socioeconomic status (SES) and those with high SES for disparities in demographic and epilepsy characteristics, treatment and health care utilization, physical and psychosocial impact, and knowledge about epilepsy. PWE and caregivers completed surveys about the aforementioned outcomes during their epilepsy clinic visit or epilepsy monitoring unit admission. Associations were evaluated using SES as a binary independent variable and the patient and caregiver related outcomes as dependent variables. Thirty-eight patients with low SES and 88 patients with high SES were recruited. Patients with low SES were more commonly non-white, uninsured, unemployed, of lower educational attainment and living in larger households. They were more likely to visit the emergency room for their seizures, were more frequently on polypharmacy and experienced more AED adverse effects. They exhibited higher depression and anxiety levels and worse quality of life. Twenty-two caregivers with low SES and 66 caregivers of high SAS were recruited. Caregivers with low SES were more likely to be non-white and single. They manifested poorer knowledge about epilepsy. There are notable inequalities in demographic, treatment-related and health care utilization aspects of care of PWE, as well as in the psychosocial impact of their disease. Additional demographic and epilepsy knowledge-related disparities are recognized in caregivers of PWE. Identification of those disparities is a critical step in the creation of appropriate interventions to eliminate them.

Stigma in psychogenic nonepileptic seizures.

OBJECTIVE: There is scarce literature on stigma in families living with psychogenic nonepileptic seizures (PNES). Using a cohort of patients with epileptic seizures (ES) and their caregivers as controls, we aimed to quantify the level of patient and caregiver stigma in PNES and identify associations of patient and caregiver characteristics with it. METHODS: Patients with PNES and ES and their caregivers completed surveys about demographic, clinical, and psychosocial characteristics. Multivariate regression analysis was used to identify correlates of patient and caregiver stigma. RESULTS: Forty-three patients with PNES and 165 patients with ES were recruited. Compared with patients with ES, patients with PNES had shorter disease duration, higher seizure frequency, normal diagnostic data, poorer psychosocial health, and fewer antiseizure medications (ASMs). A total of 76.5% of patients with PNES and 59.5% of patients with ES felt stigmatized. Patient stigma level was higher in patients with PNES compared with those with ES, and it was negatively associated with patient quality of life (QOL). Additionally, 28 caregivers of patients with PNES and 99 caregivers of patients with ES were recruited. There were no significant demographic, caregiving, or psychosocial differences between the two caregiver cohorts. Seventy-two percent of caregivers of patients with PNES and 47% of caregivers of patients with ES felt stigmatized. Caregiver stigma level was also higher in caregivers of patients with PNES compared with caregivers of patients with ES, and it was negatively associated with patient QOL and positively associated with patient and caregiver anxiety. CONCLUSION: Compared with those with ES, patients and caregivers living with PNES experience stigma more frequently and to a higher extent. Patient QOL emerges as a consistent correlate of that stigma.

Caregiver burden in psychogenic non-epileptic seizures.

OBJECTIVE: Caregiver burden in psychogenic non-epileptic seizures (PNES) is an important but understudied reality. The objective of this exploratory study was to quantify caregiver burden in PNES and to identify the patient and caregiver characteristics associated with it. METHODS: PNES patients and their identified caregivers completed surveys about demographic, disease related and psychosocial characteristics during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using the Zarit Caregiver Burden Inventory (ZCBI) score as an independent variable and the patient and caregiver related characteristics as dependent variables. RESULTS: 43 patients and 28 caregivers were recruited. The patients were on average 36 years old, single women, unemployed, with some college education. They suffered from PNES on average for 8 years, having approximately 20 seizures per month, and were previously maintained on ≥ 2 antiseizure medications. Most caregivers were first degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Caregiver burden was within the mild-moderate range (ZCBI mean score 28). The burden appeared higher in caregivers of male patients. Patient quality of life, depression and medication side effects were associated with that burden. Additionally, caregiver stigma, depression and anxiety emerged as potential contributors. In the multivariate analysis, patient quality of life and caregiver depression stood out as the most robust factors. CONCLUSION: There is substantial caregiver burden in PNES. It is associated with both the patient and the caregiver psychosocial well-being in a reciprocal relationship.

Socioeconomic disparities in patients with psychogenic nonepileptic seizures and their caregivers.

OBJECTIVE: There is no information on disparities of patients with psychogenic nonepileptic seizures (PNES) and their caregivers. The objective of this exploratory study is to compare patients with PNES and caregivers with low socioeconomic status (SES) with those of high SES for disparities in healthcare use, seizures, medication adverse effects, psychosocial impact, and knowledge about epilepsy. METHODS: Patients with PNES and caregivers completed surveys about the aforementioned outcomes during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using SES as a binary independent variable and the patient- and caregiver-related outcomes as dependent variables. RESULTS: Forty-three patients and 28 caregivers were recruited. The majority of patients were on average 36 years old, single women, unemployed, with some college education. The majority had PNES for 8 years averaging 20 seizures per month and were maintained on ≥2 antiepileptic drugs (AEDs) prior to their EMU admission. Most caregivers were first-degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Low SES patients showed poorer knowledge about epilepsy (p < 0.0001) and higher anxiety levels (p = 0.03). Conversely, high SES patients demonstrated poorer social functioning (p = 0.04). High SES caregivers showed higher caregiving burden (p = 0.01). CONCLUSION: There are noteworthy disparities in patients with PNES of different SES and their caregivers. Identification of those disparities is a critical step in the creation of appropriate interventions to address them.

A standardized diagnostic approach and ongoing feedback improves outcome in psychogenic nonepileptic seizures.

INTRODUCTION: Psychogenic nonepileptic seizures (PNES) are episodic alterations in behavior presumed to reflect a physical manifestation of underlying psychological distress. Standardized treatment approaches for PNES care are lacking. We evaluated common approaches to PNES management that do not require significant commitment of time and resources. METHODOLOGY: Patients with PNES established with video-EEG monitoring were randomized to one of the following three groups: 1) PNES diagnosis delivered per the discretion of the attending physician with advice to seek mental health assistance in the community (n=12), 2) scripted PNES diagnosis provided and inpatient psychiatry consult obtained (n=10), and 3) weekly follow-up phone calls made in addition to scripted diagnosis and inpatient psychiatry consultation (n=15). Reduction in event frequency measured at 8weeks following hospital discharge represented the primary outcome variable. Secondary variables analyzed included exploration of change in self-reported mood, quality of life, and healthcare utilization. RESULTS: No significant improvements were noted in patients simply given a PNES diagnosis and advised to seek outside care on any measure. In contrast, patients receiving a scripted diagnosis and psychiatric consultation demonstrated decreased PNES frequency accompanied by improved quality of life (QOL). Patients also receiving weekly phone calls not only demonstrated decreased PNES frequency and improvements in QOL but also exhibited improved mood. DISCUSSION: These findings demonstrate that providing diagnostic information regarding PNES is insufficient by itself to meaningfully affect patient outcome. Structured feedback and psychiatric consultation appeared adequate to significantly reduce PNES frequency and improve aspects of quality of life, while the addition of a weekly phone contact also led to improved mood.

Low vitamin D levels are common in patients with epilepsy.

PURPOSE: Vitamin D is important for bone health, and vitamin D deficiency may contribute to other disorders (e.g., autoimmune, infections, cancer, degenerative, diabetic, and vascular). Enzyme-inducing antiepileptic drugs have been particularly implicated for osteoporosis risk given their effects on vitamin D. We examined the prevalence of vitamin D deficiency in adult epilepsy patients. METHODS: We conducted an observational study of consecutive epilepsy patients treated by two clinicians at the Emory University Epilepsy Center from 2008 to 2011 in order to determine the frequency of low vitamin D levels and possible differential antiepileptic drug risks. Vitamin D 25-OH levels were categorized as low (<20 ng/ml), borderline (20-29 ng/ml), or normal (≥30 ng/ml). Antiepileptic drugs were categorized based on their enzyme inducing properties. Descriptive and inferential statistics were employed. RESULTS: Vitamin D levels were obtained on 596 patients with epilepsy. Mean age was 41 years (SD=14; range=18-81); 56% were women. Race/ethnicity was 55% Caucasian, 34% Black, 2% Asian, and 7% Unknown. The mean vitamin D level was 22.5 (SD=11.9; range = <4 to 98), and 45% had level <20 ng/ml. Mean vitamin D levels (F=6.48, p=.002) and frequencies of vitamin D categories (p=.002, Chi square test) differed across the antiepileptic drug groups. Vitamin D deficiency was present in 54% of enzyme-inducing and 37% of non-enzyme-inducing antiepileptic drugs groups. CONCLUSIONS: Vitamin D deficiency is common in patients with epilepsy on antiepileptic drugs. Monitoring of vitamin D should be considered as part of the routine management of patients with epilepsy.

Optimizing the timing of chemotherapy for mobilizing autologous blood hematopoietic progenitor cells.

BACKGROUND: Postchemotherapy mobilization results were reviewed in patients undergoing apheresis before planned autologous hematopoietic progenitor cell (HPC) transplantation to improve the timing of collection procedures. STUDY DESIGN AND METHODS: A total of 135 attempts to collect autologous HPC were studied in 132 unique patients with lymphoid malignancies (non-Hodgkin's lymphoma, multiple myeloma, and Hodgkin's disease). Chemotherapy mobilization regimens included cyclophosphamide (n = 59), ICE (n = 46), or other regimens (n = 30). Granulocyte-colony-stimulating factor (CSF) was administered once daily at a dose of 5 microg per kg starting 2 days after the last dose of chemotherapy; granulocyte-macrophage-CSF was added at a daily dose of 5 microg per kg 6 days later. Apheresis was initiated when the blood CD34+ content was more than 20 per microL. RESULTS: In an initial cohort of 37 patients, 27 percent required apheresis during the weekend. An optimized timing for chemotherapy mobilization was developed based on retrospective data; prospective implementation of the new algorithm reduced the incidence of weekend apheresis to 13 percent in the subsequent 98 consecutive patients (p < 0.05). A median of 9 x 10(6) (range, 0.4 x 10(6)-96 x 10(6)) CD34+ cells per kg was collected from the entire cohort of 135 patients after a mean of 1.8 days of apheresis. Apheresis was initiated following a median (+/-SD) of 10 +/- 2.7 days of cytokines. CONCLUSION: In the majority of patients, the first day of apheresis occurred 11 to 13 days after the last dose of chemotherapy with a variety of different chemotherapy regimens. Administering the last dose of chemotherapy on Thursday or Friday versus Monday, Tuesday, or Wednesday was associated with a 77 percent lower incidence in the frequency of weekend apheresis collections (p < 0.001).