Authors :
Caitlin McElroy-Cox, APRN – Yale Comprehensive Epilepsy Center; Hamada Altalib, DO – Yale Comprehensive Epilepsy Center; Pue Farooque, DO – Yale Comprehensive Epilepsy Center; Lawrence Hirsch, MD – Yale Comprehensive Epilepsy Center; Natalie LeBlanc, PA – Yale Comprehensive Epilepsy Center; Benjamin Tolchin, MD – Yale Comprehensive Epilepsy Center
Rationale: Patients with functional seizures (FS), also known as psychogenic nonepileptic seizures or attacks, are commonly encountered in Epilepsy Centers, with one-third of patients admitted to epilepsy monitoring units (EMUs) diagnosed with FS. Cognitive behavioral therapy (CBT) is a mainstay of treatment for FS and is typically performed by a mental health provider (MHP). There is an international shortage of MHPs, exacerbated by the COVID-19 pandemic. As a result, FS patients often go without care for months after diagnosis. Our center has one neuropsychiatrist who performs CBT but who has limited clinic capacity and average wait times of 6 months. Thus a majority of FS patients were historically referred to outside CBT providers with varying experience in treating FS. We conducted a feasibility study of an Advanced Practice Provider (APP) CBT clinic with the goal of improving access to CBT for newly diagnosed FS patients.
Methods: The Epilepsy Center ambulatory APP observed the neuropsychiatrist’s CBT clinic (using the regimen in “Treating Nonepileptic Seizures” by LaFrance et al. [1]) for 4 h/week for 3 months. Training was supplemented by an online course in “CBT Essentials”
www.aptmentalhealthtraining.com. This was followed by a 3-month period during which the APP began seeing FS patients for CBT with indirect supervision. We then developed an algorithm (Figure) employing a triage system for patients with confirmed FS based on underlying psychiatric comorbidities and existing care providers. Patients with confirmed FS and without acute psychiatric symptoms who did not have an existing MHP (or whose MHP reported discomfort treating FS) were referred to the APP CBT clinic. This clinic is 100% telehealth, with an initial consult followed by 12 weekly one-hour visits using the LaFrance regimen.
Results: Since July, 2021, 22 patients were referred to the APP CBT clinic.
Patients who were discharged from the EMU were all seen in 2-5 weeks. Six have completed the program. Five are actively enrolled. One is awaiting enrollment. Five had an initial visit but have not yet elected to start treatment. In 2 cases treatment is currently on hold (referred for psychiatric treatment). Two stopped attending clinic due to time constraints (traveling, childcare). One was lost to follow-up in our center.
Of those who completed, all had significant reduction of FS (Table), with 4/6 having none in the final >6 weeks. All 6 “graduating” patients were referred for ongoing therapy. All were scheduled for a 3 month f/u visit with the APP after program completion.
Conclusions: CBT performed by an APP in an Epilepsy Clinic setting is a feasible option for patients diagnosed with FS and has resulted in increased access to CBT for patients in our center with significantly reduced wait times and excellent preliminary outcomes. Further study of the efficacy of this treatment model is warranted. We believe that similar models of care can be extrapolated to other Epilepsy Centers.
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Reference:
1. LaFrance, Jr, W. Curt, and Jeffrey Peter Wincze. Treating Nonepileptic Seizures: Therapist Guide. Oxford University Press, 2015.
Funding: Not applicable