Abstracts

Rationale: Patients with epilepsy (PWE) and patients with non-epileptic seizures (PWNES) constitute particularly vulnerable patient populations and have high rates of psychiatric comorbidities. This potentially decreases quality of life and increases health care utilization and expenditures. However, lack of access to care or concern of stigma may preclude referral to outpatient psychiatric clinics. Furthermore, the optimal treatment of NES includes longitudinal psychiatric management. No published literature has assessed the impact of co-located psychiatric services within outpatient epilepsy clinics. We therefore evaluated the co-location of psychiatric services within a level 4 epilepsy center. Methods: From July 2013 to June 2014, a psychiatrist was co-located in the Dartmouth-Hitchcock Epilepsy Center outpatient clinic one afternoon per week (0.1 FTE) to provide medication management and time-limited structural psychotherapeutic interventions to all patients that scored greater than 15 on the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and who agreed to the referral. Psychiatric symptom severity was assessed at baseline and follow-up visits using validated scales including NDDI-E, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and cognitive subscale items from Quality of Life in Epilepsy-31 (QOLIE-31) scores. Results: Forty-three patients (18 male; 25 female) were referred to the clinic over a one-year period; 27 (64.3%) were seen in follow-up with a median of 3 follow-up visits (range 1 to 7). 37% of patients had NES exclusive of epilepsy, and 11% of patients had a dual diagnosis of epilepsy and NES. Psychiatric symptom severity decreased in 84%, with PHQ-9 and GAD-7 scores improving significantly from baseline (4.6 ± 0.4 SD improvement in PHQ-9 and 4.0 ± 0.4 SD improvement in GAD-7, p-values <0.001). NDDI-E and QOLIE-31 cognitive sub-item scores at their most recent visit were significantly improved as compared to nadir scores (3.3 ± 0.6 SD improvement in NDDI-E and 1.5 ± 0.2 SD improvement in QOLIE-31, p-values <0.001). These results are moreover clinically significant—defined as improvement by 4-5 points on PHQ-9 and GAD-7 instruments—and are correlated with an overall improvement as measured by NDDI-E and cognitive subscale QOLIE-31 items. Conclusions: A co-located psychiatrist demonstrated a reduction in psychiatric symptoms of PWE and PWNES, as well as an improvement in psychiatric access and streamlining of their care. Epileptologists were able to dedicate more time to managing epilepsy as opposed to psychiatric comorbidities. As integrated models of collaborative and co-located care are becoming more widespread, mental health care providers located in outpatient neurology clinics may provide significant benefit for both patients and providers.