Institute of Medicine Workshop on Quality, Access, and Education for the Epilepsies
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MENTAL HEALTH RESOURCES AND SERVICES ACROSS THE LIFESPAN June 29, 2011
Naomi Chaytor, PhD, ABPP University of Washington
Mental health problems are common in people with epilepsy (PWE) 2
Depression is the most common and most widely studied psychiatric co-morbidity Depression has been shown to be a primary determinant of quality of life independent of seizure frequency Depression and epilepsy are bidirectional Epilepsy increases risk of depression and depression increases risk of epilepsy Common underlying mechanisms?
Other mental health problems have been studied less (e.g., psychosis, bipolar disorder, anxiety) Mental Health Resources and Services Across the Lifespan
June 29, 2011
Treatment typically occurs within the traditional mental health system 3
Best practice: Psychotherapy and psychotropic medication, with treatment to remission
Limited research evaluating whether traditional treatments are equally effective in PWE
Common Practice: no treatment/under treatment Providers are reluctant to prescribe anti-depressants Patients are reluctant to take additional medications Limited funding for psychotherapy Common belief (providers and patients) that it is normal to be depressed if you have epilepsy Mental health providers are not trained in epilepsy-specific issues
Mental Health Resources and Services Across the Lifespan
June 29, 2011
Epilepsy specific interventions for depression: Project UPLIFT 4
Eight module program delivered weekly through the Internet or by telephone for people with epilepsy and depression. Combination of cognitive behavioral therapy and mindfulness techniques delivered in group format. Peer with epilepsy/doctoral student facilitator (supervised by clinical psychologist). Both internet and telephone delivery more effective in reducing depression than wait list control in pilot study (over 8 weeks). On-going: Using Project Uplift materials to prevent/reduce depression among adults with epilepsy and mild depressive symptoms.
Delivery by telephone or Internet, testing efficacy across four sites (N = 42 per site).
Thompson et al (2010). Distance Delivery of Mindfulness-based Cognitive Therapy for Depression: Project UPLIFT. Epilepsy & Behavior, 19(3), 247-254
June 29, 2011
Epilepsy specific interventions for depression: PEARLS 5
PEARLS (Program to Encourage Active and Rewarding Lives), originally developed for home-bound seniors, was adapted for use in people with epilepsy Problem solving, behavioral activation and psychiatric consultation Collaborative care with epileptologists/neurologists Eight 50 minute sessions over 19 weeks Delivered in the home by Master’s level social workers, with psychiatric supervision A randomized controlled trial showed reduction in depressive symptoms, suicidal ideation and emotional well being compared to usual care over 18 months. PEARLS training is available: http://www.pearlsprogram.org/Training.aspx
Since 2009, only 5 people have been trained for use in epilepsy
Chaytor et al. (2011). Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy. Epilepsy & Behavior, 20(3):545-9
June 29, 2011
Children, older adults and PNES 6
Similar issues face children and older adults with mental health problems and epilepsy
High rates of mental illness Underidentified and undertreated High impact on quality of life Treated in traditional mental health system Additional impact on academic functioning in children Increased cognitive impairment complicates treatment in older adults
Very little research has been done on treatment of Psychogenic Non-epileptic Seizures (PNES) and few providers are qualified to treat it
Patient resistance to diagnosis and treatment is common Some evidence that cognitive behavioral therapy may be effective (LaFrance, 2009) Mental Health Resources and Services Across the Lifespan
June 29, 2011
Committee Recommendations 1)
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More research is needed on the causes, risk factors, and treatment for mental health problems in PWE Increased dissemination of epilepsy specific mental health treatment is needed There is a need for increased education of mental health providers in epilepsy specific issues
Mental Health Resources and Services Across the Lifespan
June 29, 2011
More research is needed on the causes, risk factors, and treatment of mental health problems in PWE 1
No definitive treatment approach has been identified Identification of those most at risk could lead to more economical use of mental health resources Prevention/early
intervention to reduce secondary
disability
Understanding causes/risk factors could lead to novel treatment strategies Need more research on treatment for PNES and other mental health disorders Mental Health Resources and Services Across the Lifespan
June 29, 2011
Increased dissemination of epilepsy specific mental health treatments is needed 2
Epilepsy specific interventions have empirical support but are not yet in clinical use Need to focus on ease of dissemination/widespread use to overcome barriers to treatment
Telephone/internet delivery Mechanism for reimbursement/funding Need to demonstrate that these programs are cost-effective
Possible solution: Collaborative mental health care within the epilepsy medical home
Need easy access to mental health providers trained in epilepsy specific treatments within the epilepsy medical home (e.g., tertiary epilepsy centers, primary care) Training in collaborative mental health care is available: http://uwaims.org/overview.html
Mental Health Resources and Services Across the Lifespan
June 29, 2011
Education of mental health providers in epilepsy specific issues 3
Increased training of non-epilepsy providers in mental health issues associated with epilepsy is needed Use
of anti-depressants in patients with epilepsy Common misconceptions/barriers to treatment Importance of treating mental health problems Side effects of anti-epileptic medications
Psychogenic non-epileptic seizures Co-occurance
with epilepsy Diagnosis and treatment guidelines Mental Health Resources and Services Across the Lifespan
June 29, 2011
