Pilot project of psychological services integrated into a pediatric epilepsy clinic: Psychology Adding Value - Epilepsy Screening (PAVES)

What is the role of screening instruments in the management of psychiatric comorbidities in epilepsy? Tools and practical tips for the most common comorbidities: Depression and anxiety

Depression and anxiety are the most common psychiatric comorbidities in epilepsy and are known to increase healthcare utilization, the risk of refractory epilepsy, and anti-seizure medication intolerability. Despite this, depression and anxiety continue to be underrecognized and undertreated in people with epilepsy (PWE). Several barriers to the identification of depression and anxiety in PWE exist, including reliance on unstructured interviews rather than standardized, validated instruments. Moreover, there is a dearth of behavioral health providers to manage these comorbidities once identified. The use of validated screening instruments in epilepsy clinics can assist with both the identification of psychiatric symptoms and monitoring of treatment response by the epilepsy clinician for PWE with comorbid depression and/or anxiety. While screening instruments can identify psychiatric symptoms occurring within a specified time, they are not definitively diagnostic. Screeners can be time efficient tools to identify patients requiring further evaluation for diagnostic confirmation. This article reviews recent literature on the utility of depression and anxiety screening instruments in epilepsy care, including commonly used screening instruments, and provides solutions for potential barriers to clinical implementation. Validated depression and anxiety screening instruments can increase identification of depression and anxiety and guide epilepsy clinician management of these comorbidities which has the potential to positively impact patient care.

Comparison of psychosocial screeners in an epilepsy clinic

Screenings are recommended for co-occurring conditions in pediatric epilepsy. However, there is limited research regarding which screener to implement in the clinic. This study aimed to compare different screening measures for attention-deficit/hyperactivity disorder (ADHD) and emotional concerns in a pediatric epilepsy population during a routine neurology clinic visit. Fifty (22%) of 226 contacted parents of children with epilepsy ages 5-17 years old agreed to participate. Screening measures included the Strengths and Difficulties Questionnaire (SDQ; Hyperactivity/Inattention (ADHD), Emotional Problems (E) subscales), the Pediatric Quality of Life Inventory Epilepsy Module (PedsQL-EM; Executive Functioning (EF), Mood/Behavior (M/B) subscales), and the ADHD Rating Scale (ADHD-RS). Analyses comparing measures included Chi Square, Pearson's correlation, and agreement statistics (Cohen's kappa, overall agreement). Consistent with prior literature, positive screening rates ranged from 40% to 72% for ADHD concerns and 38% to 46% for emotional concerns. Agreement between measures ranged from fair to substantial, with the highest agreement (85%; κ = 0.70) between the SDQ-E and PedsQL-EM-M/B. Although all measures rendered positive screens within expected rates, there are differences among the measures that inform screening measure selection.

Screening for anxiety, depression and suicidality by epilepsy specialists in adult services in Scotland

OBJECTIVE

Clinical guidelines recommend screening people with epilepsy (PWE) regularly for mental distress, but it is unclear how guidelines are implemented. We surveyed epilepsy specialists in adult Scottish services to determine approaches used to screen for anxiety, depression, and suicidality; the perceived difficulty of screening; factors associated with intention to screen; and treatment decisions made following positive screens.

METHODS

An anonymous email-based questionnaire survey of epilepsy nurses and epilepsy neurology specialists (n = 38) was conducted.

RESULTS

Two in every three specialists used a systematic screening approach; a third did not. Clinical interview was employed more often than standardized questionnaire. Clinicians reported positive attitudes towards screening but found screening difficult to implement. Intention to screen was associated with favorable attitude, perceived control, and social norm. Pharmacological and non-pharmacological interventions were proposed equally often for those screening positive for anxiety or depression.

CONCLUSION

Routine screening for mental distress is carried out in Scottish epilepsy treatment settings but is not universal. Attention should be paid to clinician factors associated with screening, such as intention to screen and resulting treatment decisions. These factors are potentially modifiable, offering a means of closing the gap between guideline recommendations and clinical practice.

Questionnaire-based screening for mental distress in epilepsy: Outline and feasibility of an outpatient screening and intervention pathway

OBJECTIVE

Mental distress is present in a significant proportion of people with epilepsy (PWE), with a negative impact across life domains. It is underdiagnosed and under-treated despite guidelines recommending screening for its presence (e.g., SIGN, 2015). We describe a tertiary-care epilepsy mental distress screening and treatment pathway, with a preliminary investigation of its feasibility.

METHODS

We selected psychometric screening instruments for depression, anxiety, quality of life (QOL), and suicidality, establishing treatment options matched to instrument scores on the Patient Health Questionnaire 9 (PHQ-9), along 'traffic light' lines. We determined feasibility outcomes including recruitment and retention rates, resources required to run the pathway, and level of psychological need. We undertook a preliminary investigation of change in distress scores over a 9-month interval and determined PWE engagement and the perceived usefulness of pathway treatment options.

RESULTS

Two-thirds of eligible PWE were included in the pathway with an 88% retention rate. At the initial screen, 45.8% of PWE required either an 'Amber-2' intervention (for moderate distress) or a 'Red' one (for severe distress). The equivalent figure at the 9-month re-screen was 36.8%, reflective of an improvement in depression and QOL scores. Online charity-delivered well-being sessions and neuropsychology were rated highly for engagement and perceived usefulness, but computerized cognitive behavioral therapy was not. The resources required to run the pathway were modest.

CONCLUSION

Outpatient mental distress screening and intervention are feasible in PWE. The challenge is to optimize methods for screening in busy clinics and to determine the best (and most acceptable) interventions for screening positive PWE.