Psychiatric co-morbidity of drug-resistant epilepsy in Veterans

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

Comorbidities in Hispanic/Latino Veterans with epilepsy

BACKGROUND

Hispanic/Latino people with epilepsy may be at a differential risk of medical and psychiatric comorbidities given genetic, environmental, sociocultural, and quality of care factors. In people with epilepsy, comorbidities are especially crucial to investigate given the well-known impact on quality of life and risk of adverse outcomes. Yet, Hispanic/Latino Veterans with Epilepsy (HL-VWE) remain an understudied population. The present nationwide population study sought to investigate medical and psychiatric comorbidities in this group.

METHODS

Data from the Veterans Health Administration (VHA) Corporate Data Warehouse administrative data were used to identify 56,556 VWE (5.7 % HL-VWE) using a one-year cross-sectional analysis of ICD codes. Elixhauser Comorbidity Index scores and psychiatric diagnoses were calculated based on ICD-9/ICD-10-CM diagnoses using a lookback period. Comparisons were made between HL-VWE and non-HL-VWE using chi-squared and student t-tests. Regression analyses were then performed to examine group differences while accounting for age.

RESULTS

HL-VWE had higher probability of being diagnosed with several psychiatric conditions when accounting for age, including depression (OR 1.21, 95 % CI 1.13-1.31) and schizophrenia (OR 1.56, 95 % CI 1.31-1.84). There were no significant differences in medical comorbidities between the HL-VWE and non-HL-VWE groups.

CONCLUSIONS

We present results from the largest known study of HL people with epilepsy examining their psychiatric and medical comorbidities and one of the first to specifically study HL-VWE. Compared to non-HL-VWE, the Hispanic/Latino group had comparable medical comorbidity, but higher rates of multiple psychiatric conditions. Results indicate a need for increased screening and interventions in this population to reduce psychiatric disease burden.

Effects of Psychiatric Comorbidities on the Prognosis of New-Onset Pediatric Epilepsy: A Retrospective Nationwide Cohort Study

Background/Objectives: To determine the impact of psychiatric disorders on epilepsy treatment outcomes and healthcare utilization in children with epilepsy (CWE) based on the presence or timing of the onset of psychiatric disorders. Methods: This retrospective controlled study enrolled children (age < 18 years) with newly diagnosed epilepsy into four groups stratified by the presence and timing of the onset of psychiatric disorders (None: no psychiatric disorders; Before: psychiatric disorders only preceding the epilepsy diagnosis; After: new psychiatric disorders diagnosed only after the epilepsy diagnosis; Mixed: different psychiatric disorders diagnosed both before and after epilepsy diagnosis) and compared the intergroup differences in epilepsy treatment outcomes and healthcare utilization. Results: Among the CWE (n = 37,678), 13,285 (35.26%) had comorbid psychiatric disorders. The After (n = 7892), Mixed (n = 3105), and Before (n = 2288) groups had significantly longer treatment periods than those in the None group (p < 0.001). Compared with the None group, the remaining groups had significantly higher frequencies of outpatient visits, emergency room visits, and admissions and higher rates of status epilepticus and drug-resistant epilepsy (p < 0.001, respectively), with higher odds ratios [95% confidence interval] for status epilepticus (2.92 [2.68-3.18]) and drug-resistant epilepsy (3.01 [2.85-3.17]) in the After group. Conclusions: Psychiatric comorbidities, diagnosed before and after epilepsy diagnosis, negatively affected the treatment outcomes. CWE without prior psychiatric disorders that were newly diagnosed during epilepsy treatment had the worst outcomes and the highest healthcare utilization rates.

The neuropsychological presentation of women with epilepsy: Clinical considerations and future directions

Objective: Cognitive, mood, and behavioral changes are common among persons with epilepsy (PWE), resulting in a complex neuropsychological presentation. Women with epilepsy (WWE) represent a distinct cohort within the broader epilepsy population due to sex and gender-specific factors impacting epilepsy semiology and treatment. However, unique neuropsychological profiles among WWE have not been established. This narrative review aims to further define neuropsychological correlates in WWE and promote meaningful discussion related to enhancing the provision of neuropsychological care within this clinical population. Method: Current literature in PWE examining differences in cognitive function, mental health, and quality of life (QoL) between women and men was critically reviewed, emphasizing considerations for neuropsychological practice. Results: WWE demonstrate a preservation of verbal learning and memory compared to men both pre- and post-surgically, with sex-based, neurobiological mechanisms likely contributing to this association. WWE also have elevated risk for affective disorder psychopathology, suicidality, and traumatic experiences. Epidemiology related to psychotic and bipolar spectrum disorders is less clear, and findings are mixed regarding sex-specific behavioral side effects of antiseizure and psychotropic medication. Finally, hormonal and obstetric factors are highlighted as important contributors to neuropsychological symptoms in WWE, with elevated risk for low QoL and increased stigma associated with greater medical and psychiatric comorbidities compared to men. Conclusions: While emerging literature has begun to characterize the neuropsychological presentation of WWE, future research is needed to define sex and gender differences in neuropsychological sequalae among PWE to ensure consistency and quality of care for WWE.

Prospective memory is associated with aspects of disability and quality of life in people with epilepsy

INTRODUCTION

Episodic memory disruptions in epilepsy stem from shared neurocircuitry. While prior research has focused on retrospective memory (RM), prospective memory (PM; i.e. remembering to remember) also deserves consideration given its critical role in the management of daily activities. The current investigation assessed whether PM is associated with disability and quality of life in people with epilepsy.

METHODS

This cross-sectional, correlational study included a consecutive series of 50 people with epilepsy presenting for neuropsychological evaluation who completed the Royal Prince Alfred Prospective Memory Test (RPA) and Prospective and Retrospective Memory Questionnaire (PRMQ) and 63 demographically comparable healthy adults. The participants with epilepsy also completed clinical measures of neuropsychological ability and questionnaires assessing disability and quality of life.

RESULTS

People with epilepsy had significantly more frequent memory symptoms as compared to healthy adults at a very large effect size. Worse mood was associated with lower PM ability at a medium effect size and more frequent PM symptoms at a large effect size. A hierarchical linear regression indicated that PM explained 52% of the variance in disability and 43% of the variance in quality of life after accounting for RM ability.

CONCLUSIONS

PM is associated with poorer everyday functioning among people with epilepsy and shows evidence of incremental value beyond RM ability in that regard. Future studies are needed to understand the complex pathways from PM to functional limitations to inform clinical intervention.

Psychiatric Comorbidities in Women Veterans with Epilepsy

Background: Women Veterans with epilepsy (WVE) may have unique psychiatric comorbidities that affect presentation, treatment, and outcomes. This large, nationally representative study of Veterans Health Administration (VHA) patients explores sex differences in psychiatric diagnoses and treatment to better characterize WVE. Methods: This study included a retrospective cohort design utilizing VHA Corporate Data Warehouse administrative data. Data from 58,525 Veterans with epilepsy (8.5% women) were obtained. Psychiatric diagnoses and treatment were analyzed, with comparisons between men with epilepsy and WVE. Secondary analyses included further exploration of select gynecological conditions. Results: WVE had higher psychiatric burden than men, as evidenced by higher rates of nearly all psychiatric diagnoses, including depression (59.1% vs. 38.9%; χ2 = 771.6), posttraumatic stress disorder (42.0% vs. 26.5%; χ2 = 549.1), and anxiety disorder (44.9% vs. 24.5%; χ2 = 977.7), as well as higher use of psychotropic medication prescriptions (2.3 vs. 1.4 average number of psychotropics prescribed). Furthermore, higher percentages of women versus men utilized the emergency room for psychiatric purposes (11.7% vs. 6.9%; χ2 = 153.06) and were hospitalized with psychiatric diagnoses (9.8% vs. 6.1%; χ2 = 100.95). Discussion: Veterans with epilepsy represent a unique group with high rates of psychiatric comorbidity. These results suggest that among Veterans, men and women with epilepsy have differing psychiatric comorbidities, leading to disparate health care needs. Based on this study's findings, WVE may require a different approach to care with an increased focus on specialized psychiatric treatment for WVE.

Epilepsy surgery perceptions among general neurologists and epilepsy specialists: A survey

OBJECTIVE

Surgical intervention for drug-resistant epilepsy (DRE) is a safe and efficacious evidence-based treatment. Yet, neurologists have historically revealed hesitance in referring patients for surgical evaluations. The present study surveyed general neurologists and epilepsy specialists to assess their views and process in referring patients for specialized epilepsy care and epilepsy surgery.

METHODS

A 14-item survey assessing epilepsy referrals and views of epilepsy surgery was distributed to all neurologists currently practicing in a large national integrated health system using REDCap. Responses were qualitatively analyzed and differences between general neurologists and epileptologists were assessed using chi-squared tests.

RESULTS

In total, 100 responses were received from 67 general neurologists and 33 epileptologists with several similarities and differences emerging between the two groups. Both groups endorsed surgery and neuromodulation as treatment options in DRE, felt that seizure frequency rather than duration was relevant in considering epilepsy surgery, and indicated patient preference as the largest barrier limiting epilepsy surgery. General neurologists were more likely to require ≥ 3 ASMs to fail to diagnose DRE compared to epileptologists (45% vs. 15%, p < 0.01) who more often required ≥ 2 ASMs to fail. Epileptologists were also more likely than neurologists to try a new ASM (75.8% vs. 53.7%, p < 0.05) or optimize the current ASM (75.8% vs. 49.3%, p < 0.05) in DRE. General neurologists were more likely to consider epilepsy surgery to be less efficacious (p = 0.001) or less safe (p < 0.05).

SIGNIFICANCE

Overall, neurologists appear to have generally positive opinions of epilepsy surgery, which is a change from prior literature and represents a changing landscape of views toward this intervention. Furthermore, epileptologists and general neurologists endorsed more similarities than differences in their opinions of surgery and steps to referral, which is another encouraging finding. Those gaps that remain between epileptologists and general neurologists, particularly in standards of ASM prescription, may be addressed by more consistent education about DRE and streamlining of surgical referral procedures.