Niruj Agrawal

The national service framework for long term conditions

Aims to meet psychological, social, and emotional needs in neurological disorders I n March 2005 the UK Department of Health released the national service framework for long term conditions.1 This framework comprises 11 requirements for improving, over the next 10 years, the quality of health and social care services for people with long term neurological conditions: persistent brain disorders with a wide range of complex physical, social, and psychological complications. This document may go some way towards raising awareness of some of the greatest unmet needs in the NHS. The burden of such conditions is huge. Fifteen years ago the World Health Organization showed that broadly defined neuropsychiatric disorders were the most important cause of disability worldwide.w1 Some 10 million people across the United Kingdom have a neurological condition, and nearly 2 million care for someone with either a neurological or a mental health problem.w2 Around half the patients with long term active neurological conditions in the …

Screening for depression in epilepsy clinics. A comparison of conventional and visual‐analog methods

Purpose:  Depression is an important but underdiagnosed complication of epilepsy. This study compares potentially suitable screening tools head‐to‐head.

Screening for depression in epilepsy: A model of an enhanced screening tool

OBJECTIVE Depression is common but frequently underdiagnosed in people with epilepsy. Screening tools help to identify depression in an outpatient setting. We have published validation of the NDDI-E and Emotional Thermometers (ET) as screening tools for depression (Rampling et al., 2012). In the current study, we describe a model of an optimized screening tool with higher accuracy. METHODS Data from 250 consecutive patients in a busy UK outpatient epilepsy clinic were prospectively collected. Logistic regression models and recursive partitioning techniques (classification trees, random forests) were applied to identify an optimal subset from 13 items (NDDI-E and ET) and provide a framework for the prediction of class membership probabilities for the DSM-IV-based depression classification. RESULTS Both logistic regression models and classification trees (random forests) suggested the same choice of items for classification (NDDI-E item 4, NDDI-E item 5, ET-Distress, ET-Anxiety, ET-Depression). The most useful regression model includes all 5 mentioned variables and outperforms the NDDI-E as well as the ET with respect to AUC (NDDI-E: 0.903; ET7: 0.889; logistic regression: 0.943). A model developed using random forests, grown by restricting the possible splitting of variables to these 5 items using only subsets of the original data for single classification, performed similarly (AUC: 0.949). CONCLUSIONS For the first time, we have created a model of a screening tool for depression containing both verbal and visual analog scales, with characteristics supporting that this will be more precise than previous tools. Collection of a new data sample to assess out-of-sample performance is necessary for confirmation of the predictive performance.

Clinical correlates of memory complaints during AED treatment

To investigate clinical correlates of memory complaints (MC) during anti‐epileptic drug (AEDs) treatment in adults with epilepsy with special attention to the role of depression, using user‐friendly standardized clinical instruments which can be adopted in any outpatient setting.

Depression correlates with quality of life in people with epilepsy independent of the measures used

PURPOSE A number of studies have suggested that depressed mood is one of the most important predictors of quality of life (QoL) in patients with epilepsy. However, the QoL measure used in previous studies was limited to the Quality of Life in Epilepsy (QOLIE) scales. It could be questioned whether correlation of QOLIE with measures of depression is influenced by the properties of the instruments used rather than being a valid effect. By using visual analogue scales, the current study aimed to clarify whether depression and QoL are truly correlated in patients with epilepsy. METHODS Data from a sample of 261 outpatients with epilepsy attending the Epilepsy Clinics of the Atkinson Morley Outpatient Department, St Georges Hospital in London, were analyzed. Patients were screened using the European Quality-of-Life scale (EQ-5D-3L) which includes an overall visual analogue score (EQ-VAS), the Emotional Thermometer (ET7), the Beck Depression inventory-II (BDI-II), the Hospital Anxiety and Depression scale (HADS), and the Major Depression inventory (MDI). RESULTS Depression was found to significantly correlate with EQ-VAS score with r coefficient ranging from 0.42 to 0.51 and r(2) coefficients ranging between 0.18 and 0.26. In addition, we identified patients who were depressed according to DSM-IV criteria (MD) and those with atypical forms of depression (AD). The EQ-5D-3L scores in these subjects compared with those without depression (ND) showed a different impact of AD and MD on QoL. CONCLUSIONS The relationship between depression and QoL in people with epilepsy has been demonstrated to be a robust and valid effect, not a result of potential bias of the specific measures used. However, the strength of the association is influenced by the individual instrument. Atypical or subsyndromic forms of depression are as relevant as DSM-based depression in terms of impact on QoL.

Treating functional non-epileptic attacks – Should we consider acceptance and commitment therapy?

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.

Evaluation of a pilot innovative cognitive-behavioral therapy-based psychoeducation group treatment for functional non-epileptic attacks

A high proportion of patients presenting at epilepsy clinics experience functional non-epileptic attacks (FNEA), and while psychological treatment is generally thought to be the required intervention, evidence regarding psychological treatment of FNEA is limited. A small number of psychoeducation treatments have been evaluated, with promising results. As part of routine care within a neuropsychiatry service, a 3-session cognitive-behavior therapy- (CBT-) informed psychoeducation group was developed. Patients with comorbid epilepsy were included. The groups effectiveness was evaluated in terms of attack frequency, mood, illness perception, dissociative experiences, and patient feedback. Pre- and post-treatment data were obtained for 19 patients. The proportion of patients experiencing attacks significantly decreased, with almost 40% of treatment completers reporting being attack-free at the end of treatment. Significant improvements were also found on level of psychological distress, illness beliefs, and understanding of the condition. No significant changes in mood or general functioning were observed. High satisfaction was reported by almost all patients. Treatment outcome was not significantly affected by the level of dissociative experiences. The results suggest that CBT-based psychoeducation group treatment can be a beneficial part of treatment for those with FNEA, even for those experiencing high levels of dissociation. Further controlled studies with larger sample sizes are required.

Fatigue during treatment with antiepileptic drugs: A levetiracetam-specific adverse event?

PURPOSE To examine the prevalence and clinical correlates of fatigue as an adverse event (AE) of antiepileptic drug (AED) treatment in patients with epilepsy. METHODS Data from 443 adult outpatients with epilepsy assessed with the Adverse Event Profile (AEP) and the Neurological Disorder Depression Inventory for Epilepsy (NDDIE) were analysed. RESULTS Fatigue is reported by 36.6% of patients as always a problem during AED treatment. Fatigue is more likely to be reported by females (64.8% vs. 35.2%; Chi-Square=16.762; df=3; p=0.001) and during treatment with levetiracetam (42.3% vs. 33.2%; Chi-Square=11.462; df=3; p=0.009). The associations with the female gender and levetiracetam treatment were not mediated by depression, as identified with the NDDIE, and could not be simply explained by the large number of subjects on levetiracetam treatment, as analogous figures resulted from the analysis of a monotherapy subsample (41.7% vs. 30.3%; Chi-Square=11.547; df=3; p=0.009). CONCLUSIONS One third of patients with epilepsy reports fatigue as a significant problem during AED treatment. Fatigue is more likely to be reported by females and seems to be specifically associated with LEV treatment. However, fatigue is not mediated by a negative effect of LEV on mood.

038 Screening for anxiety and depression in epilepsy—preliminary findings

Aims Anxiety and depression are more common in people with epilepsy than the general population and are associated with poor quality of life. This study aims to study the performance of a short non-verbal screening tool (revised emotional thermometer (ET) tool) for these conditions which are under-identified and undertreated in the epileptic patient group. Methods A total of 122 people (53% female, 66% White British, age range 16–89, mean 39.6) attending the epilepsy clinic at Atkinson Morley Neurosciences centre completed five screening tools for anxiety and depression (NDDI-E; MDI; BDI-II; HADS; Revised Emotional Thermometers). These scales were scored and for depression BDI-II, NDDI-E, MDI, HADS depression and ET were compared while for anxiety HADS -anxiety and ET were compared. Results The preliminary results for screening of depression suggest that the revised ET is a potentially useful tool with 44% of patients responding with clinically significant scores. This is comparable to the BDI-II (43%) and NDDI-E (35%). The MDI identified 19% of cases fulfilling ICD-10 diagnostic criteria for depression. Based on this sensitivity of all the tools is comparable (NDDI-E 96%, BDI 96%, ET 83%, HADS 70%). In screening for anxiety, the proportion of patients scoring positive for anxiety from ET are comparable with HADS (53% vs 48%). Conclusions Results so far suggest that a brief non-verbal screening instrument (revised ET tool) may be useful in screening for anxiety and depression in patients with epilepsy. Further analysis of data is required to assess the sensitivity and specificity of this instrument and its overall usefulness in this population.