This article was coauthored by the following clinicians from VA Epilepsy Centers of Excellence. Hamada Altalib, DO, MPH (West Haven Campus, VA Connecticut Healthcare System); Jose Cavazos, MD, PhD, and Mary Jo Pugh, PhD (Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas); Aatif Hussain, MD,Pamela Kelly-Foxworth, DHA, MBA/HCM, and Tung Tran (Durham VAMC, North Carolina); Allan Krumholz, PhD (Baltimore VAMC, Maryland); W. Curt LaFrance, MD, MPH (Providence VAMC, Rhode Island); M. Raquel Lopez, MD (Bruce W. Carter VAMC, Miami, Florida); Paul Rutecki, MD (William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin); Anne Van Cott, MD (VA Pittsburgh Healthcare System, Pennsylvania).
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
People with epilepsy have a number of psychiatric comorbidities. Suicide and suicide attempts are 6 to 25 times more common in patients with temporal lobe epilepsy compared with those in the general population.36-38 Although the FDA identified all seizure medications as potential contributors to suicide risk, a recent longitudinal study of suicidal ideation and attempt found that those who received seizure medications were more likely to have suicidal ideation and attempt than those who did not received seizure medications, suggesting that medication may relate to baseline depression or suicidal ideation.39 When seeing patients with epilepsy, screening for suicidal ideation is good practice.
Depression and anxiety disorders are the most common psychiatric comorbidities in people with epilepsy.40,41 About half of people with epilepsy have symptoms of depression, and 40% have anxiety.42 Depression often precedes the diagnosis of epilepsy, and anxiety often is present and related to the fear of having seizures and of social embarrassment.43 People with epilepsy may not self-report these symptoms if not asked directly. Identification of comorbid depression and anxiety should lead to appropriate treatment. The CB-ip being used for PNES also is being used for treatment of epilepsy and its comorbidities.44
Mild traumatic brain injury (mTBI) has a small increased risk of epilepsy.45 Veterans with mTBI that occurs in the context of blasts are set up for the development of PTSD. These veterans may have other mild cognitive symptoms that can be confused with seizures. Furthermore, mTBI and PNES often occur together, more so than do mTBI and epileptic seizures.14 Video-EEG monitoring may be warranted for these patients.
Education and Self-Management
The IOM report on epilepsy identified patient and family education as essential for better epilepsy care.6 Providers should help educate patients about their epilepsy and refer them to resources available online (Table 3). A continuing exchange about their condition and treatment with seizure medications should occur with each visit. People with epilepsy should also receive guidance regarding how to manage their epilepsy and day-to-day issues. Referring, patients to social workers, psychologists, vocational rehabilitation services, and support groups can enhance a patient’s QOL.3,6 The stigma of epilepsy is another burden that can be diminished by attending support groups. Recently, being a part of an online patient community of veterans was found to improve self-management.46
Conclusion
People with epilepsy have many issues that are unique to the condition and, in part, are related to the unpredictable occurrence of seizures and loss of function. Ideally, seizure control provides a normal lifestyle; however, some mood and anxiety comorbidities may persist despite seizure control. Care in the VA system includes access to 16 sites that have programs dedicated to treating veterans with epilepsy and many more consortium sites that interact with the ECoE to provide high-quality patient care (http:\\www.epilepsy.va.gov). The ECoE also provides a readily available resource to optimally manage veterans with epilepsy. Attention to the issues addressed in this article will promote quality care for veterans with epilepsy.
