Article

Epilepsy Care Planning in Psychiatric Inpatient Settings

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Abstract

Murphy, V., Gulati, G., Luppe, S., & Chaila, E. (2017). Letter to the Editor. Irish Journal of Psychological Medicine, 1-1. doi:10.1017/ipm.2016.48 We describe the development of a diagnosis triggered tool to assist the care plannng for those with epilepsy in psychiatric inpatient settings. The tool is available on an open access basis alongside this publication.

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Article
Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.
Article
Aims To ascertain epilepsy prevalence in Irish psychiatric inpatient units and compliance with care planning guidelines. Methods Case records were reviewed in seven psychiatric inpatient units. Results The prevalence of epilepsy across seven psychiatric inpatient units (n=9/267) was three times that of general population estimates. Minimal data was recorded pertaining to seizure type (n=1,11.1%), triggers (n=2,22.2%), clinical investigations relating to epilepsy (n=2,22%) and no epilepsy risk assessments were recorded (n=0,0%). Conclusions The introduction of appropriate care plans is needed to optimise physical and mental wellbeing of those with epilepsy in psychiatric units.
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Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms or seizures occur in patients with known psychiatric illness. We present clinical profiles of six patients with epilepsy (three male, mean age 39 ± 12 years) that presented with prominent psychiatric symptoms. Two patients had pre-existing psychiatric illnesses. Three patients were initially diagnosed with panic attacks, two with psychosis, and one with schizophrenia. Five patients had temporal lobe epilepsy (TLE) while the sixth patient was subsequently found to have absence status epilepticus (SE). Cranial computed tomogram (CT) including contrast study was unremarkable in five patients and showed post-traumatic changes in one patient. Cranial magnetic resonance imaging (MRI) revealed dysembryoplastic neuroepithelial tumour (DNET) in one patient, cavernous hemangioma in one, and post-traumatic changes plus bilateral mesial temporal sclerosis in another patient but it was normal in two TLE patients. Routine electroencephalography (EEG) revealed absence SE in one patient but it was non-diagnostic in the TLE patients. Video-EEG telemetry in the epilepsy monitoring unit (EMU) was necessary to establish the diagnosis in four TLE patients. None of the patients responded to medications aimed at treating psychiatric symptoms alone. Two patients required surgery while the other four required treatment with anti-epileptic drugs. All the patients had favorable response to the treatment of their epilepsy. This case series illustrates that epileptic patients may experience non-convulsive seizures that might be mistaken as primary psychiatric illnesses. In this subset of patients, evaluation by an epileptologist, MRI of the brain, and/or video-EEG telemetry in an EMU was necessary to confirm the diagnosis of epilepsy if routine EEGs and cranial CT are normal.
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Antiepileptic drugs (AEDs) are widely used as long-term adjunctive therapy or as monotherapy in epilepsy and other indications and consist of a group of drugs that are highly susceptible to drug interactions. The purpose of the present review is to focus upon clinically relevant interactions where AEDs are involved and especially on pharmacokinetic interactions. The older AEDs are susceptible to cause induction (carbamazepine, phenobarbital, phenytoin, primidone) or inhibition (valproic acid), resulting in a decrease or increase, respectively, in the serum concentration of other AEDs, as well as other drug classes (anticoagulants, oral contraceptives, antidepressants, antipsychotics, antimicrobal drugs, antineoplastic drugs, and immunosupressants). Conversely, the serum concentrations of AEDs may be increased by enzyme inhibitors among antidepressants and antipsychotics, antimicrobal drugs (as macrolides or isoniazid) and decreased by other mechanisms as induction, reduced absorption or excretion (as oral contraceptives, cimetidine, probenicid and antacides). Pharmacokinetic interactions involving newer AEDs include the enzyme inhibitors felbamate, rufinamide, and stiripentol and the inducers oxcarbazepine and topiramate. Lamotrigine is affected by these drugs, older AEDs and other drug classes as oral contraceptives. Individual AED interactions may be divided into three levels depending on the clinical consequences of alterations in serum concentrations. This approach may point to interactions of specific importance, although it should be implemented with caution, as it is not meant to oversimplify fact matters. Level 1 involves serious clinical consequences, and the combination should be avoided. Level 2 usually implies cautiousness and possible dosage adjustments, as the combination may not be possible to avoid. Level 3 refers to interactions where dosage adjustments are usually not necessary. Updated knowledge regarding drug interactions is important to predict the potential for harmful or lacking effects involving AEDs.
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Epilepsy is highly prevalent in people with intellectual disabilities and mortality is increased in people with epilepsy generally. This review summarises research on the comparative risk of mortality in people with intellectual disabilities and epilepsy compared to the general population, people with intellectual disabilities without epilepsy, and people with epilepsy without intellectual disabilities. Studies were identified via electronic searches using Medline, Cinahl and PsycINFO and cross-citations. Information extracted from studies was tabulated and reviewed narratively. Sixteen studies met the inclusion criteria. Epilepsy was associated with increased mortality in people with intellectual disabilities in most studies, particularly in those experiencing recent seizures. Further research is needed to substantiate some of the reported findings. Services must be equipped with the skills and information needed to manage this condition in order to minimise the risk of death in people with intellectual disabilities and epilepsy. Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
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Psychopathology has long been associated with epilepsy and should not be overlooked as it could exacerbate the epilepsy itself and impair the health-related quality of life of sufferers. A higher prevalence of psychiatric disorders has frequently been demonstrated amongst patients with epilepsy compared both with the general population and with individuals presenting neurological or non-neurological conditions. This review critically evaluates selected studies on the prevalence of psychiatric disorders in epilepsy patients compared with the general population and controls. Heterogeneity exists across the research methodologies, therefore further research, using less selected groups, should be undertaken to allow valid comparisons and the identification of more precise prevalence rates.
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Antiepileptic drugs are important psychotropic agents that are commonly used to treat psychiatric disorders. The behavioral effects of antiepileptic drugs may differ between epilepsy and psychiatric patient populations. Randomized, double-blind, controlled data on the psychotropic efficacy of antiepileptic drugs are limited mainly to bipolar disorder.
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