1. Cognitive and Behavioral Interventions in Patients With Epilepsy
Deepti Anbarasan, MD
The Neurological Institute of New York, Columbia University Medical Center, New York, New York
A REPORT FROM THE 69th ANNUAL MEETING OF THE AMERICAN EPILEPSY SOCIETY
© 2016 Direct One Communications, Inc. All rights reserved

2. Addressing Psychiatric Comorbidities
Patients with epilepsy are more likely to exhibit depression, anxiety, and other psychiatric comorbidities than patients without epilepsy.
In addition, epileptic seizures may increase the risk of depression and anxiety.
Patients with epilepsy tend to rate such psychosocial factors as psychological distress, loneliness, coping and adjustment, and stigma perception as being more important to their quality of life than such clinical factors as seizure onset and frequency and the side effects of antiepileptic drugs (AEDs).
Tellez-Zenteno et al. Epilepsia. 2007;48:2336; Thapar A et al. Epilepsy Behav. 2009;14:134; Suurmeijer T et al. Epilepsia. 2001; 42:1160
© 2016 Direct One Communications, Inc. All rights reserved

3. Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) uses mindfulness and behavioral change to address patients’ perceptions of being diagnosed with epilepsy.
Clinicians using this form of cognitive-behavioral therapy seek to increase psychological flexibility by using both acceptance and mindfulness strategies to help change patient behavior.
ACT also has been useful in treating depression, anxiety, diabetes, chronic pain, and drug resistance in patients with epilepsy.
Lundgren T et al. Epilepsia. 2006;47:2173; Lundgren T et al. Epilepsy Behav. 2008;13:102
© 2016 Direct One Communications, Inc. All rights reserved

4. ACT for Refractory Epilepsy
The benefits and limitations of ACT were recently evaluated in an uncontrolled, prospective study involving 60 consecutive patients who were referred for outpatient psychological treatment due to emotional difficulties related to refractory epilepsy.
One therapist administered an initial 1.5-hour assessment followed by 6–20 individual outpatient sessions, spaced 1–2 weeks apart and lasting 50 minutes each; patients also were given a workbook.
Patients completed a battery of self-administered questionnaires at referral, upon conclusion of the outpatient sessions, and 6 months afterward.
Dewhurst E et al. Epilepsy Behav. 2015;46:234
© 2016 Direct One Communications, Inc. All rights reserved

5. ACT for Refractory Epilepsy continued
Completion of the ACT module was associated with significant improvements in self-reported psychiatric symptoms.
Dewhurst E et al. Epilepsy Behav. 2015;46:234
© 2016 Direct One Communications, Inc. All rights reserved

6. ACT for Refractory Epilepsy continued
The investigators noted significant improvements in anxiety and depression symptoms, work and social functioning, and patient self-esteem.
Improvements also were seen in most scales of the SF-12, although changes in the physical-functioning subscale and the physical-health summary scale were not significant.
No significant differences were seen between outcome measures obtained in the immediate posttherapy period and 6 months posttherapy, indicating that the benefits of ACT therapy were sustainable for at least 6 months.
Dewhurst E et al. Epilepsy Behav. 2015;46:234
© 2016 Direct One Communications, Inc. All rights reserved

7. ACT for Refractory Epilepsy continued
This ACT-based psychotherapeutic intervention not only resulted in significant and sustainable effects on depression, anxiety, quality of life (QOL), social adjustment, and self-esteem but also was relatively cost-effective, based on quality-adjusted life year (QALY) gains and overall cost of the therapy.
The mean cost of treatment for one patient (~ $718) was associated with a 0.08 QALY gain; based on these measures, the cost/QALY amount associated with sustained improvement of symptoms for 6 months was $18,016, and the amount associated with sustained benefits for 12 months was $8,979.
Dewhurst E et al. Epilepsy Behav. 2015;46:234
© 2016 Direct One Communications, Inc. All rights reserved

8. Targeting Stress in Patients With Epilepsy
Studies have indicated that patients with epilepsy who perceive stress have a higher probability of experiencing seizures during the next 24 hours.
In addition, patients with epilepsy who report having stress-precipitated seizures tend to have higher scores on anxiety tests and to find that stress-reduction methods improve seizure control.
Consequently, interventions that target stress may be helpful in patients with epilepsy who report stress as a possible trigger.
Haut SR et al. Neurology. 2007; 68: 262; Privitera M et al. Epilepsy Behav. 2014;41:74
© 2016 Direct One Communications, Inc. All rights reserved

9. Targeting Stress continued
Physiologically, stress activates the hypothalamic-pituitary-adrenal (HPA) axis and can lead to proconvulsant release of glucocorticoids, such as corticosterone.
Seizure-induced activation of the HPA axis may contribute to additional seizure susceptibility.
Using pilocarpine to induce seizures in mice increases circulating levels of corticosterone.
Treatment with a corticotropin-releasing hormone antagonist can block seizure activation in mice.
O’Toole K et al. Epilepsy Res. 2014;108;29
© 2016 Direct One Communications, Inc. All rights reserved

10. Progressive Muscle Relaxation (PMR)
Polak and colleagues conducted a randomized, controlled, double-blind trial in which an integrative medicine approach, such as diaphragmatic breathing and PMR, was used with seizure-prediction methods as part of the Stress Management Intervention for Living With Epilepsy (SMILE) study.
Patients were eligible for inclusion in the SMILE study if they experienced at least two seizures per month, identified stress as a seizure trigger, and were on a stable AED regimen.
In all, 67 patients completed the study.
Polak E et al. Epilepsy Behav. 2012;25:505
© 2016 Direct One Communications, Inc. All rights reserved

11. Progressive Muscle Relaxation continued
For the entire 5 months of the study, all participants monitored their levels of stress and other seizure triggers multiple times a day using a smartphone.
After the first 2 months, patients were randomly assigned to the active-treatment group, which used slow diaphragmatic breathing and PMR twice daily, or a control group for the remainder of the study.
The control group received a similar sham treatment, in which patients were led through a series of movements in the morning and then were asked to write down activities of the previous day in the evening.
Polak E et al. Epilepsy Behav. 2012;25:505
© 2016 Direct One Communications, Inc. All rights reserved

12. Progressive Muscle Relaxation continued
Median seizure frequency was reduced by 29% in the active-treatment group (P = 0.006) and by 25% in the sham-treatment arm (P = 0.064).
No significant difference between the active- and sham-treatment arms was observed.
However, when the month 5 data where excluded and data from months 1 and 2 were compared with the data from months 3 and 4, there was a 33% reduction in seizures in the active-treatment arm (P = 0.009) and an 18% reduction in the sham-treatment arm (P = 0.171); this difference between between active and sham treatment was significant.
Polak E et al. Epilepsy Behav. 2012;25:505
© 2016 Direct One Communications, Inc. All rights reserved

13. Progressive Muscle Relaxation continued
Both the active- and sham-treatment groups appeared to improve from baseline, even though the primary outcome of seizure reduction over 3 months did not attain statistical significance.
Use of the smartphone diary to record mood, stress, and seizures may have reduced seizure frequency without formal relaxation interventions; even sham treatment may have had some therapeutic benefits in terms of stress reduction.
The investigators next plan to study cognitive and mindfulness treatments in addition to PMR.
Polak E et al. Epilepsy Behav. 2012;25:505
© 2016 Direct One Communications, Inc. All rights reserved

14. Improving Cognitive Impairments
Vast discrepancies exist between patients’ actual concerns about living with epilepsy and practitioners’ impressions of these concerns.
Patients identified their top three concerns as (1) unexpected seizures, (2) issues related to driving, and (3) memory problems.
Practitioners predicted the importance of the first two issues, but they did not identify memory problems as a prominent concern for patients with epilepsy.
McAuley J et al. Epilepsy Behav. 2010;19:580
© 2016 Direct One Communications, Inc. All rights reserved

15. Improving Cognitive Impairments continued
Subjective memory complaints have been associated with word-finding difficulties and depression; as such, efforts to address depression in patients with epilepsy by improving identification of depressive symptoms and access to psychiatric care may improve both subjective memory and mood.
Another potential therapeutic consideration may be cognitive rehabilitation; however, interventions do not appear to improve patients’ subjective memory complaints and require extensive resources and patient compliance, including frequent clinic visits and personal engagement.
Chen J et al. Epilepsy Behav. 2014;39:92; Farina E et al. Epilepsy Res. 2015;109:210
© 2016 Direct One Communications, Inc. All rights reserved

16. The HOBSCOTCH Program
The HOBSCOTCH (Home-based Self-Management and Cognitive Training Changes Lives) program for patients with epilepsy and memory or cognitive deficits uses self-management and problem-solving therapy to improve memory.
It consists of one in-person office visit at the beginning and end of the program and six weekly telephone sessions with an assigned memory coach.
During the eight 45- to 60-minute sessions, patients learn skills related to memory, epilepsy, organization, and social function; they then exercise and apply their problem-solving techniques between sessions.
Caller T et al. Epilepsy Behav. 2015;44:192
© 2016 Direct One Communications, Inc. All rights reserved

17. The HOBSCOTCH Program continued
In a recent study, 66 patients with epilepsy were enrolled, randomized, and assigned to one of three groups; 45 patients completed the study.
Patients in the HOBSCOTCH and HOBSCOTCH Plus groups reported significant improvement in QOL compared with those in the control group.
Patients in the two HOBSCOTCH groups also had higher posttreatment memory scores than those in the control group due to significantly improved attention subscores.
No significant changes in depressive symptoms were observed.
Caller T et al. Epilepsy Behav. 2015;44:192
© 2016 Direct One Communications, Inc. All rights reserved

18. The HOBSCOTCH Program continued
Neuropsychological effects of HOBSCOTCH program:
Caller T et al. Epilepsy Behav. 2015;44:192
© 2016 Direct One Communications, Inc. All rights reserved

19. The HOBSCOTCH Program continued
The HOBSCOTCH program may be a helpful intervention to consider for patients with epilepsy having difficulty coping with memory-related disability.
This program does not have to be delivered by a specialized provider (such as a neuropsychologist), and a significant portion of the intervention can be delivered over the telephone.
In fact, the two in-person sessions at the start and end of the program may be accomplished virtually to enhance cost-effectiveness and compliance; this modification must be studied further, however.
Caller T et al. Epilepsy Behav. 2015;44:192
© 2016 Direct One Communications, Inc. All rights reserved