1. Epilepsy Behav. 2014 Oct;39:92-6. doi: 10.1016/j.yebeh.2014.07.015. Epub 2014 Sep
18.

Reducing severity of comorbid psychiatric symptoms in an epilepsy clinic using a 
colocation model: results of a pilot intervention.

Chen JJ(1), Caller TA(2), Mecchella JN(3), Thakur DS(4), Homa K(3), Finn CT(4),
Kobylarz EJ(2), Bujarski KA(2), Thadani VM(2), Jobst BC(2).

Author information: 
(1)Behavioral Health Services, Cheyenne Regional Medical Center, Cheyenne, WY,
USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth College,
Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
Electronic address: jjchencheyenne@gmail.com.
(2)Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical
Center Drive, Lebanon, NH, USA.
(3)Leadership Preventive Medicine Residency, Dartmouth-Hitchcock Medical Center, 
One Medical Center Drive, Lebanon, NH, USA.
(4)Department of Psychiatry, Geisel School of Medicine at Dartmouth College,
Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.

RATIONALE: Patients with epilepsy (PWEs) and patients with nonepileptic seizures 
(PWNESs) constitute particularly vulnerable patient populations and have high
rates of psychiatric comorbidities. This potentially decreases quality of life
and increases health-care utilization and expenditures. However, lack of access
to care or concern of stigma may preclude referral to outpatient psychiatric
clinics. Furthermore, the optimal treatment for NESs includes longitudinal
psychiatric management. No published literature has assessed the impact of
colocated psychiatric services within outpatient epilepsy clinics. We, therefore,
evaluated the colocation of psychiatric services within a level 4 epilepsy
center.
METHODS: From July 2013 to June 2014, we piloted an intervention to colocate a
psychiatrist in the Dartmouth-Hitchcock Epilepsy Center outpatient clinic one
afternoon a week (0.1 FTE) to provide medication management and time-limited
structural psychotherapeutic interventions to all patients who scored greater
than 15 on the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) 
and who agreed to referral. Psychiatric symptom severity was assessed at baseline
and follow-up visits using validated scales including NDDI-E, Patient Health
Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and cognitive
subscale items from Quality of Life in Epilepsy-31 (QOLIE-31) scores.
RESULTS: Forty-three patients (18 males; 25 females) were referred to the clinic 
over a one-year interval; 27 (64.3%) were seen in follow-up with a median of 3
follow-up visits (range: 1 to 7). Thirty-seven percent of the patients had NESs
exclusive of epilepsy, and 11% of the patients had dual diagnosis of epilepsy and
NESs. Psychiatric symptom severity decreased in 84% of the patients, with PHQ-9
and GAD-7 scores improving significantly from baseline (4.6±0.4 SD improvement in
PHQ-9 and 4.0±0.4 SD improvement in GAD-7, p-values<0.001). Cognitive subitem
scores for NDDI-E and QOLIE-31 at their most recent visit were significantly
improved compared with nadir scores (3.3±0.6 SD improvement in NDDI-E and 1.5±0.2
SD improvement in QOLIE-31, p-values<0.001). These results are, moreover,
clinically significant-defined as improvement by 4-5 points on PHQ-9 and GAD-7
instruments-and are correlated with overall improvement as measured by NDDI-E and
cognitive subscale QOLIE-31 items.
CONCLUSION: A colocated psychiatrist demonstrated reduction in psychiatric
symptoms of PWEs and PWNESs, improving psychiatric access and streamlining their 
care. Epileptologists were able to dedicate more time to managing epilepsy as
opposed to psychiatric comorbidities. As integrated models of collaborative and
colocated care are becoming more widespread, mental health-care providers located
in outpatient neurology clinics may benefit both patients and providers.

Copyright © 2014 Elsevier Inc. All rights reserved.

DOI: 10.1016/j.yebeh.2014.07.015 
PMID: 25238553  [Indexed for MEDLINE]