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Adherence to Psychotherapy May Improve Outcomes in Patients With Psychogenic Nonepileptic Seizures

Self-identified minority status and a history of childhood abuse are risk factors for nonadherence to psychotherapy.


WASHINGTON, DC—Adherence to psychotherapy is associated with a 50% or greater reduction in psychogenic nonepileptic seizures (PNES), improved quality of life, and decreased emergency department visits, according to research presented at the 71st Annual Meeting of the American Epilepsy Society.

Twenty-five percent to 40% of patients in epilepsy monitoring units are ultimately diagnosed with PNES. Research has indicated that psychotherapy reduces seizure frequency and improves quality of life in patients with PNES, but 20% to 30% of patients fail to attend their first appointment after diagnosis.

An Obstacle to Treatment

To determine whether nonadherence to psychotherapy may affect patient outcomes, Benjamin Tolchin, MD, Assistant Professor of Neurology at Yale School of Medicine in New Haven, Connecticut, and colleagues followed 105 consecutive patients with video-EEG confirmed PNES at Brigham and Women’s Hospital in Boston from March 2013 to August 2015. At baseline, researchers assessed patients’ psychiatric comorbidities and abuse history in a semistructured neuropsychiatric interview.

Benjamin Tolchin, MD

Following diagnosis, participants were referred for psychotherapy at Brigham and Women’s Hospital or with a local community therapist. Psychotherapy at Brigham and Women’s Hospital included a manualized regimen of 12 weekly one-hour sessions. In addition, a neuropsychiatrist called all local therapists to review the diagnosis and principles of treatment.

The researchers defined adherence to psychotherapy as attending at least eight sessions over the course of 16 weeks. The primary outcome was the proportion of participants with a 50% or greater reduction in PNES frequency at a 12- to 24-month telephone follow-up. Secondary outcomes included the rate of seizure freedom, change in quality of life, and change in number of monthly emergency department visits, which were assessed during the telephone follow-up and with medical chart review. Researchers used Fischer’s exact test and Student’s t-test to assess the correlation of outcomes with adherence to psychotherapy.

At follow-up, 84% of patients who were adherent with treatment achieved a significant reduction in seizure frequency, compared with 61% of patients who were nonadherent. Patients who were adherent had an average 7.2-point improvement on the Quality of Life in Epilepsy-10, whereas patients who were nonadherent had a mean 2.8-point improvement. Mean change in monthly emergency department visits was significantly reduced among patients who were adherent to treatment, compared with patients who were not adherent. After adjusting for potential confounders, treatment adherence remained a significant predictor of 50% reduction in seizure frequency (odds ratio, 3.81). Overall, 60% of participants were nonadherent. Risk factors for nonadherence included self-identified minority status and history of childhood abuse.

“New interventions, such as motivational interviewing, are needed to improve adherence with psychotherapy among patients with PNES,” Dr. Tolchin said.

Motivational Interviewing

In a separate study, Dr. Tolchin and colleagues evaluated whether motivational interviewing improved treatment adherence and outcomes among 60 patients with video-EEG confirmed PNES. Patients who were randomized to receive a 30-minute motivational interviewing session before psychotherapy were more adherent to psychotherapy and had greater improvements in PNES frequency and quality of life, compared with patients randomized to psychotherapy alone. “Motivational interviewing-based interventions can improve the common problem of nonadherence with psychotherapy among patients diagnosed with PNES,” the researchers said. They added that this technique potentially could be delivered remotely to improve outcomes.

—Erica Tricarico

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