title: Reducing severity of comorbid psychiatric symptoms in an epilepsy clinic using a colocation model: results of a pilot intervention.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Jasper J
authors.initials: JJ
authors.lastname: Chen
authors.affiliation: Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Tracie A
authors.initials: TA
authors.lastname: Caller
authors.affiliation: Leadership Preventive Medicine Residency, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: John N
authors.initials: JN
authors.lastname: Mecchella
authors.affiliation: Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Devendra S
authors.initials: DS
authors.lastname: Thakur
authors.affiliation: Leadership Preventive Medicine Residency, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Homa
authors.affiliation: Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Christine T
authors.initials: CT
authors.lastname: Finn
authors.affiliation: Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Kobylarz
authors.affiliation: Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Krzysztof A
authors.initials: KA
authors.lastname: Bujarski
authors.affiliation: Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Vijay M
authors.initials: VM
authors.lastname: Thadani
authors.affiliation: Department of Neurology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
authors.forename: Barbara C
authors.initials: BC
authors.lastname: Jobst
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D015897:Comorbidity; D004827:Epilepsy / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000628:therapy*; D008605:Mental Health Services / Q000592:standards*; D008875:Middle Aged; D010865:Pilot Projects; D011788:Quality of Life; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: Access to health care; Anxiety; Cognition; Colocated; Depression; Embedded; Epilepsy; Psychiatry; Psychogenic nonepileptic seizures (PNESs); Quality improvement