The prevalence of epilepsy and association with traumatic brain injury in veterans of the Afghanistan and Iraq wars.

OBJECTIVE: To examine the association of epilepsy with traumatic brain injury (TBI) in Afghanistan and Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) Veterans. DESIGN: Cross-sectional observational study. PARTICIPANTS: A total 256 284 OEF/OIF Veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009-2010. MAIN OUTCOME MEASURES: We used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses. RESULTS: Epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37 718 individuals with a diagnosis of TBI, 29 297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43-1.89]). CONCLUSIONS: Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association. Because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.

MRSI of the medial temporal lobe at 7 T in explosive blast mild traumatic brain injury.

PURPOSE: Up to 19% of veterans returning from the wars in Iraq and Afghanistan have a history of mild traumatic brain injury with 70% associated with blast exposure. Tragically, 20-50% of this group reports persistent symptoms, including memory loss. Unfortunately, routine clinical imaging is typically normal, making diagnosis and clinical management difficult. The goal of this work was to develop methods to acquire hippocampal MRSI at 7 T and evaluate their sensitivity to detect injury in veterans with mild traumatic brain injury. METHODS: At 7 T, hippocampal MRSI measurements are limited by: (1) poor B(0) homogeneity; (2) insufficient B(1)(+) strength and homogeneity; and (3) chemical shift dispersion artifacts. To overcofme these limitations we: (1) used third degree B(0) shimming; (2) an inductively decoupled transceiver array with radiofrequency shimming; and (3) a volume localized single slice sequence using radiofrequency shimming-based outer volume suppression. RESULTS: In 20 controls and 25 veterans with mild traumatic brain injury due to blast exposure with memory impairment, hippocampal N-acetyl aspartate to choline (P < 0.001) and N-acetyl aspartate to creatine (P < 0.001) were decreased in comparison to control subjects. CONCLUSION: With the appropriate methods robust spectroscopic imaging of the hippocampus can be carried out at 7 T. MRSI at 7 T can detect hippocampal injury in veterans with mild traumatic brain injury.

Influence of anxiety on memory performance in temporal lobe epilepsy.

This study examined the degree to which anxiety contributed to inconsistent material-specific memory difficulties among 243 patients with temporal lobe epilepsy from the Multisite Epilepsy Study. Visual memory performance on the Rey Complex Figure Test (RCFT) was poorer for those with high versus low levels of anxiety but was not found to be related to the TLE side. The verbal memory score on the California Verbal Learning Test (CVLT) was significantly lower for patients with left-sided TLE than for patients with right-sided TLE with low anxiety levels but equally impaired for those with high anxiety levels. These results suggest that we can place more confidence in the ability of verbal memory tests like the CVLT to lateralize to left-sided TLE for those with low anxiety levels, but that verbal memory will be less likely to produce lateralizing information for those with high anxiety levels. This suggests that more caution is needed when interpreting verbal memory tests for those with high anxiety levels. These results indicated that RCFT performance was significantly affected by anxiety and did not lateralize to either side, regardless of anxiety levels. This study adds to the existing literature which suggests that drawing-based visual memory tests do not lateralize among patients with TLE, regardless of anxiety levels.

Providers' perspectives on treating psychogenic nonepileptic seizures: frustration and hope.

Recent diagnostic and treatment advances in psychogenic nonepileptic seizures (PNES) have the potential to improve care for patients, but little is known about the current state of PNES care delivery in the Veterans Health Administration (VA). We conducted semistructured interviews with 74 health-care clinicians and workers in the VA, eliciting provider perceptions of PNES care. Data were analyzed according to principles of Grounded Theory. The results revealed variation in care and two emergent domain themes of frustration and hope. Frustration was manifest in subthemes including Complexity, Patient Acceptance, Uncertainty About Treatment, Need for Evidence-based Treatment, and Failure of Cross-Disciplinary Collaboration between neurologists and mental health providers. Hope encompassed subthemes of Positive Attitudes, Developing Cross-Disciplinary Treatment, and Specific PNES Care. Increased resources for diagnosing, treating, and researching PNES have improved awareness of the disorder. More research is needed to understand patients' and caregivers' perceptions of PNES care.

Should antidepressant drugs of the selective serotonin reuptake inhibitor family be tested as antiepileptic drugs?

For a long time, there has been a misconception that all antidepressant drugs have proconvulsant effects. Yet, antidepressants of the selective serotonin reuptake inhibitor (SSRI) family not only have been shown to be safe when used in patients with epilepsy (PWE) but also have been found to possess antiepileptic properties in animal models of epilepsy. In humans randomized to SSRIs vs. placebo for the treatment of major depressive episodes, the incidence of epileptic seizures was significantly lower among those treated with the antidepressants. These data raise the question of whether there is enough evidence that would support a randomized placebo-controlled trial to test antiepileptic effect of SSRIs in PWE. This article reviews the preclinical and clinical data to address this question.

Impaired consciousness in epilepsy investigated by a prospective responsiveness in epilepsy scale (RES).

PURPOSE: Impaired consciousness in epileptic seizures has a major negative impact on patient quality of life. Prior work on epileptic unconsciousness has mainly used retrospective and nonstandardized methods. Our goal was to validate and to obtain initial data using a standardized prospective testing battery. METHODS: The responsiveness in epilepsy scale (RES) was used on 52 patients during continuous video-electroencephalography (EEG) monitoring. RES begins with higher-level questions and commands, and switches adaptively to more basic sensorimotor responses depending on patient performance. RES continues after seizures and includes postictal memory testing. Scoring was conducted based on video review. KEY FINDINGS: Testing on standardized seizure simulations yielded good intrarater and interrater reliability. We captured 59 seizures from 18 patients (35% of participants) during 1,420 h of RES monitoring. RES impairment was greatest during and after tonic-clonic seizures, less in partial seizures, and minimal in auras and subclinical seizures. In partial seizures, ictal RES impairment was significantly greater if EEG changes were present. Maximum RES impairment (lowest ictal score) was also significantly correlated with long postictal recovery time, and poor postictal memory. SIGNIFICANCE: We found that prospective testing of responsiveness during seizures is feasible and reliable. RES impairment was related to EEG changes during seizures, as well as to postictal memory deficits and recovery time. With a larger patient sample it is hoped that this approach can identify brain networks underlying specific components of impaired consciousness in seizures. This may allow the development of improved treatments targeted at preventing dysfunction in these networks.

Impaired consciousness in temporal lobe seizures: role of cortical slow activity.

Impaired consciousness requires altered cortical function. This can occur either directly from disorders that impair widespread bilateral regions of the cortex or indirectly through effects on subcortical arousal systems. It has therefore long been puzzling why focal temporal lobe seizures so often impair consciousness. Early work suggested that altered consciousness may occur with bilateral or dominant temporal lobe seizure involvement. However, other bilateral temporal lobe disorders do not impair consciousness. More recent work supports a 'network inhibition hypothesis' in which temporal lobe seizures disrupt brainstem-diencephalic arousal systems, leading indirectly to depressed cortical function and impaired consciousness. Indeed, prior studies show subcortical involvement in temporal lobe seizures and bilateral frontoparietal slow wave activity on intracranial electroencephalography. However, the relationships between frontoparietal slow waves and impaired consciousness and between cortical slowing and fast seizure activity have not been directly investigated. We analysed intracranial electroencephalography recordings during 63 partial seizures in 26 patients with surgically confirmed mesial temporal lobe epilepsy. Behavioural responsiveness was determined based on blinded review of video during seizures and classified as impaired (complex-partial seizures) or unimpaired (simple-partial seizures). We observed significantly increased delta-range 1-2 Hz slow wave activity in the bilateral frontal and parietal neocortices during complex-partial compared with simple-partial seizures. In addition, we confirmed prior work suggesting that propagation of unilateral mesial temporal fast seizure activity to the bilateral temporal lobes was significantly greater in complex-partial than in simple-partial seizures. Interestingly, we found that the signal power of frontoparietal slow wave activity was significantly correlated with the temporal lobe fast seizure activity in each hemisphere. Finally, we observed that complex-partial seizures were somewhat more common with onset in the language-dominant temporal lobe. These findings provide direct evidence for cortical dysfunction in the form of bilateral frontoparietal slow waves associated with impaired consciousness in temporal lobe seizures. We hypothesize that bilateral temporal lobe seizures may exert a powerful inhibitory effect on subcortical arousal systems. Further investigations will be needed to fully determine the role of cortical-subcortical networks in ictal neocortical dysfunction and may reveal treatments to prevent this important negative consequence of temporal lobe epilepsy.

Anxiety symptoms in epilepsy: salient issues for future research.

This paper reviews the distinct symptom profile, epidemiology, pathogenesis, assessment, and treatment of anxiety disorders. It highlights emerging neuroimaging research in mood and anxiety disorders in people with epilepsy. While structural neuroimaging has implicated frontal temporal grey matter structures in mood and anxiety disorders, diffusion tensor imaging and magnetic resonance spectroscopy (MRS) show promise in elucidating white matter changes. In addition, future MRS studies may demonstrate changes in glutamate and gamma-aminobutyric acid (GABA) levels in these regions and hopefully help inform response to treatment.

Suicide outcomes after resective epilepsy surgery.

People with epilepsy have a higher risk for suicide than people without epilepsy. The relationship between seizure control and suicide is controversial. A standardized protocol to record history, diagnostic testing, and neuropsychiatric assessments was administered. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were administered presurgically and yearly for up to 5 years. Among the 396 enrolled, 4 of 27 deaths were attributed to suicide. The standardized mortality ratio, compared with suicides in the U.S. population and adjusted for age and gender, was 13.3 (95% CI=3.6-34.0). Only one patient had a BDI score suggestive of severe depression (BDI=33), one had depressive symptoms that did not the meet the depressive range (BDI=7), and the other two reported no depressive symptoms. Two of the patients reported moderate to severe anxiety symptoms (BAI=17 and 21, respectively). Suicide may occur after epilepsy surgery, even when patients report excellent seizure control.

A prospective study of loss of consciousness in epilepsy using virtual reality driving simulation and other video games.

Patients with epilepsy are at risk of traffic accidents when they have seizures while driving. However, driving is an essential part of normal daily life in many communities, and depriving patients of driving privileges can have profound consequences for their economic and social well-being. In the current study, we collected ictal performance data from a driving simulator and two other video games in patients undergoing continuous video/EEG monitoring. We captured 22 seizures in 13 patients and found that driving impairment during seizures differed in terms of both magnitude and character, depending on the seizure type. Our study documents the feasibility of a prospective study of driving and other behaviors during seizures through the use of computer-based tasks. This methodology may be applied to further describe differential driving impairment in specific types of seizures and to gain data on anatomical networks disrupted in seizures that impair consciousness and driving safety.

Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries.

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.

Treating adult attention deficit hyperactivity disorder in hospitalized psychiatric patients.

OBJECTIVES: We intend to review the importance of appropriately recognizing and managing attention deficit/attention deficit hyperactivity disorder (ADD/ADHD) in the acute psychiatric hospital setting. METHODS: We demonstrate the management of three patients with associated ADD/ADHD diagnosis in the hospital setting. This case series is followed by a review of the literature on the treatment of ADD/ADHD with particular focus on inpatient treatment. RESULTS: Given that the core symptoms of ADD/ADHD are inattention, hyperactivity, poor concentration, impulsivity, poor organization and emotional instability, it follows that a comprehensive inpatient treatment plan should address these issues in order to obtain sustained, focused participation on the part of the patient. Suppression of ADD/ADHD symptoms with stimulants greatly enhanced our patients' ability to more productively and actively participate in the treatment of the acute psychiatric problems which led to their admission. CONCLUSIONS: Currently, no published data exist on prevalence of ADD/ADHD in psychiatric hospitals, rates of treatment and outcome of treatment with regard to recovery and quality of aftercare. Nonetheless, the benefits of treating ADD/ADHD among psychiatric inpatients may be seen in case examples and are also apparent in the data concerning treatment of ADD/ADHD in the dually diagnosed.

Developing Iraq's mental health policy.

As Iraq faces the challenge of securing a sustainable resolution to the current violence, the burden of mental illness is likely to increase dramatically. The impact of Saddam Hussein's dictatorship, the Iran-Iraq war, U.S.-led economic sanctions, the Persian Gulf wars, and the U.S. invasion and subsequent violent insurgency have devastated Iraq's governmental and social infrastructure. Health care delivery across sectors has suffered greatly. During the reconstruction phase, the United States and coalition forces allocated resources to restructure Iraq's health care system. Many multinational organizations, governments, and policy makers had the political will as well as the financial and human resources to greatly influence Iraq's mental health program. However, the lack of an existing mental health plan stifled these efforts. Applying Kingdon's model for policy development, which includes political analysis, problem defining, and proposal drafting, the authors describe the development of Iraq's current mental health policy.

Using CBPR for Health Research in American Muslim Mosque Communities.

BACKGROUND: American Muslims are understudied in health research, and there are few studies documenting community-based participatory research (CBPR) efforts among American Muslim mosque communities. OBJECTIVES: We highlight lessons learned from a CBPR partnership that explored the health care beliefs, behaviors, and challenges of American Muslims. METHODS: We established a collaboration between the University of Michigan and four Muslim-focused community organizations in Michigan. Our collaborative team designed and implemented a two-phase study involving interviews with community stakeholders and focus groups and surveys with mosque congregants. LESSONS LEARNED: Although we were successful in meeting our research goals, maintaining community partner involvement and sustaining the project partnership proved challenging. CONCLUSIONS: CBPR initiatives within mosque communities have the potential for improving community health. Our experience suggests that successful research partnerships with American Muslims will utilize social networks and cultural insiders, culturally adapt research methods, and develop a research platform within the organizational infrastructures of the American Muslim community.

Ischemic stroke in Jordan 2000 to 2002: a two-year, hospital-based study.

A total of 200 consecutive patients with first ischemic stroke seen at Jordan University Hospital in Amman, Jordan, during a 2-year period were studied retrospectively. Mean age was 61.2 years (range: 29-95 years). The most common stroke subtype was lacunar infarct (51%), but the frequency of cardioembolic strokes was low (8%). Hypertension, diabetes mellitus, coronary artery disease, and smoking were the most common risk factors for atherosclerotic noncardioembolic strokes. Chronic atrial fibrillation was the most common risk factor for cardioembolic strokes. No patient had significant (>50%) extracranial carotid or vertebral artery stenosis. The outcome was relatively good; 85% of patients were discharged home, the majority with only mild neurologic deficit. The favorable outcome is most likely because of the relatively young mean age and the predominance of lacunar infarcts.

A primary care study of the correlates of depressive symptoms among Jordanian women.

A standardized Arabic version of the Beck Depression Inventory-II was administered to 493 randomly selected Arab women attending primary care out-patient centers in West Amman, Jordan. Women were asked about demographic data as well as questions from a negative life events questionnaire. The mean Beck score was 13.02 (+/- 8.13). Demographic factors and negative life events accounted for 17.1% of the variance in the total Beck score. Self-reported financial problems and health problems as well as marital separation were the strongest contributors. Family problems and work stress made smaller contributions to depressive symptoms.

Concussive brain injury from explosive blast.

OBJECTIVE: Explosive blast mild traumatic brain injury (mTBI) is associated with a variety of symptoms including memory impairment and posttraumatic stress disorder (PTSD). Explosive shock waves can cause hippocampal injury in a large animal model. We recently reported a method for detecting brain injury in soldiers with explosive blast mTBI using magnetic resonance spectroscopic imaging (MRSI). This method is applied in the study of veterans exposed to blast. METHODS: The hippocampus of 25 veterans with explosive blast mTBI, 20 controls, and 12 subjects with PTSD but without exposure to explosive blast were studied using MRSI at 7 Tesla. Psychiatric and cognitive assessments were administered to characterize the neuropsychiatric deficits and compare with findings from MRSI. RESULTS: Significant reductions in the ratio of N-acetyl aspartate to choline (NAA/Ch) and N-acetyl aspartate to creatine (NAA/Cr) (P < 0.05) were found in the anterior portions of the hippocampus with explosive blast mTBI in comparison to control subjects and were more pronounced in the right hippocampus, which was 15% smaller in volume (P < 0.05). Decreased NAA/Ch and NAA/Cr were not influenced by comorbidities - PTSD, depression, or anxiety. Subjects with PTSD without blast had lesser injury, which tended to be in the posterior hippocampus. Explosive blast mTBI subjects had a reduction in visual memory compared to PTSD without blast. INTERPRETATION: The region of the hippocampus injured differentiates explosive blast mTBI from PTSD. MRSI is quite sensitive in detecting and localizing regions of neuronal injury from explosive blast associated with memory impairment.

Mood, anxiety, and incomplete seizure control affect quality of life after epilepsy surgery.

OBJECTIVE: We examined the complex relationship between depression, anxiety, and seizure control and quality of life (QOL) outcomes after epilepsy surgery. METHODS: Seven epilepsy centers enrolled 373 patients and completed a comprehensive diagnostic workup and psychiatric and follow-up QOL evaluation. Subjects were evaluated before surgery and then at 3, 6, 12, 24, 48, and 60 months after surgery. Standardized assessments included the Quality of Life in Epilepsy Inventory-89, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). A mixed-model repeated-measures analysis was used to analyze associations of depression, anxiety, seizure outcome, and seizure history with overall QOL score and QOL subscores (cognitive distress, physical health, mental health, epilepsy-targeted) prospectively. RESULTS: The groups with excellent and good seizure control showed a significant positive effect on the overall QOL compared to the groups with fair and poor seizure control. The BDI and BAI scores were both highly and negatively associated with overall QOL; increases in BDI and BAI scores were associated with decreased overall QOL score. CONCLUSIONS: Depression and anxiety are strongly and independently associated with worse QOL after epilepsy surgery. Interestingly, even partial seizure control, controlling for depression and anxiety levels, improved QOL. Management of mood and anxiety is a critical component to postsurgical care.