Epilepsy in Irish psychiatric inpatient settings

V. Murphy1, B. Hallahan2, D. Smithwick3, S. Costello4, N. Moloney5, G. Gulati5

1Department of Psychiatry, University College Cork, Cork, Ireland
2Department of Psychiatry, NUI Galway, Galway, Ireland
3Department of Psychiatry, Ennis General Hospital, Ireland
4Department of Psychiatry, University Hospital Galway, Ireland
5Department of Psychiatry, University of Limerick, Ireland

Abstract

Aims
To ascertain epilepsy prevalence in Irish psychiatric inpatient units and compliance with care planning guidelines.

Methods
Case records were reviewed in seven psychiatric inpatient units.

Results

The prevalence of epilepsy across seven psychiatric inpatient units (n=9/267) was three times that of general population estimates. Minimal data was recorded pertaining to seizure type (n=1,11.1%), triggers (n=2,22.2%), clinical investigations relating to epilepsy (n=2,22%) and no epilepsy risk assessments were recorded (n=0,0%).

Conclusions

The introduction of appropriate care plans is needed to optimise physical and mental wellbeing of those with epilepsy in psychiatric units.

Introduction
Epilepsy is one of the most common neurological disorders worldwide with a prevalence in Ireland of approximately 1%1. Epilepsy is associated with increased mortality rates, in particular for those with uncontrolled seizures. Psychiatric morbidity is over-represented in individuals with epilepsy with increased rates of affective disorders (25-74%), anxiety disorders (10-25%) and psychosis (2-7%)2. Psychiatric medication has the potential to reduce seizure threshold and alter pharmacokinetics of antiepileptic medication. Patients with epilepsy have a unique risk profile associated with activities of daily living. Consequently, the provision of appropriate care planning for individuals with epilepsy when admitted to acute psychiatric inpatient units is necessary. However, limited data is present pertaining to the prevalence of individuals with epilepsy admitted to acute psychiatric inpatient units or care planning for such patients. In this study, we aimed to ascertain the prevalence of epilepsy in acute psychiatric inpatient units in Ireland and ascertain if guidelines pertaining to care planning for these patients are being complied with.

Methods
The prevalence of epilepsy in 7 acute psychiatric inpatients units was measured. Cases were identified through responsible care teams and identification augmented by clinical record review. Of those individuals identified as diagnosed with epilepsy, clinical records were examined in depth to ascertain adherence with National Institute for Health and Care Excellence (NICE) guidelines3 in relation to the management of epilepsy. Patient records were cross-sectionally reviewed to evaluate whether in those with epilepsy, such records reflected the documentation of seizure type, seizure description, investigations, medication for epilepsy, risk assessments around epilepsy and an epilepsy care plan.

Results
Nine of 267 patients (3.37%) across seven units were identified as suffering from epilepsy. Minimal data was recorded pertaining to seizure type (n=1,11.1%), triggers for a seizure (n=2, 22.2%), or clinical investigations relating to epilepsy (n=2,22.2%) with no documentation of seizure pattern (n=0,0%) and no risk assessments (n=0,0%) performed relating to risks associated with experiencing a seizure. All individuals were correctly prescribed their regular antiepileptic medications (n=9, 100%) but the prescription of ‘as required/rescue’ medication was minimal (n=2,22.2%).

Discussion
The prevalence of epilepsy in acute psychiatric inpatients was approximately three times that of the general population. This needs to be interpreted with caution given the small sample size, cross sectional nature of the study and potential limitations in case ascertainment. There are little comparative data internationally. We found that the documentation of care planning to support individuals with epilepsy was limited, particularly in relation to performance of risk assessments for management of seizures. The introduction of appropriate tools for care planning4 may not just ameliorate the management of epilepsy and reduce risk of physical harm but may also positively impact on mental health care5-7 given the adverse impact that epilepsy may have on a range of mental health disorders, particularly if not fully controlled. Our findings suggest scope for training psychiatrists in relation to the relevance of epilepsy and the use of diagnosis triggered tools8 that highlight essential diagnostic, therapeutic and risk areas as relevant to inpatient psychiatric care.

Conflict of Interest
The authors have no conflicts of interest to declare.

Acknowledgements
The authors thank Dr Sebastian Luppe MRCP, Department of Neurology, North Bristol NHS Trust and Dr Elijah Chaila MRCPI, Department of Neurology, University Hospital Limerick for their assistance.

Correspondence:
Gautam Gulati MD FRCPsych,
Department of Psychiatry,
University Hospital Limerick,
Co. Limerick,
Ireland.
E-mail: gautam.gulati@hse.ie (Corresponding author)

References
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2. Jones R, Rickards H and Cavanna AE. The prevalence of psychiatric disorders in epilepsy: a critical review of the evidence. Functional neurology. 2010; 25 (4), 191-94.
3. NICE. Epilepsies: Diagnoses and Management: CR137. National Institute of Health and Clinical Excellence. 2016. Available from: https://www.nice.org.uk/guidance/CG137.
4. Murphy V, Gulati G, Luppe S, & Chaila E. Letter to the Editor. Irish Journal of Psychological Medicine. 2017;34(2), 149-149. doi:10.1017/ipm.2016.48
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8. Murphy V, Gulati G, Luppe S & Chaila E. Epilepsy Care Planning in Psychiatric Inpatient Settings – the ‘Yellow Card’. International Journal of Integrated Care. 2017; 17(5): A553. DOI. http://doi.org/10.5334/ijic.3873

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