High TBI, PTSD Comorbidity in Recent Veterans
By Brenda L. Mooney
WASHINGTON — U.S. veterans deployed since 2001 suffer high rates of epilepsy and other neurological disorders, and the VA is challenged in both diagnosing and treating them.
Recent studies document that those veterans are at a particularly high risk for traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), psychological nonepileptic seizures (PNES) and epileptic seizure diagnoses.
According to a study by the VA’s Southeast Epilepsy Centers of Excellence and Duke University Medical Center in Durham, NC, 87,377 veterans with seizures diagnoses were managed within the VHA during fiscal year 2011. That translates into a prevalence rate of 15.5 per 1,000 and incidence rate of 148.2 per 100,000, according to the research presented late last year at the American Epilepsy Society’s 67th Annual Meeting in Washington.1
The risks are especially great for those serving during Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND), according to the research.
Study authors note that, not only do veterans have high rates of epilepsy diagnoses overall, but “more young and female veterans are being diagnosed with epilepsy. OEF/OIF/OND veterans are at particularly high risk of TBI, PTSD, and seizure diagnoses.”
“Appropriately diagnosing and treating veterans with TBI and PTSD is notoriously difficult,” added lead author Tung T. Tran, MD. “It involves a multidisciplinary approach to include both epilepsy and mental health specialists.”
For veterans with epilepsy, according to the study, the percentages of comorbid TBI and PTSD were 15.8% and 24.1%, respectively. For OEF/OIF/OND veterans, however, percentages increased to 52.6% and 70.4%, respectively. That was especially the case for female veterans, the authors noted.
A report from the Durham Center for Excellence published last year in U.S. Medicine’s 2013 Compendium of Federal Medicine noted that the numbers of seizure, TBI and PTSD patients are increasing in the VA and suggested “the high prevalence could be attributed, in part, to a high percentage of [psychogenic nonepileptic seizures (PNES)] in this population.”
That view was supported by another study presented at the American Epilepsy Society conference. Researchers from the Baylor College of Medicine in Houston reviewed the results of video-EEG (VEEG) monitoring data for veterans of OEF/OIF from the Michael E. DeBakey VA Medical Center from January 2008 to May 2013, finding a comparatively higher prevalence of PNES.2
Among patients with a definitive diagnosis of PNES, 63% of the subjects had PTSD alone, 50% had mTBI alone and 41.3% had a combination of the two, the Baylor researchers found. They also determined that 90.6% of subjects with PTSD who received definitive VEEG diagnoses also had PNES.
Study authors noted that their research uncovered a comparatively higher prevalence for PNES among OEF/OIF veterans who completed VEEG monitoring.
“Our research identified the presence of mild traumatic brain injury (mTBI) and PTSD,” explained lead author Shirish Satpute, DO. “Both were common morbidities in this population, and appear to be independently predictive of subsequent VEEG confirmation of PNES.”
Another study, conducted by researchers at the Portland, OR, VAMC, pointed out that PNES are diagnosed in 25% of veterans admitted to Epilepsy Monitoring Units (EMU) but that little data exists on their outcomes.3
“This information is important for planning therapeutic trials and assessing prognostic factors,” the authors wrote. “The outcome of veterans with PNES may differ from that of civilians due to the age and sex of the patients, proposed seizure etiologies, and the nature of the medical system.”
After reviewing all patients meeting criteria for PNES at the Portland VAMC from 2000-2011, the researchers found that the majority of veterans continued to report seizures even after three years of follow-up. In fact, only 21% remained continuously seizure-free.
The study also determined that more than 80% of PNES patients received anti-epileptic drugs (AEDs) for seizures prior to EMU evaluation but were able to remain continuously off the drugs through 36 months of follow-up.
“The unsatisfactory seizure outcomes underscore the need for effective PNES treatment protocols within the VAMC,” said lead author Martin C. Salinsky, MD. “On a positive note, the elimination of unnecessary AED therapy could avoid potential side effects and reduce the cost of care.”
A fourth study, meanwhile, determined that an algorithm validated for identifying epilepsy in geriatric patients was not appropriate for making the diagnosis in the general population. One statistic spurring the study was that the number of veterans being treated for epilepsy at the VA decreased by 7,818 — from 68,909 to 61,091 from fiscal 2010 to fiscal 2011.4
ECoE researchers looked at administrative databases and defined epilepsy as patients having a seizure diagnosis on at least one encounter and prescribed at least one AED during the same fiscal year. When epilepsy specialists at three ECoE sites in Durham, Miami and Tampa, FL, used that criteria to review electronic charts of 527 FY10 patients who were not captured in FY11, 308 were confirmed to have epilepsy.
“The previously validated algorithm for geriatric patients is unsuitable for general epilepsy patients in the VHA,” the authors concluded. “This algorithm underestimated epilepsy patients due to inadequate documentation of clinical encounters. On the other hand, it captured patients who were on AEDs for conditions other than epilepsy. Chart audits revealed that most epilepsy patients were not assigned a specific diagnosis.”
The study also noted that the mean age of deceased epilepsy patients, 97% male, was 69.9% at the VA compared to 76.3 for males in the United States overall. Researchers urged better diagnosis and more access to specialty care to remedy that discrepancy.
1Tran T, Rehman R, Kelly P, Husain A. Epilepsy in the Veteran Health Administration: Demographics and Disease Frequencies. (Abst. 2.263 ). Paper presented at the American Epilepsy Society Annual Meeting. Dec. 5-9, 2013; Washington.
2Satpute S, Franks R, Chen D. Diagnoses of Neurobehavioral Paroxysms in Veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) – Experiences form a VA Epilepsy Center. (Abst. 2.042 ). Paper presented at the American Epilepsy Society Annual Meeting. Dec. 5-9, 2013; Washington.
3Salinsky M, Storzbach D, Evrard C, Goy E. Psychogenic Seizures in U.S. Veterans; Outcome Following Diagnosis (Abst. 2.070 ). American Epilepsy Society Annual Meeting. Dec. 5-9, 2013; Washington.
4Rehman R, Everhart A, Figueroa-Garcia A, Frontera A, Riley D, Schoof D, Lopez M. Validation of an Algorithm for the Identification of Epilepsy Patients in the Veterans Health Administration (VHA) (Abst. 2.273 ). American Epilepsy Society Annual Meeting. Dec. 5-9, 2013; Washington.