Psychiatric and behavioral disorders are important aspects of epilepsy and have received increasing attention in the last several years. The literature upon which most of the field relies contains some biases that must be carefully examined and resolved in future studies: (1) In the pediatric epilepsy literature, many reports find children with epilepsy have high levels of behavioral and psychiatric disorders when compared to appropriate controls. Most of these studies rely on parent-proxy completed instruments to assess these behavioral endpoints. Parents’ reports are not objective but reflect parents’ reactions and emotions. Increasing evidence suggests inherent biases in proxy reports and highlights the need to assess children directly. (2) Peri-ictal phenomena may be mischaracterized as underlying mood disorders. (3) Many studies report elevated levels of psychiatric morbidity before and after the diagnosis of epilepsy suggesting an inherent relation between the two types of disorders. Psychogenic nonepileptic seizures, while widely recognized as posing a diagnostic dilemma in the clinic, may account for some of these research findings. Diagnostic errors between epilepsy and PNES need careful consideration when evaluating studies demonstrating associations between psychiatric disorders and epilepsy or poorer seizure control in association with psychiatric disorders in people who have epilepsy. Mental health concerns are important for everyone. An accurate, undistorted understanding of the relation between mental health disorders and epilepsy is essential to insure appropriate therapy and avoid unnecessary and potentially harmful treatments and avoid common misconceptions.

Summary Objective We conducted a randomized controlled trial of motivational interviewing (MI) as an intervention to improve psychotherapy adherence and outcomes, including frequency of psychogenic nonepileptic seizures (PNES), quality of life, and emergency department utilization, among participants with PNES. Methods Sixty participants were randomized to receive either psychotherapy alone or MI plus psychotherapy. Participants and therapists were contacted at 16‐week follow‐up. Participants were considered adherent with psychotherapy if they attended at least eight sessions within 16 weeks following referral. Results Among control participants, 31.0% were adherent, whereas among MI participants, 65.4% were adherent (P = 0.015, absolute risk reduction = 34.4%, number needed to treat = 2.9). In the control arm, PNES frequency decreased by 34.8% (standard deviation [SD] = 89.7%), whereas in the MI arm, PNES frequency decreased by 76.2% (SD = 39.2%; P = 0.034, Cohen’s d = 0.59). Among control participants, 10.7% achieved PNES freedom versus 30.8% of MI participants (P = 0.095). Quality of Life in Epilepsy–10 scores (a 40‐point scale) improved by an average of 1.8 (SD = 7.9) points among control participants, and by 7.2 (SD = 10.0) points among MI participants (P = 0.047, Cohen’s d = 0.60). Monthly emergency department visits increased by 0.06 (SD = 0.47) visits per month among control participants versus a decrease of 0.15 (SD = 0.76) among MI participants (P = 0.23). Significance Motivational interviewing improved treatment adherence, PNES frequency, and quality of life among our participants with PNES. Our study is limited in that it was conducted at a single quaternary care medical center, and MI was provided by a single neurologist, which may limit generalization of results.

Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.

Objective: Previous studies have shown the effectiveness of manual-based treatment for psychogenic nonepileptic seizures (PNES), but access to mental health care still remains a problem, especially for patients living in areas without medical professionals who treat conversion disorder. Thus, we evaluated patients treated with cognitive behavioral therapy-informed psychotherapy for seizures with clinical video telehealth (CVT). We evaluated neuropsychiatric and seizure treatment outcomes in veterans diagnosed with PNES seen remotely via telehealth. We hypothesized that seizures and comorbidities will improve with treatment. Methods: This was a single-arm, prospective, observational, cohort, consecutive outpatient study. Patients with video-electroencephalography-confirmed PNES (n = 32) documented their seizure counts daily and comorbid symptoms prospectively over the course of treatment. Treatment was provided using a 12-session manual-based psychotherapy treatment given once per week, via CVT with a clinician at the Providence Veterans Affairs Medical Center. Results: The primary outcome, seizure reduction, was 46% (P = .0001) per month over the course of treatment. Patients also showed significant improvements in global functioning (Global Assessment of Functioning, P = < .0001), quality of life (Quality of Life in Epilepsy Inventory-31, P = .0088), and health status scales (Short Form 36 Health Survey, P < .05), and reductions in both depression (Beck Depression Inventory-II, P = .0028) and anxiety (Beck Anxiety Inventory, P = .0013) scores. Significance: Patients with PNES treated remotely with manual-based seizure therapy decreased seizure frequency and comorbid symptoms and improved functioning using telehealth. These results suggest that psychotherapy via telehealth for PNES is a viable option for patients across the nation, eliminating one of the many barriers of access to mental health care.