Antiseizure medication (ASM) withdrawal in seizure-free patients

Posted on November 25, 2024 by Maurice Preter MD

Here’s a very detailed summary of the practice advisory update on antiseizure medication (ASM) withdrawal in seizure-free patients:

Objective and Methods

  • Update the 1996 American Academy of Neurology practice parameter
  • Systematic review of literature published from January 1991 to March 2020

Key Findings

Adults

  • Long-term (24-60 months) risk of seizure recurrence:
    • Possibly higher among those who taper ASMs vs. those who don’t
    • 15% vs. 7% recurrence rate (Class I study)
    • Hazard ratio for recurrence: 2.9 (95% CI 1.8-4.6) in one Class III study

Children

  • No significant difference in seizure recurrence between:
    • Tapering ASMs after 2 years vs. 4 years of seizure freedom
    • Tapering at 18 months vs. 24 months (insufficient evidence)

Risk Factors for Seizure Recurrence

  • Adults:
    • Shorter seizure-free period (2 years vs. longer)
    • Abnormal psychiatric examination
    • Specific ASMs (valproate, phenobarbitone, primidone, phenytoin)
  • Children:
    • Epileptiform activity on EEG possibly increases risk

Status Epilepticus

  • ASM withdrawal possibly does not increase risk in adults

Quality of Life

  • ASM weaning possibly does not change quality of life in seizure-free adults

Mortality

  • Insufficient evidence to support or refute changes in mortality risk

Speed of ASM Withdrawal (Children)

  • No significant difference in recurrence risk between:
    • 25% reduction every 10 days to 2 weeks
    • 25% reduction every 2 months

Recommendations

  1. Clinicians should inform adults who have been seizure-free for 24 months or more that:
    • There is a possibility of increased seizure recurrence risk with ASM withdrawal
    • Recurrence risk is likely low overall but may double compared to those who continue ASMs
    • There is uncertainty about the exact risk increase
  2. Clinicians should advise children who have been seizure-free for at least 2 years that:
    • There is probably no additional risk reduction by waiting 4 years vs. 2 years to withdraw ASMs
  3. Clinicians should counsel children and caregivers that:
    • An epileptiform EEG abnormality may be associated with increased seizure recurrence risk
  4. Clinicians may advise patients that:
    • ASM withdrawal possibly does not increase the risk of status epilepticus (adults)
    • ASM withdrawal possibly does not change quality of life (adults)
  5. When withdrawing ASMs in children, clinicians may consider:
    • Using a withdrawal rate of 25% reduction every 10 days to 2 weeks
    • Or using a withdrawal rate of 25% reduction every 2 months

Limitations and Considerations

  • Limited high-quality evidence for many aspects of ASM withdrawal
  • Individualized decision-making is crucial, considering patient preferences and risk factors
  • Further research needed on specific electroclinical syndromes and post-epilepsy surgery patients
  • EEG type and duration for assessing recurrence risk not specified in studies

This summary provides a comprehensive overview of the key points from the practice advisory update on ASM withdrawal in seizure-free patients.

Source: Gloss et al. 2021

Posted in Psychiatry/Neurology | Tagged , |

Lyme disease in neurology – a primer

Posted on November 25, 2024 by Maurice Preter MD

Here is a detailed summary of the key points about Lyme disease and its neurologic complications:

Causative agent and transmission:

  • Caused by spirochetes of the genus Borrelia, primarily Borrelia burgdorferi in North America
  • Transmitted by bite of infected Ixodes tick
  • Tick must typically remain attached for 24-48 hours to transmit Borrelia

• Geographic distribution:

  • Highest incidence in northeastern and north-central United States
  • Endemic areas include Connecticut, Vermont, Maine, Massachusetts, New Hampshire, Rhode Island, New Jersey, Pennsylvania, New York, Wisconsin, Minnesota

• Clinical manifestations:

  • Initial sign is often erythema migrans rash at site of tick bite
  • Can progress to systemic involvement if untreated
  • Most common neurologic complications:
    1. Cranial neuritis (especially facial nerve palsy)
    2. Meningitis
    3. Radiculoneuritis/mononeuropathy multiplex

• Diagnosis:

  • Two-step serologic testing recommended by CDC:
    1. Enzyme-linked immunosorbent assay (ELISA)
    2. If ELISA positive/borderline, Western blot for IgM and IgG
  • CSF analysis may be needed in early infection or equivocal cases
  • CSF typically shows lymphocytic pleocytosis in active neuroborreliosis

• Treatment:

  • Oral doxycycline for most cases of neuroborreliosis
  • IV antibiotics (ceftriaxone, cefotaxime, penicillin G) for severe manifestations
  • Duration typically 2-4 weeks

• Post-treatment Lyme disease syndrome:

  • Persistent symptoms like fatigue, pain, cognitive issues after treatment
  • Not indicative of ongoing infection
  • No benefit from prolonged antibiotic therapy

• Chronic Lyme disease controversy:

  • Not a recognized clinical entity
  • Symptoms attributed to Lyme without evidence of infection
  • Long-term antibiotics not recommended

• Key points for neurologists:

  • Consider Lyme in endemic areas for patients with facial palsy, meningitis, radiculitis
  • Understand proper diagnostic testing and interpretation
  • Recognize limitations of serology in early infection
  • Be aware of guidelines for appropriate antibiotic treatment
Posted in News |

Essential tremor is a complex neurological disorder characterized by rhythmic shaking, primarily affecting the hands, head, and voice.

Posted on November 25, 2024 by Maurice Preter MD

Essential tremor is a complex neurological disorder characterized by rhythmic shaking, primarily affecting the hands, head, and voice. Here’s a comprehensive overview of its diagnosis and management:

Clinical Manifestations

Limb Tremor

Essential tremor primarily manifests as a bilateral upper extremity action tremor. Key features include:

  • Kinetic tremor with or without postural tremor
  • Frequency between 8-12 Hz
  • Kinetic tremor more severe than postural tremor in about 95% of cases
  • Mild to moderate asymmetry common
  • Rest tremor possible in longstanding cases (prevalence 2-46%)
  • Intention tremor may develop later, associated with disease duration

Head Tremor

Head tremor is a common late manifestation:

  • Present in about 39% of patients
  • More common in women and older patients
  • Often exacerbated during phonation tasks
  • May have an intention component
  • Can be “no-no” (horizontal), “yes-yes” (vertical), or mixed directional

Vocal Tremor

Vocal changes are frequent, especially in older patients:

  • More common in women
  • Patients describe voice as “weak,” “unstable,” “shaky,” or “hoarse”
  • Can involve muscles of the palate, pharynx, tongue, and larynx

Other Manifestations

  • Chin/jaw tremor: Uncommon, increases with disease severity
  • Balance difficulties and gait impairment
  • Hearing loss: Higher prevalence of hearing impairment and hearing aid use
  • Olfactory changes: Mixed findings, may be normal in many cases
  • Eye findings: Oculomotor changes, including square wave jerks and altered saccades

Psychiatric and Cognitive Symptoms

  • Higher rates of depression, anxiety, and sleep disturbances
  • Increased pain severity and interference
  • Mild cognitive impairment, particularly in executive function, attention, and working memory

Diagnosis

Essential tremor is primarily a clinical diagnosis based on history and examination:

  • Assess tremor during different activities and impact on daily living
  • Family history and alcohol responsiveness can be helpful clues
  • Perform multiple bedside tests (e.g., arm extension, finger-to-nose movements, spiral drawing)
  • Complete neurological examination to rule out other conditions

Diagnostic pearls:

  • Extension-flexion at the wrist during arm extension
  • Intention tremor in finger-to-nose testing (>25% of cases)
  • Characteristic axis in writing and spiral drawings (8-2 o’clock for right-handed, 10-4 o’clock for left-handed)
  • “Head snap” during finger-to-nose examination in up to 20% of cases

Classification

The International Parkinson and Movement Disorder Society redefined essential tremor in 2018 as a syndrome, recognizing its heterogeneity. The new classification includes:

  • Essential tremor
  • Essential tremor plus (with additional neurological signs)

Treatment

First-line treatments:

  • Propranolol
  • Primidone

For severe cases:

  • Deep brain stimulation (traditional target: ventral intermediate nucleus of thalamus; emerging target: caudal zona incerta)
  • MRI-guided high-intensity focused ultrasound

Emerging treatments:

  • Novel oral medications
  • Chemodenervation
  • Noninvasive neuromodulation

Prognosis

Essential tremor is progressive, but less than 10% of patients with long disease duration develop significant disability. Predictors of faster progression include:

  • Longer disease duration
  • Asymmetrical tremor
  • Isolated limb involvement at onset
  • Older age of onset

In conclusion, essential tremor is a complex and heterogeneous disorder requiring careful clinical assessment for accurate diagnosis and appropriate management.

 
Posted in Psychiatry/Neurology | Tagged , |

How Often Do I Need to Attend Psychotherapy?

Posted on November 19, 2024 by admin

The frequency of psychodynamic psychotherapy sessions typically ranges from one to two times per week, with once-weekly sessions being the most common starting point for most individuals. However, the ideal frequency can vary based on several factors:

Factors Influencing Session Frequency

Treatment Phase:

– Initial phase: Weekly or twice-weekly sessions are often recommended

– As treatment progresses: Frequency may be adjusted based on progress and needs

– Maintenance phase: Sessions may occur less frequently, such as bi-weekly or monthly

Severity of Symptoms: More frequent sessions (e.g., twice weekly) may be beneficial for acute stress, crisis situations, or severe symptoms.

Treatment Goals: The complexity and nature of your goals can influence how often you should attend therapy.

Individual Needs: Your personal circumstances, including availability, financial considerations, and the intensity of support required, play a role in determining session frequency.

Benefits of Regular Sessions

Attending psychodynamic therapy consistently, typically at least once a week, offers several advantages:

– Builds a strong therapeutic relationship

– Allows for deeper exploration of unconscious patterns

– Provides consistent support and progress monitoring

– Facilitates the development of self-awareness and insight

– Enables more effective processing of emotions and experiences

Research Findings

Studies have shown that higher session frequency in psychodynamic therapy can lead to better outcomes:

– A study found that increasing session frequency from once to twice per week increased the effect size by 0.45.

– Another study reported that patients seen more than once a week had more positive perceptions of their recovery compared to those seen only once a week.

Adjusting Frequency

It’s important to note that therapy frequency is not fixed and can be adjusted over time. You and your therapist may decide to change the frequency based on your progress, current life circumstances, and evolving needs.

Conclusion

While weekly sessions are a common starting point in psychodynamic therapy, the ideal frequency should be determined collaboratively between you and your therapist. It’s crucial to discuss your specific needs, goals, and circumstances to establish the most appropriate schedule. Remember that psychodynamic therapy is typically a longer-term approach and consistency in attending sessions is key to achieving lasting and meaningful change.

Posted in News |

Here’s a comprehensive guide on how to effectively utilize out-of-network health insurance benefits for psychotherapy in New York City

Posted on November 11, 2024 by Maurice Preter MD

Here’s a comprehensive guide on how to effectively utilize out-of-network health insurance benefits for psychotherapy in New York City:

Understanding Out-of-Network Benefits

Out-of-network benefits allow you to see healthcare providers who are not in your insurance plan’s network. While you may pay more upfront, you can often receive reimbursement from your insurance company[1][3].

Key benefits of using out-of-network providers include:

– Greater flexibility in choosing a therapist
– Access to specialists who may not be in-network
– Potentially shorter wait times for appointments
– More control over your treatment plan

Steps to Use Out-of-Network Benefits

1. Check your out-of-network benefits[8]:
– Review your insurance policy documents
– Look for information on behavioral health or mental health coverage

2. Call your insurance company to verify benefits[8]:
– Ask about your out-of-network deductible for mental health services
– Inquire about coinsurance rates for out-of-network providers
– Confirm if you need a referral from an in-network provider
– Ask about the process for submitting claims

3. Find a therapist:
– Ask for recommendations from trusted sources
– Use online directories to find therapists in NYC
– Schedule initial consultations with potential therapists

4. Discuss fees and insurance with your chosen therapist:
– Ask if they offer sliding scale fees
– Inquire about their experience with out-of-network claims

5. Pay for sessions upfront:
– Most out-of-network providers require full payment at the time of service[1]

6. Obtain a superbill from your therapist:
– This detailed receipt contains necessary information for insurance claims[8]

7. Submit claims to your insurance company:
– Follow your insurer’s process for submitting out-of-network claims
– Some therapists may offer to submit claims on your behalf for a fee[3]

8. Receive reimbursement:
– Your insurance company will process the claim and send you reimbursement based on your plan’s out-of-network benefits[8]

Important Considerations

– Out-of-network deductibles are often higher than in-network deductibles[12]
– Reimbursement rates vary, typically ranging from 50-80% of the session fee[4]
– There may be limits on the number of covered sessions per year[6]
– Some plans have out-of-pocket maximums for out-of-network care[12]

Potential Advantages in NYC

Many therapists in New York City choose not to participate in insurance networks due to low reimbursement rates and administrative burdens[11]. This means that using out-of-network benefits can give you access to a wider pool of experienced therapists.

Tips for Maximizing Benefits

– Keep detailed records of all sessions and payments
– Submit claims promptly and regularly
– Follow up with your insurance company if reimbursements are delayed
– Consider using health savings accounts (HSAs) or flexible spending accounts (FSAs) to pay for therapy with pre-tax dollars

By understanding and effectively using your out-of-network benefits, you can potentially access high-quality psychotherapy in New York City while managing costs. Always verify your specific plan details and discuss options with potential therapists to make the most informed decision about your mental health care.

Citations:
[1] https://www.zocdoc.com/blog/what-does-it-mean-to-get-an-out-of-network-therapist/
[2] https://uncovercounseling.com/blog/out-of-network-vs-in-network-therapy-in-nyc/
[3] https://crowncounseling.com/out-of-network-coverage/
[4] https://blog.zencare.co/a-therapists-guide-to-out-of-network-benefits/
[5] https://www.integrative-psych.org/out-of-network-reimbursement-a-comprehensive-guide
[6] https://www.nyc.gov/site/doh/health/health-topics/health-insurance-behavioral.page
[7] https://www.gatewaytosolutions.org/about-therapy/using-your-out-of-network-insurance-benefits/
[8] https://blog.zencare.co/guide-to-out-of-network-benefits/
[9] https://mywellbeing.com/therapy-101/insurance
[10] https://byrepose.com/check-your-out-of-network-benefits
[11] https://tribecatherapy.com/1449/out-of-network-psychotherapy-nyc/
[12] https://blog.opencounseling.com/out-of-network-therapist-tips/

Posted in News, Psychiatry/Neurology |