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The Effect of Selective Serotonin Reuptake Inhibitors on the Frequency of Psychogenic Nonepileptic Seizures: A Critically Appraised Topic

Bravo, Thomas P. MD*; Hoffman-Snyder, Charlene R. DNP, RN-BC*; Wellik, Kay E. MLS, AHIP, FMLA*,†; Martin, Kari A. MD; Hoerth, Matthew T. MD*; Demaerschalk, Bart M. MD, MSc, FRCP(C)*; Wingerchuk, Dean M. MD, MSc, FRCP(C)*

doi: 10.1097/NRL.0b013e31827c6bfd
Critically Appraised Topics

Background: Psychogenic nonepileptic seizures (PNES) are commonly encountered problem in neurological practice and usually are accompanied by other psychiatric comorbidities. Despite its prevalence and profound impact on patients and families, there have been few trials addressing treatment. Cognitive behavioral therapy may be effective but the role of pharmacologic therapy remains unclear.

Objective: To critically evaluate evidence that PNES frequency may be reduced by treatment with selective serotonin reuptake inhibitors.

Methods: The objective was addressed through the development of a structured, critically appraised topic. We incorporated a clinical scenario, background information, a structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, epileptology, and psychiatry content experts.

Results: A pilot randomized control clinical trial was selected for critical appraisal. Thirty-eight PNES patients were randomized to flexible-dose sertraline (target dose, 200 mg/d) or placebo. Only 68% of patients contributed data to the primary analysis and baseline PNES frequency was notably dissimilar. Twelve-week seizure frequency rates, as compared with baseline, were 45% lower in the sertraline group (P=0.03) but unchanged in the placebo group (8% increase; P=0.78). After adjustment for baseline differences, between-treatment group comparison revealed a trend toward lower event frequency in the sertraline group (risk ratio 0.51; 95% confidence interval, 0.25-1.05; P=0.29). Psychosocial and quality of life measures did not differ between treatment groups.

Conclusions: There is insufficient evidence to recommend routine treatment with sertraline to reduce PNES event frequency but these pilot data suggest a possible benefit worthy of further exploration.

Departments of *Neurology

Library Services, Division of Education Administration

Department of Psychiatry, Mayo Clinic, Scottsdale, AZ and Phoenix, AZ

D.M.W. and B.M.D., Co-Directors of Mayo Clinic Evidence Based Clinical Practice, Research, Informatics, and Training (MERIT) Center at Mayo Clinic Arizona were supported by Clinician Educator grants from the Mayo Clinic College of Medicine.

The authors declare no conflict of interest.

Reprints: Dean M. Wingerchuk, MD, MSc, FRCP(C), Mayo Clinic, 13400 E Shea Blvd., Scottsdale, AZ 85259. E-mail:

© 2013 by Lippincott Williams & Wilkins