Objective:

To identify predictors of emergency care utilization among Veterans with PNES.

Background:

Veterans with psychogenic nonepileptic seizures (PNES) often present to emergency departments (ED) due to diagnostic uncertainty and complex medical and psychiatric comorbidities. System-level factors within the Veterans Affairs (VA) facilities may further influence acute care utilization, yet the determinants of ED use that contribute to high healthcare utilization and cost burden remain poorly understood.

Design/Methods:

A retrospective analysis of Veterans with PNES confirmed by video-EEG across 129 VA epilepsy facilities. The primary outcome was the total number of ED visits occurring within five years post-diagnosis. Negative binomial regression was used after confirming overdispersion. Predictors included demographic factors, seizure frequency, psychiatric history, comorbid conditions, and psychotropic medication. Incidence rate ratios (IRRs) with 95% confidence intervals were estimated. 

Results:

Among 1,175 Veterans, 70% had no ED visits during the five-year follow-up period. The mean age was 52.6 years, and 40% (n=468) were female. Among those with ≥1 visits (30%, n=359), utilization was right-skewed (median: 2; [IQR 1-3.5]; mean: 3.32). Prior psychiatric hospitalization was the strongest predictor, nearly doubling ED visit rates (IRR = 1.95, 95% CI 1.27–3.02, p = 0.001). Depression (IRR = 1.42, 95% CI 1.04–1.95, p = 0.03) and sedative/hypnotic use (IRR = 1.37, 95% CI 1.00–1.90, p = 0.05) were also associated with increased utilization. Conversely, PTSD was associated with lower ED use (IRR = 0.68, 95% CI 0.50–0.92, p = 0.009).

Conclusions:

Psychiatric history, particularly prior hospitalization, strongly predicts ED utilization among Veterans with PNES. These findings highlight the need for interventions to better integrate and coordinate mental health care within PNES care pathways. Future studies should examine whether early psychiatric interventions reduce emergency care burden.