mental health issues in epilepsy
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Mental Health Issues in Epilepsy
Salah Mesad, M.D.Northeast Regional Epilepsy Group
Introduction
• Epilepsy was considered as a mental illness• Most patients with epilepsy have the same
risk of psychiatric conditions as in general population
• There is a significantly increased risk of psychopathology in patients with drug-resistant seizures
Psychopathology in Epilepsy
• Psychiatric conditions are not unique to patients with epilepsy
• Chronic disease (DM, rheumatoid arthritis)• Chronic CNS disease (MS, Parkinson’s disease)
Mechanisms
• Depression as a “chemical imbalance”• Seizures as an “electrical imbalance”• Epilepsy as an “electro-chemical imbalance”
Causes and mechanisms
• Underlying etiology (trauma, tumor, encephalitis)
• Epileptogenic localization (temporal, frontal)• Seizure types and frequency• Medications, addition or withdrawal.– AEDs– Non-AEDs
• Psycho-social support• Coincidental
Classification of psychiatric co-morbidities
Temporal relationship to seizures• Peri-ictal• Ictal• Post-ictal• Inter-ictal
Classification
• Depression• Anxiety disorder• Psychosis• Personality disorder
Psychiatric co-morbidities
• General population• 20-80% of patients have psychological
disturbance• Higher prevalence in patients with TLE
Depression
• Subdued mood• Feeling of worthlessness• Guilt• Loss of energy and interest• Sleep disturbance• Change in appetite• Anhedonia• Suicidal ideation (SI)
Depression
• Most frequent psychiatric condition in patients with epilepsy
• Controlled seizures – 10% to 20%• Poorly controlled seizures – 20% to 60%• General population – 5% to 17%
Depression
• Bi-directional relationship between epilepsy and depression
• Strong determinant of quality of life in patients with epilepsy
Risk factors for depression
• Frequent seizures• Partial epilepsy, esp. left sided• Younger age at onset• Psychosocial difficulties• Poly-pharmacy• Mesial temporal sclerosis
Mood disorders
• Major depressive disorder• Dysthymia– More chronic– Less severe
• Interictal dysphoric disorder– Intermittent– Begins and ends abruptly
Depression
• Most commonly seen in TLE• Typical major depressive disorder• Atypical presentation (NOS)• Pre-, ictal, postictal and interictal• Increased suicide risk
Depression
• Under-reported• Under-recognized• Under-treated– Usually neurologist does not diagnose or treat
psychiatric conditions– Worry about worsening seizures with
psychotropics– Patients might be reluctant to accept diagnosis
and treatment
Suicidality
• Twice the risk in general population (12%)• Elevated risk in children and adolescent• Ictal and postictal depression• Increased risk in TLE
Treatment considerations• ~40% never received treatment for depression• Optimal seizure control, medical and surgical• Optimal drug treatment
– Mono-therapy• Eliminate iatrogenic factors
– Recognize ADRs• AEDs induced depression• Phenobarbital, primidone, vigabatrin, tiagapine, levetiracetam, zonisamide,
felbamate
– Use drugs with neutral or positive psychotropic effects, if possible (lamotrigine, carbamazepine, valproate, gabapentin)
– Review non-AEDS – Recognize current and unrecognized medical conditions (thyroid disease,
alcohol and drug abuse)
Treatment
• Anti-depressants and seizure threshold– Higher dosing– Rapid rate of escalation– Higher risk in patients with PGE– Drugs to avoid, whenever possible
• TCAs: amitriptyline, amoxapine, clomipramine, desipramine, imipramine, nortriptyline
• Bupropion, maprotiline• Willbutrin
– SSRIs unlikely to worsen seizures• Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine,
sertaline
Treatment
• Venlafaxine for depression with melancholic features
• Cognitive-behavioral therapy• Psychotherapy• ECT for refractory depression
Anxiety disorders
• Generalized anxiety• Panic disorder• OCD• Phobias
Generalized Anxiety Disorder
• Excessive daily worry about many issues• Restlessness, fatigue• Irritability• Poor concentration• Sleep dysfunction
Generalized Anxiety
• More common in patients with refractory TLE (20%) • Pre-ictal, ictal, postictal– Ictal fear – medical temporal seizures
– Can also be related to seizures originating from the frontal and cingulate regions
• Contributing factors:– Unpredictability of seizures– Psychosial difficulties– Meds: lamotrigine, felbamate, vigabatrin, TPM
• Withdrawal of AEDs: benzos, phenobarbital• Paradoxical reaction to SSRs
Anxiety Treatment
• SSRIs• Benzodiazepines• Buspirone may worsen seizures• Non-pharmacologic– Counseling– Psychotherapy– CBT
Panic Disorder
• Symptoms:– Fear of loss of control or death– Lightheadedness, tremor, breathing difficulty– Chest pain, palpitations, perspiration– Sensation of choking, abdominal discomfort– Derealization, persistent worry
• Ictal fear or panic (right anterior temporal)• Meds: sertaline,paroxetine, clonazepam,
alprazolam
OCD
• Repetitive thoughts and ritualistic behavior• ~14% to 20% in patients with TLE• 1% to 3% in general population• Psychotherapy• Anti-depressants• Carbamazepine and oxcarbazepine
Phobias
• Occur in 20% of patients with epilepsy• Agoraphobia in up to 9% of patients with
refractory TLE• Social phobia in 29% of patients with
refractory TLE• Treatment: CBT
Psychosis
• Delusion, paranoia, hallucinations• Postictal and interictal psychosis• Ictal psychosis as complex partial or absence
status epilepticus• Interictal psychosis
Psychosis
• Absence of negative symptoms or formal thought disorder (unlike schizophrenia)
• Older age of onset than schizophrenia• “Forced normalization”
Postictal psychosis
• Mean age of onset 32-35 years• Risk Factors: – family history of psychosis and depression– Multi-focal epilepsy– Refractory seizures and status
• Begins 24-48 hours after the seizures• May last few days to several weeks
Treatment of psychosis
• Antipsychotic medications– Older drugs are associated with a greater risk of
seizure exacerbation than newer atypical drugs– Avoid clozapine, chlopromazine and loxapine– Ziprasidone (Geodon) and quetiapine (Seroquel)
• Psychotherapy• ECT
Personality disorders
• Controversial issue• Contradictory study results• “Interictal personality syndrome” in TLE
Summary• “ask-tell” approach• Optimal seizure control• Individualized treatment• Screening for mental health issues– Direct questioning– Educational program– Routine forms
• Identify risk eliminate correctable causes• Promptly treat and refer to a mental health professional
familiar with specific needs of patients with epilepsy• Ultimate goal: freedom from seizures AND optimal
quality of life and wellbeing
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