Depression and stress in Depression and stress in epilepsy: Management epilepsy: Management

strategiesstrategiesLorna Myers, Ph. D.Lorna Myers, Ph. D.

Director of Clinical Neuropsychology Director of Clinical Neuropsychology Northeast Regional Epilepsy GroupNortheast Regional Epilepsy Group

Chronic epilepsy and psychiatric Chronic epilepsy and psychiatric disordersdisorders

High estimates: 50-60% of patients with High estimates: 50-60% of patients with chronic epilepsy have depressive or chronic epilepsy have depressive or anxiety disordersanxiety disordersMore likely 30% have depressionMore likely 30% have depression

Chronic epilepsy and psychiatric Chronic epilepsy and psychiatric disordersdisorders

• Changes in neurotransmitters, vitamin or Changes in neurotransmitters, vitamin or folic acid deficiencies can worsen folic acid deficiencies can worsen depressiondepression

• Life limitations (driving, working, Life limitations (driving, working, schooling) and stigmaschooling) and stigma

* Suicide: 5 times higher than in the general * Suicide: 5 times higher than in the general population and 25 times higher in complex population and 25 times higher in complex partial seizures (temporal lobe)partial seizures (temporal lobe)

Depression in EpilepsyDepression in Epilepsy

Inter-ictal: Depression that occurs between Inter-ictal: Depression that occurs between seizures-not during an active seizureseizures-not during an active seizure

Peri-Ictal: Depression just before or after Peri-Ictal: Depression just before or after (hours or days) a seizure(hours or days) a seizure

Ictal: the seizure co-occurs with Ictal: the seizure co-occurs with depressive symptomsdepressive symptoms

CharacteristicsCharacteristics of depression in of depression in epilepsyepilepsy

Peri-ictal depressions tend to be Peri-ictal depressions tend to be associated to psychotic or paranoid associated to psychotic or paranoid symptomssymptoms

They tend to respond to changes in anti-They tend to respond to changes in anti-epileptic or antidepressive medicationsepileptic or antidepressive medications

These patients tend to be more irritable These patients tend to be more irritable and emotionaland emotional

Many have dysthymia between seizuresMany have dysthymia between seizures

Important Facts about Important Facts about depresisondepresison

Over 80% of those treated for depression Over 80% of those treated for depression improve. improve. Depression can affect people of all ages, races, Depression can affect people of all ages, races, SES, and genders. However, the ratio of women SES, and genders. However, the ratio of women to men is 2:1to men is 2:1Nearly half of all people who are depressed do Nearly half of all people who are depressed do not receive the appropriate treatment because not receive the appropriate treatment because they are not correctly diagnosedthey are not correctly diagnosedSevere depression is associated to decline in Severe depression is associated to decline in mental function as time passesmental function as time passes

Types of depressionTypes of depression??

Major DepressionMajor Depression

Minor Depression Minor Depression (dysthymia)(dysthymia)

Bipolar Disorder (manic-depressive)Bipolar Disorder (manic-depressive)

What is major depressionWhat is major depression??

Depressed mood almost all day longDepressed mood almost all day longReduced interest in activities or peopleReduced interest in activities or peopleWeight change (5% in one month)Weight change (5% in one month)Insomnia/hypersomniaInsomnia/hypersomniaMotor retardation or activationMotor retardation or activationFatigueFatigueGuilt or low self worthGuilt or low self worthConcentration problemsConcentration problemsSuicidal thoughts or actsSuicidal thoughts or acts

Minor DepressionMinor Depression

Feeling depressed almost every day for at Feeling depressed almost every day for at least 2 yearsleast 2 yearsHaving 2 or more of the following:Having 2 or more of the following: Changes in appetiteChanges in appetite Insomnia/hypersomniaInsomnia/hypersomnia Low self esteemLow self esteem FatigueFatigue Concentration problemsConcentration problems HopelessnessHopelessness

Bipolar DisorderBipolar Disorder

Manic cyclesManic cycles (hyperactivity, agitation, (hyperactivity, agitation, insomnia, hypersexuality, grandiosity, insomnia, hypersexuality, grandiosity, sometimes, psychosis, racing thoughts, sometimes, psychosis, racing thoughts, pressured speech) lasting one week or pressured speech) lasting one week or moremore

Intense depressive cyclesIntense depressive cycles

Anxiety and epilepsyAnxiety and epilepsy

Generalized Anxiety Disorder (GAD): Generalized Anxiety Disorder (GAD): disabling and free floating anxiety that disabling and free floating anxiety that lasts for at least 6 months (+poor sleep, lasts for at least 6 months (+poor sleep, appetite, concentration).appetite, concentration).

In epilepsy: it can present with a fear of In epilepsy: it can present with a fear of future seizures/of medical complicationsfuture seizures/of medical complications

Panic attacks and epilepsyPanic attacks and epilepsy

Sudden and severe panic on a frequency of more than one attack per week for a period of at least 1 month

Patients with epilepsy have panic attacks up to six times more frequently than control populations

Why depression and anxiety in Why depression and anxiety in epilepsy? epilepsy?

Psychological reaction to epilepsy Psychological reaction to epilepsy Social factors (lost driver’s license, job, Social factors (lost driver’s license, job, loss of control)loss of control)Secondary medication effects (eg. Secondary medication effects (eg. polypharmacy, high doses, sudden polypharmacy, high doses, sudden discontinuation)discontinuation)Left temporal or frontal lobe epilepsy Left temporal or frontal lobe epilepsy exhibits a greater association to exhibits a greater association to depressiondepression

Why depression and anxiety in Why depression and anxiety in epilepsy?epilepsy?

The effect of electrical discharges in or The effect of electrical discharges in or near the limbic systemnear the limbic system

Treatments for clinical range Treatments for clinical range depression/anxietydepression/anxiety

Prescription of psychiatric meds with Prescription of psychiatric meds with the epileptologist’s blessingthe epileptologist’s blessing

Talk-therapy with a Talk-therapy with a psychologist/social workerpsychologist/social worker

Close monitoring by the epileptologist Close monitoring by the epileptologist especially if there is a connection especially if there is a connection between epilepsy and moodbetween epilepsy and mood

Treatments for clinical range Treatments for clinical range depression/anxietydepression/anxiety

Individual therapy (cognitive behavioral Individual therapy (cognitive behavioral and supportive) and supportive)

Family therapy and psychoeducationFamily therapy and psychoeducation

Vagal Nerve Stimulator (FDA approved for Vagal Nerve Stimulator (FDA approved for mood disorders)mood disorders)

For refractory major depression: Electro For refractory major depression: Electro shock (ECT) or Transcranial magnetic shock (ECT) or Transcranial magnetic stimulation (TMS)stimulation (TMS)

Alternative treatmentsAlternative treatments

Must consult with doctor Must consult with doctor prior to taking any prior to taking any of the following herbs/supplements: of the following herbs/supplements: St. St. John’s Wort, Echinacea, Valerian or John’s Wort, Echinacea, Valerian or aromatherapy-they have the potential to aromatherapy-they have the potential to interact with AEDsinteract with AEDs

Careful with some hands on techniques Careful with some hands on techniques (thai massage, cranio sacral massage, (thai massage, cranio sacral massage, chiropraxis). Consult your doctor.chiropraxis). Consult your doctor.

What can I do to help myself?What can I do to help myself?

Exercise: yoga, pilates, non-aerobic Exercise: yoga, pilates, non-aerobic physical exercise, weight lifting under physical exercise, weight lifting under supervision). 30’ per day improves moodsupervision). 30’ per day improves moodDiet: consult with nutritionist: proper Diet: consult with nutritionist: proper calorie intake, fruits, vegies, whole wheat, calorie intake, fruits, vegies, whole wheat, low fat meats, avoid caffeine and alcohollow fat meats, avoid caffeine and alcoholSleep hygieneSleep hygieneAttend epilepsy support group and Attend epilepsy support group and activitiesactivities

What can I do to help myself?What can I do to help myself?

Strategies to support treatment or work on Strategies to support treatment or work on small mood shifts:small mood shifts:

Apply positive psychology principlesApply positive psychology principles

Learn and use relaxation techniquesLearn and use relaxation techniques

Watch out for Worry WordsWatch out for Worry Words

Work towards OptimismWork towards Optimism

Exercise 1: Gratitude (Which three people Exercise 1: Gratitude (Which three people in your life have most helped you. Write in your life have most helped you. Write them a letter, call them, write about them)them a letter, call them, write about them)

Savoring life (enjoy each moment)Savoring life (enjoy each moment)

How can you become more How can you become more optimisticoptimistic

Reframe an event, finding a hidden Reframe an event, finding a hidden blessing or strength (cognitive blessing or strength (cognitive restructuring). restructuring). Not being able to drive for 6 months or a year Not being able to drive for 6 months or a year

will allow me to start walking much more.will allow me to start walking much more. Being at home more time allows me to spend Being at home more time allows me to spend

time on my garden.time on my garden.

How to achieve greater How to achieve greater happinesshappiness

Practice acts of kindness, volunteerPractice acts of kindness, volunteer

Learn to forgive/ Forgiveness is a way of healing Learn to forgive/ Forgiveness is a way of healing yourselfyourself

Take time for yourself (walk, massage, facial, Take time for yourself (walk, massage, facial, read a book, go to the gym, watch a movie, etc.read a book, go to the gym, watch a movie, etc.

Focus on what you can control and let go of the Focus on what you can control and let go of the rest.rest.

Try not to avoid judging yourself or others Try not to avoid judging yourself or others (should, could)(should, could)

How to achieve greater How to achieve greater happiness?happiness?

Commit to your goals and pursue them Commit to your goals and pursue them (even small ones)(even small ones)

If finding yourself in an unhappy situation, If finding yourself in an unhappy situation, start planning how you will change this.start planning how you will change this.

Use humorUse humor

How do I work on my stress How do I work on my stress levels?levels?

Breathing exercises (when nervous, we Breathing exercises (when nervous, we breathe fast, shallow. When calm, we breathe fast, shallow. When calm, we breathe slow and deep)breathe slow and deep)

Autogenic trainingAutogenic training

Deep muscle relaxationDeep muscle relaxation

Track your worry wordsTrack your worry words

Tune into your self-talkTune into your self-talk

Get a small notepad and carry it with you Get a small notepad and carry it with you for a few days.for a few days.

Listen to what you say to yourself when Listen to what you say to yourself when stressed and write down the internal stressed and write down the internal chatter.chatter.

Then check your monologue for worry Then check your monologue for worry wordswords

What are worry words?What are worry words?

ExtremistExtremist: Horrible, awful, dreadful, etc. : Horrible, awful, dreadful, etc.

All-or-noneAll-or-none: All, always, completely, never, : All, always, completely, never, none, etc. none, etc.

Judging, commanding, and labelingJudging, commanding, and labeling: bad, : bad, wrong, must, should, idiot, jerk, pig, etc.wrong, must, should, idiot, jerk, pig, etc.

VictimVictim: I Can’t, impossible, overwhelmed, : I Can’t, impossible, overwhelmed, worn out, etc. worn out, etc.

Correcting worry words to Correcting worry words to reasonable alternativesreasonable alternatives

ExtremistExtremist example: That was the worst example: That was the worst speech I ever gave.speech I ever gave.

Reasonable alternativeReasonable alternative: Could’ve done : Could’ve done better but at least got through it in one better but at least got through it in one piece. piece.

All or noneAll or none ex: “I’m always so bad at this”. ex: “I’m always so bad at this”.

Reasonable alternativeReasonable alternative: “With practice I : “With practice I know I will improve”.know I will improve”.

Practice makes perfectPractice makes perfect

Practice relaxation techniques daily (at Practice relaxation techniques daily (at least 2 months running)-30 minutesleast 2 months running)-30 minutesEstablish self-care activities in your regular Establish self-care activities in your regular schedule (e.g. hair stylist appt, watch a schedule (e.g. hair stylist appt, watch a favorite show, facials)favorite show, facials)Watch your diet regularly but allow Watch your diet regularly but allow yourself some pleasures.yourself some pleasures.Physical exercisePhysical exercise

References and resourcesReferences and resources

Psychiatric Issues in Epilepsy, Edited by Psychiatric Issues in Epilepsy, Edited by Ettinger, A & Kanner A (2001). Lippincott, Ettinger, A & Kanner A (2001). Lippincott, Williams & WilkinsWilliams & Wilkinshttp://www.nimh.nih.gov/publicat/spdep5122.cfm1-866-615-NIMH (6464)1-866-615-NIMH (6464)Autogenic training Autogenic training (http://www.youtube.com/watch?(http://www.youtube.com/watch?v=t05S6O6YWgw)v=t05S6O6YWgw)Deep muscle relaxation (Deep muscle relaxation (http://www.youtube.com/watch?v=PYsuvRNZfxE))

Thank you!Thank you!

Be wellBe well