Depression in epilepsy: Depression in epilepsy: recognition and recognition and

treatmenttreatmentLorna Myers, Ph. D.Lorna Myers, Ph. D.

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

Epilepsy and psychiatric Epilepsy and psychiatric disordersdisorders

50-60% of patients with chronic epilepsy 50-60% of patients with chronic epilepsy have depressive or anxiety disordershave depressive or anxiety disorders

No known association between depression No known association between depression and seizure typeand seizure type, frequency, duration, or , frequency, duration, or age of seizure onsetage of seizure onset

Left temporal or frontal lobe epilepsy Left temporal or frontal lobe epilepsy exhibits a greater association to exhibits a greater association to depressiondepression

Epilepsy and psychiatric Epilepsy and psychiatric disordersdisorders

• Suicide: 10 times higher than in the Suicide: 10 times higher than in the general population and 25 times higher in general population and 25 times higher in complex partial seizures (temporal lobe)complex partial seizures (temporal lobe)

• Depression in epilepsy impacts quality of Depression in epilepsy impacts quality of life more than other medical issueslife more than other medical issues

• Depression can worsen seizure control Depression can worsen seizure control and treatment successand treatment success

Why so much depression in Why so much depression in epilepsy? epilepsy?

Psychological reaction to epilepsy Psychological reaction to epilepsy (sadness, hopelessness, change in life)(sadness, hopelessness, change in life)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)

Why depression in epilepsyWhy depression in epilepsy

The effect of electrical discharges in or The effect of electrical discharges in or near the brain structures and systems that near the brain structures and systems that control emotioncontrol emotion

Severity of seizuresSeverity of seizures

Medically refractory seizuresMedically refractory seizures

Depression in childrenDepression in children

Depression rates are higher in children Depression rates are higher in children with epilepsy-even in more benign with epilepsy-even in more benign epilepsies (i.e. Absences, benign rolandic)epilepsies (i.e. Absences, benign rolandic)

Sometimes there are important Sometimes there are important discrepancies between parental and child discrepancies between parental and child ratingsratings

BullyingBullying

Academic difficultiesAcademic difficulties

Depression in womenDepression in women

Considerably higher rates of depression Considerably higher rates of depression than in menthan in men

Specific differences in hormonal activitySpecific differences in hormonal activity

Internalizing tendenciesInternalizing tendencies

Depression in older persons Depression in older persons with epilepsywith epilepsy

Depression in this population is also Depression in this population is also elevatedelevated

More research neededMore research needed

Depression in different Depression in different ethnicitiesethnicities

Hispanics with epilepsy have a higher rate Hispanics with epilepsy have a higher rate of depression than American born patients of depression than American born patients with epilepsywith epilepsy

Other ethnic groups may be similarly Other ethnic groups may be similarly inclined: future studies neededinclined: future studies needed

Facts about DepressionFacts about Depression

Depression can affect people of all agesDepression can affect people of all ages

Depression can affect all SESDepression can affect all SES

Depression can affect all races and Depression can affect all races and ethnicities (although it may be expressed ethnicities (although it may be expressed differently)differently)

Genders: the ratio of women to men is 2:1Genders: the ratio of women to men is 2:1

Important Facts about Important Facts about depresisondepresison

Over 80% of those treated for depression Over 80% of those treated for depression improve. improve.

Nearly 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 diagnosed

Severe depression is associated to decline in Severe depression is associated to decline in mental function as time passesmental function as time passes

What should I be looking forWhat should I be looking for??

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

What should I be looking for?What should I be looking for?

Unreasonable feelings of guiltUnreasonable feelings of guilt

Feeling “less than” compared to othersFeeling “less than” compared to others

IrritabilityIrritability

Feelings of hopelessnessFeelings of hopelessness

Decrease in sexual desireDecrease in sexual desire

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

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)

PsychotherapyPsychotherapy

An objective listenerAn objective listener

Problem solvingProblem solving

Learn:Learn: that what we think affects our feelingsthat what we think affects our feelings to detect negative thoughts and defuse themto detect negative thoughts and defuse them Positive psychology exercisesPositive psychology exercises Mindfulness approachesMindfulness approaches Relaxation exercisesRelaxation exercises

Alternative treatmentsAlternative treatments

Must consult with doctor prior to taking any Must consult with doctor prior to taking any of the following herbs/supplements: of the following herbs/supplements: St. St. John’s Wort, Echinacea, Valerian-they John’s Wort, Echinacea, Valerian-they have the potential to interact with AEDshave the potential to interact 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 meatslow fat meatsTreatment for sleep disorderTreatment for sleep disorderAttend epilepsy support group and Attend epilepsy support group and activitiesactivities

Achieving OptimismAchieving Optimism

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

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

Thank you!Thank you!

Be wellBe well

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=KxQJIiu9tK0&feature=related ) )

References and resourcesReferences and resources

Depression in elderly patients with Depression in elderly patients with epilepsy (2010) epilepsy (2010) Olgica Laban-Grant, E. Olgica Laban-Grant, E. Fertig, J. Kanter, H. Husaini, L. Myers and Fertig, J. Kanter, H. Husaini, L. Myers and M. LancmanM. Lancman