Project Care 4 Epilepsy

Depression, Anxiety and

EpilepsyTatiana Falcone, M.D.

Jane Timmons-Mitchell, Ph.D.

December 16, 2014

Introduction

• Despite remarkable progress in diagnosis,treatment and positive long term seizureoutcome in children with epilepsy, the highprevalence of mental health problems hasnot changed in 30 years

• Population studies of children with epilepsy(CWE) reported poor psychosocial outcomesin adulthood

• Davies et al. A population Survey of mental health problems in children with epilepsy.Dev Med Child Neur 2003 45:292- 295

• Rutter and Yule Neuropsychiatric study in Childhood 1970

Why do people develop mental

illness?

Many factors contribute to mental health problems, including:

• Life experiences, such as trauma or a history of abuse

• Biological factors, such as genes or chemical imbalances in your brain (epilepsy)

• Family history of mental health problems

• Certain Medical problems- chronic medical illness specially those that affect the brain

Psychiatric Comorbidities in

Epilepsy

• Depression and anxiety are the mostcommon psychiatric comorbiditiesassociated with epilepsy

• They affect quality of life and how apatient responds to poor seizure control,most cases of depression goundiagnosed and untreated in thesepatients

• Jacoby A et al. The clinical course of epilepsy and its psychosocial correlates, findings from a UK community study. Epilepsia 1996; 37 :148 -61

• Boylan L. Depression but not seizure frequency predicts quality of life in treatment resistant epilepsy. Neurology 2004; 62 :258- 61

Epidemiologic data

• Lifetime prevalence ofMDD 3.7-6.7 (generalpopulation)

• Lifetime prevalence inepilepsy 22.2%

• Higher rates of depressionin younger pts

• Lifetime suicidal ideationin general population13.3% (12.8 -13.9 95% CI)

• Lifetime suicidal ideationin epilepsy 25% (16.6-33.3% CI)

• Up to 40% of youth withepilepsy experienceanxiety

• Tellez-Zenteno, et al psychiatric comorbidity in epilepsy a population based analysis Epilepsia 2007

Predictors of mood disorder in

children and adolescents

• Gender effect, with more depression inadolescent girls with epilepsy

• Age effect, more depression older than 12

• No association with seizure variables

• No studies on suicidal ideation and seizurevariables

• More severe mood disorders in children withmental retardation

• Increased family discord in children withepilepsy, increased number of stressful lifeevents

• Caplan (2005), Dunn (2005), Hessdorffer (2005),Jones (2008)

Mental Health Screening in the

Pediatric Epilepsy Clinic

• To improve access to services for patients with epilepsy in a timely fashion, every family during their outpatient appointment

• Every patient is screened at least one time every six months (if the patient is coming for an appointment)

• Screening measure severity of epilepsy, side effects from the medications, impact on family function and mental health screening

Mental health and Epilepsy

In 2007, a study of mental health

problems in children

• 16.7% epileptic children with

psychiatric diagnosis

Compared to:

• 6.4% in children with diabetes

• 4.2% in general population

Factors that Cause Mental Health

Issues

Internal Factors

- Biological Makeup

• Genetics

- Illnesses

• Disruption in brain

function (epilepsy) also

affects mood and

behavior

External Factors

o Environmental Conditions-

Bullying

o Reactions from others to

epilepsy

o Lack of acceptance by others

o Individuals own reaction and

acceptance of their condition

Bullying

20% of US high school

students were bullied on

school property

16.2% electronically bullied

ere bullied on school

property

(16)

Depression

In general, there has been an increase in stress and mental health issues during childhood

1 in 33 children experience depression

1 in 8 adolescents are depressed

Clinical depression often 1st appears in adolescence

Symptoms of Depression in Teens

• Teens may feel sad or cry a lot, for long periods of time.

• Feel guilty for no real reason; feel like they are no good; or they have lost their confidence.

• Feel like life seems meaningless, or like nothing good will ever happen again.

• Teens may have a negative attitude a lot of the time (irritated), or seems like they have no feelings.

Depression and Epilepsy

• Teens don't feel like doing a lot of the

things they used to do, like music,

sports, being with friends, going out,

and they want to be left alone most of

the time.

• Sleeping and eating more or less.

• Grades drop.

Extreme Symptoms of

Depression

• Talk about death and suicide.

• Use drugs and/or alcohol.

• Get into trouble with the law at school

or in the community.

Basic concepts –

• Did the symptoms of depression appear

following the introduction or increase of

the AED?

• Did the symptoms follow the

discontinuation of a psychiatric

medication?

• Did the symptoms occur after introduction

of enzyme inducing AED?

• Is the patient experiencing any other

psychiatric symptoms?

SUICIDE IN THE EPILEPSIES: A META-ANALYTIC

INVESTIGATION OF 29 COHORTS

M. Pompili et al. / Epilepsy & Behavior 7 (2005) 305–310

Symptoms of Anxiety

Anxiety affects the way a person thinks, but the anxiety can lead to physical symptoms, as well. Symptoms of anxiety can include:

• Excessive, ongoing worry and tension

• An unrealistic view of problems

• Restlessness or a feeling of being "edgy"

• Irritability

• Muscle tension

• Headaches

Symptoms of anxiety

• Choking, chest pains, distress

• Fear, fright, afraid, anxious

• Hot flashes, or sudden chills

• Tingling in fingers or toes ('pins and

needles')

• Fearful that you're going to go crazy or

are about to die

Panic Attacks

Symptoms of a Panic Attack include:

• Racing heartbeat , lightheadedness or nausea

• Difficulty breathing, feeling as though you

can't get enough air

• Terror that is almost paralyzing , feeling of

dread

• Nervous, shaking, dizziness,

• Trembling, sweating, shaking

Treatment

Do we have effective treatments?

What to do--Medication

• Medications for Anxiety and Depression

- SSRIs (selective serotonin reuptake

inhibitors) used most frequently

- Common brand names: Prozac,

Zoloft, Celexa, Lexapro, Paxil

- Common generic names: fluoxetine,

sertraline, citolopran, escitalopram,

paroxetine

- Can improve symptoms of anxiety

and depression without increasing

seizures

What to do --Psychotherapy

• Cognitive Behavioral Therapy (CBT)

can be effective.

• CBT helps youth interrupt and change

negative thoughts

• A behavioral health specialist is needed

to help youth learn specific strategies

Key components of CBT• Learning how to recognize which thoughts

are not based in reality and how to change them.

• Learning relaxation and deep breathing.

• Making a plan to increase social and exercise activities.

• Identifying things that cause fear or worry and learning how to tolerate them in small steps.

• Talking with the entire family about the best way to help your child.

• Including everyone who works with your child in the plan.

Tools

• Charting, journaling

• Homework

• Family therapy

• Group therapy

What to do about Depression

• Developing a positive attitude about

epilepsy, for both you and your child.

• Learning skills to support self-esteem.

• Challenging extreme, disasterizing

thinking. (In Australia, “warpy”

thoughts)

• Learning to relax and manage stress

What to do--Bullying

• Burden falls to parents to advocate for their children and teach age appropriate self-advocacy skills.

• Promote expectation that there is something positive to do that child can participate in and adults can make happen.

• Attend school meeting; point out student’s strengths.

What to do about Bullying?

• StandUp is a Bullying Prevention Program for

teens.

• We are enrolling for this free program, which

students complete on their own computer at

their convenience.

• If your child with epilepsy is in High School-

• Stand Up- Denise Hagen 216-444-0514

What is StandUp?

Stand Up is a computer-based program designed to help high

school students

develop and use skills for relating to others in healthy ways.

Using the skills and ideas in this program can help teens to:

• Treat themselves and others with respect

• Avoid being a bully

• Get help if they’re a victim of bullying

• Stand up to stop bullying when they see it going on around them

This program is designed for all teens, no matter if...

• They’ve had any experience with bullying or not

• They’re ready to make changes in the way they relate to others or

not

• They’re ready to take a stand against bullying or not

StandUp Teaches

Healthy Relationship Skills

1. Trying to understand and respect the other person’s feelings and needs

2. Using calm, nonviolent ways to deal with disagreements (for example,

leaving the room to cool down, offering solutions)

3. Respecting the other person’s boundaries (for example, how close they

want to get and what they’re comfortable and uncomfortable sharing with

others)

4. Communicating your own feelings and needs clearly and respectfully

5. Making decisions that you know are right for you in social situations

6. Taking a stand to stop bullying when you see it (for example, by saying

something to the bully, or telling an adult)

Your Role as

Parents/Caregivers

• Overcome Fears and Stigma

• Help your teenager to cope/manage illness

Self–esteem and a positive self-image are critical to the success and happiness your teen experiences for the rest of their life.

Now it is time for a Question

and Answer session