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