Mood Disorders and Epilepsy Scott E. Hirsch, MD NYU-Langone Medical Center May 2012

No financial support from pharmaceutical companies. Information obtained from best available evidence from: –Medical Literature –Clinical Experience Disclosures

Epilepsy The management of patients with epilepsy is focused on: Controlling seizures Avoiding treatment side effects Maintaining quality of life.

Epilepsy and Quality of Life If seizure free, people with epilepsy enjoy a quality of life similar to the general population. One third of people with epilepsy continue to have seizures despite treatment. Because people with recurring seizures may have lower quality of life, every effort must be made to restore quality of life.

Possible Consequences of Epilepsy May be unable to legally drive. May have memory problems or cognitive issues. May be exposed to stigma or feel embarrassment. May have restricted independence. Medication dependence. Employment problems. These quality of life issues are important!

Adjustment Disorder When coping and problem-solving strategies fail, depressed mood and anxiety symptoms may result. This isn’t necessarily a “disorder,” but rather acknowledgement that the person is having trouble adjusting to a life change or a new stressor. Bolstering social support, attending support groups, and learning new coping skills often helps adjustment and leads to resolution of symptoms.

Feeling sad sometimes is normal Feeling sad, “blue,” or “down” is part of our normal human experience. Appropriate when we experience tragedy, loss, or receive bad news. When these feelings persist for more than 2 weeks and also interfere with daily functioning, then we think about “Major Depression.”

Epilepsy and Depression Depressed mood is NOT normal in people with epilepsy. Depression can be part of a complex partial seizure. Depression can also be pre-ictal or post-ictal. Untreated depression is associated with more difficulty achieving seizure freedom.

Depression Depression is under-recognized; occurs in up to 43% of people with epilepsy. Depression is a significant factor adversely affecting quality of life. Risk factors for depression: – Epilepsy-related disability – Unemployment – Activity restriction/Loss of Independence – Impaired social support – Stigma associated with Epilepsy

What causes Depression in Epilepsy? Psychological factors: – difficulty coping with stressors, such as recurrent seizures – real or perceived losses – life experiences that set the stage for later depression Biological factors: – prior history of mental illness – family history of mental illness – some seizure types – Epilepsy itself increases the risk of depression Social factors: – social isolation – financial issues – limits on independence

Depression Important to treat in both children and adults. Treating depression improves quality of life in people with epilepsy.

Criteria for Major Depression Over a 2 week period, most of the day, nearly every day: A.Depressed Mood OR A.Loss of pleasure AND… 4 or more of the following nearly every day: Significant change in appetite or weight Trouble falling asleep, staying asleep, waking early/late Observable slowness of thought and movement Fatigue or loss of energy Feelings of worthlessness or excessive guilt Difficulty thinking or concentrating Recurring thoughts of death or suicide

Feeling down vs. Major Depression Nearly all of the symptoms outlined for Major Depression can be part of our normal experiences. BUT… it’s not normal to experience 5 of the 9 possible symptoms together persistently over 2 weeks. Major Depression is NOT just a reaction to having Epilepsy. Major Depression cannot be willed or wished away. When left untreated, Major Depression is associated with worse outcomes.

Children and Adolescents Depression may present with different symptoms than in adults: – Irritable mood – Disruptive behavior – Negative thoughts about themselves – Decline in academic performance – Agitation – Intense worry or phobias – Regressive behaviors, including separation anxiety

Screening for Depression Over the past 2 weeks, how often have you been bothered by the following problems: 1. Little interest or pleasure in doing things? – Not at all, 0 – Several days, 1 – More than half the days, 2 – Nearly every day, 3 2. Feeling down, depressed, or hopeless? – Not at all, 0 – Several days, 1 – More than half the days, 2 – Nearly every day, 3

Screening for Depression: PHQ-2 Patient Health Questionnaire-2 – Scored from 0-6 – Score greater than 3 indicates a 75% positive predicative value for presence of a mood disorder. – Score greater than 3 indicates a 40% positive predicative value for presence of a Major Depressive Disorder diagnosis. – Score greater than 3 should lead to psychiatric evaluation.

STAR*D: Efficacy of Treatment for Depression Sequenced Treatment Alternatives to Relieve Depression. Nationwide public health clinical trial funded by the NIH. NOT funded by pharmaceutical companies! Largest and longest study to evaluate depression treatment. Randomized, Double blinded study. 2,876 participants, ages in Level 1. Fewer participants in subsequent levels by design. Standardized rating system and treatment.

STAR D* Study Design Level 1: Celexa (an SSRI) for weeks a. Symptom free -> 12 month follow-up b. Symptoms persist or intolerable side effects -> Level 2 Level 2: Participant given option of switching to Talk therapy, a different medication or adding talk therapy or a new medication a. Symptom free -> 12 month follow-up b. Symptoms persist or intolerable side effects -> Level 3 Level 3: Participant given option of switching or adding different medication a. Symptom free -> 12 month follow-up b. Symptoms persist or intolerable side effects -> Level 4 Level 4:All medications discontinued Randomly switched to 4 th line medication

STAR D* Conclusions 50% of participants had remission after 2 treatments 75% of participants had remission after 4 treatments May need to try more than one treatment for remission

Barriers in treating Depression People do not recognize or believe they need treatment. People think current mood or anxiety problems are related to a temporary situation. People do not want to consider taking another medicine. Concern about worsening seizures with medication. Concern about side effects. Stigma.

Treatments for Depression Talk therapy: the first line of treatment – Individual therapy – Group therapy – Family therapy – Support groups – Caregiver support Goals of therapy include: – Developing solutions to immediate problems in living. – Implementing lifestyle modifications. – Correcting maladapative thoughts or behaviors. – Uncovering thoughts that lead to feelings of helplessness and hopelessness. – Overcoming fears of dependency or abandonment. – Learning new coping skills (relaxation techniques, imagery, focused breathing exercises, meditation, and progressive muscle relaxation).

Medication for Depression and Anxiety Medications are a mainstay of management for people with Major Depression and Anxiety Disorders. Antidepressants are safe and effective in people with Major Depression and Anxiety Disorders when taken under a doctor’s care. Medications: – Alleviate depressed mood and anxiety symptoms. – Reduce emotional lability, irritability, and worry. – Reduce social withdrawal. – Improve a person’s ability to participate in epilepsy treatments. – Improve overall functioning.

Selective Serontonin Reuptake Inhibitors (SSRI’s): – Prozac – Paxil – Zoloft – Celexa – Lexapro Selective Serotonin/Norepinephrine Reuptake Inhibitors (SNRI’s): – Effexor – Cymbalta – Pristiq Mediciatons with unique mechanisms of action: – Remeron – Buspar GABA-enhancing agents for Anxiety only: – Xanax – Ativan – Valium – Klonopin