1. Mental Health Issues in Epilepsy
Salah Mesad, M.D.
Northeast Regional Epilepsy Group

2. 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

3. Psychopathology in Epilepsy
Psychiatric conditions are not unique to patients with epilepsy
Chronic disease (DM, rheumatoid arthritis)
Chronic CNS disease (MS, Parkinson’s disease)

4. Mechanisms Depression as a “chemical imbalance”
Seizures as an “electrical imbalance”
Epilepsy as an “electro-chemical imbalance”

5. 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

6. Classification of psychiatric co-morbidities
Temporal relationship to seizures
Peri-ictal
Ictal
Post-ictal
Inter-ictal

7. Classification Depression Anxiety disorder Psychosis
Personality disorder

8. Psychiatric co-morbidities
General population
20-80% of patients have psychological disturbance
Higher prevalence in patients with TLE

9. Depression Subdued mood Feeling of worthlessness Guilt
Loss of energy and interest
Sleep disturbance
Change in appetite
Anhedonia
Suicidal ideation (SI)

10. 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%

11. Depression Bi-directional relationship between epilepsy and depression
Strong determinant of quality of life in patients with epilepsy

12. Risk factors for depression
Frequent seizures
Partial epilepsy, esp. left sided
Younger age at onset
Psychosocial difficulties
Poly-pharmacy
Mesial temporal sclerosis

13. Mood disorders Major depressive disorder Dysthymia
More chronic
Less severe
Interictal dysphoric disorder
Intermittent
Begins and ends abruptly

14. Depression Most commonly seen in TLE Typical major depressive disorder
Atypical presentation (NOS)
Pre-, ictal, postictal and interictal
Increased suicide risk

15. 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

16. Suicidality Twice the risk in general population (12%)
Elevated risk in children and adolescent
Ictal and postictal depression
Increased risk in TLE

17. 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)

18. 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

19. Treatment Venlafaxine for depression with melancholic features
Cognitive-behavioral therapy
Psychotherapy
ECT for refractory depression

20. Anxiety disorders
Generalized anxiety
Panic disorder
OCD
Phobias

21. Generalized Anxiety Disorder
Excessive daily worry about many issues
Restlessness, fatigue
Irritability
Poor concentration
Sleep dysfunction

22. 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

23. Anxiety Treatment SSRIs Benzodiazepines Buspirone may worsen seizures
Non-pharmacologic
Counseling
Psychotherapy
CBT

24. Panic Disorder Symptoms: Ictal fear or panic (right anterior temporal)
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

25. 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

26. 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

27. Psychosis Delusion, paranoia, hallucinations
Postictal and interictal psychosis
Ictal psychosis as complex partial or absence status epilepticus
Interictal psychosis

28. Psychosis
Absence of negative symptoms or formal thought disorder (unlike schizophrenia)
Older age of onset than schizophrenia
“Forced normalization”

29. Postictal psychosis Risk Factors:
Mean age of onset years
Risk Factors:
family history of psychosis and depression
Multi-focal epilepsy
Refractory seizures and status
Begins hours after the seizures
May last few days to several weeks

30. 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

31. Personality disorders
Controversial issue
Contradictory study results
“Interictal personality syndrome” in TLE

32. 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