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Mental Health Issues in Epilepsy

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

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Mental Health Issues in Epilepsy

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  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: • 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 • 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

  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

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