Academic journal article Current Psychiatry

Managing Psychiatric Illness in Patients with Epilepsy: Appropriate Treatment of Mental Health Problems Can Improve the Global Prognosis for the Patient Who Has a Seizure Disorder

Academic journal article Current Psychiatry

Managing Psychiatric Illness in Patients with Epilepsy: Appropriate Treatment of Mental Health Problems Can Improve the Global Prognosis for the Patient Who Has a Seizure Disorder

Article excerpt

Patients who have epilepsy have a higher incidence of psychiatric illness than the general population--at a prevalence of 60%) Establishing a temporal association and making a psychiatric diagnosis can be vexing, but awareness of potential comorbidities does improve the clinical outcome' (Box, page 32). As this article discusses, psychiatric presentations and ictal disorders can share common pathology and exacerbate one another. (3) Their coexistence often results in frequent hospitalization, higher treatment cost, and drug-resistant seizures. (4) Risk factors for psychopathology in people who have epilepsy include psychosocial stressors, genetic factors, early age of onset of seizures, and each ictal event. (5) Among ictal disorders, temporal-lobe epilepsy confers the highest rate of comorbidity. (3)

Mood disorders

Mood disorders are the most common psychiatric disorder comorbid with epilepsy (irrespective of age, socioeconomic status, and ethnicity), affecting 43% of patients who have a seizure disorder. (5) These disorders present as an ictal aura in 1% of cases; the presence of a comorbid mood disorder implies a more severe form of epilepsy. (2) Most mood disorders are underdiagnosed in epilepsy, however, because of the mistaken assumption that depression is a normal reaction to having a seizure disorder.

Interictal depression is the most commonly reported complaint, although dysphoria also can present peri-ictally. (6) The severity of depression and the seizure disorder often are directly proportional to each other.' Decreased levels of serotonin and norepinephrine, or abnormalities in their transport or postsynaptic binding, have been reported in epilepsy and in affective illness. (6) MRI studies have documented that patients who have a depressive disorder have more gray-matter loss compared with healthy controls. (7) Depression diminishes the quality of seizure remission after medical and surgical interventions for epilepsy. (8)

Taking a multidisciplinary approach to treating a mood disorder in a patient who has epilepsy might improve ictal and mood outcomes.9Anhedonia is the most common presenting symptom, but some patients do not meet DSM-5 criteria. Depression exhibits atypically, with fatigue, irritability poor frustration tolerance, anxiety, and mood lability. (6) Self-report screening scales, such as the Neurological Disorders Depression Inventory for Epilepsy, are helpful for making a diagnosis. (10)

Treatment. Prompt antidepressant treatment is indicated. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors are the most common agents in this setting. (11) Consider possible cytochrome P450 interactions between antiepileptic drugs (AEDs) and antidepressants; sertraline, citalopram, and escitalopram have the lowest incidence of adverse effects. Because tricyclic antidepressants have proconvulsant properties, they are not commonly prescribed in these pa tientsn (Table 1). (13)

Electroconvulsive therapy and vagus nerve stimulation (14) are effective interventions in treatment-resistant depression. The efficacy of transcranial magnetic stimulation remains to be clarified.

AEDs can produce psychiatric effects, even in nonconvulsive epilepsies. Twenty-eight percent of cases of depression that are comorbid with epilepsy have an iatrogenic basis, and can be induced by barbiturates, topiramate, vigabatrin, tiagabine, and levetiracetam. (13) These adverse effects are a common reason that patients discontinue drug treatment and obtain psychiatric consultation. (15)

Neurosurgical management of epilepsy carries a low risk of depression compared with pharmacotherapy because the surgery offers better ictal control. (16) Because some AEDs have mood-stabilizing properties, discontinuing one might unmask an underlying mood disorder. (17)

The incidence of adjustment disorder with depressed mood in persons who have epilepsy is 10%; with dysthymia, the incidence is 4%. …

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