Transcript 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
• There is a significantly increased risk of
psychopathology in patients with drugresistant 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
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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 comorbidities
Temporal relationship to seizures
• Peri-ictal
• Ictal
• Post-ictal
• Inter-ictal
Classification
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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
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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
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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
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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
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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
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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
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Generalized anxiety
Panic disorder
OCD
Phobias
Generalized Anxiety Disorder
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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
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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
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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
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“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