Transcript Depression and Anxiety in Epilepsy

Depression
and Anxiety
in Epilepsy
Kirsty Bortnik, Ph.D.
Northeast Regional Epilepsy Group
Epilepsy and Psychiatric
Disorders
• 50-60% of patients with chronic epilepsy have
depressive or anxiety disorders.
• Increased risk of suicide in patients with epilepsy
compared to people with no epilepsy.
Depression in epilepsy
• One of most common psychiatric disorders among
people with epilepsy.
• Having epilepsy increases the risk of depression (more
than 2 times the risk compared to people without
epilepsy).
• Review of studies have shown 32-48% rates of
depression in individuals with epilepsy.
• Depression more common in epilepsy compared to
other chronic medical problems.
1. Fiest et al, Neurology, 2013; 2. Rai et al, Epilepsia, 2012; 3. Ettinger et al, Neurology, 2004
Impact of depression in
epilepsy
• Depression is associated with lack of response to epilepsy
treatment.
• Depression is the most important predictor of quality of life
in patients with epilepsy (more so than seizure frequency).
• Depression can happen in any kind of epilepsy, but there has
been a stronger association with temporal lobe epilepsy. No
laterality preference.
• Decrease in depression at 3 months and then again approx. 2
years after epilepsy. Depression may appear “de novo” (for
the first time) after surgery.
1. Hitiris et al, Epilepsy Research, 2007; 2. Boylan et al, Neurology, 2004; 3. Foong and Flugel, Epilepsy Research,
2007.
Why depression in
epilepsy?
• Psychosocial factors:
* Psychological reaction to epilepsy
* Effects on daily functioning (driving, employment, etc.)
* Effects on social functioning (social stigma/discrimination,
etc.)
• Neurobiological factors:
* Effect of long-term electrical discharges
* Effects of antiepileptic drugs
* Changes in “stress hormone” reactivity
* Changes in brain structure and function
* Changes in chemistry in the brain
* Changes in inflammatory response
1.
Hoppe and Elger, Nat Rev Neurol, 2011; 2. Kanner, Lancet Neurology, 2012; 3. Clarke et al, Biol Psych, 2012.
Depression in children
with epilepsy
• Depression rates are higher in children with
epilepsy vs. general population and other
chronic diseases.
• Sometimes there are discrepancies between
parental and child ratings
• Academic difficulties, behavioral problems, etc.
• Bullying
How to recognize
depression?
• Learn about symptoms of depression
• Self-report questionnaires to identify symptoms of
depression – but always discuss what it means with a health
care professional.
• Investigate time relationship to seizures: does the mood
change happen ONLY before or after a seizure, and/or
depression happens irrespective of seizure occurrence?
• Investigate historically when mood changes started: any
relationship to medication changes?, or to change in seizure
severity or seizure characteristics?, or to change in
psychosocial situations?
PHQ-9
(Patient Health Questionnaire – 9)
Over the last 2 weeks, how often have you been bothered by any
of the following problems?
Not at all
Several
days
More
than half
the days
Nearly
every
day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that you are a failure or have
let yourself or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could have
noticed? Or the opposite — being so fidgety or restless that you
have been moving around a lot more than usual
0
1
2
3
9. Thoughts that you would be better off dead or of hurting
yourself in some way
0
1
2
3
Scoring: 0-4: None; 5-9: Mild depression; 10-14: Moderate depression; 15-19: Moderately severe
depression; 20 -27: Severe depression. Spitzer et al, 1999
CES-D
(Center for Epidemiologic Studies
Depression Scale)
Radloff, L. S. (1977).
BYI-II
(Beck Youth Inventories)
• Self-report scales that assess a child’s
experience of depression, anxiety, anger,
disruptive behavior, and self-concept
• Ages 7-18 years
Typical symptoms of
depression
Standard criteria: For 2 or more weeks:
• Mood is predominantly “sad” or “down”
• There is lack of interest in things that are usually enjoyable
• Changes in sleep, appetite, energy levels, sexual desire,
concentration
• Changes in motor activity (too slowed down or too fidgety)
• Increase in negative thoughts about oneself or the future
(feeling there is no hope, that one is “less” than others, increased
thoughts of guilt)
• Thoughts that life is not worth living and/or thoughts of suicide or
self-harm
Irritability and increased somatic symptoms (i.e., pain) described in
depression in epilepsy.
Some patients have a chronic course, interrupted by brief periods
of “normal” mood.
1. American Psychiatric Association, DSM-5, 2014; 2. Blumer et al, Epilepsy & Beh, 2004; 3. Kanner, Biol Psych, 2003.
Epilepsy and suicide
• Increased risk of suicide in patients with epilepsy compared to
people with no epilepsy.
• Suicide attempts are more common in epilepsy, even in those
without a history of depression.
• Anti-epileptic drugs can increase risk of suicide behaviors and
their prescription require close monitoring of such symptoms.
• High risk subgroups: newly diagnosed epilepsy, tertiary care
settings, temporal lobe epilepsy, post-epilepsy surgery,
previously having a psychiatric diagnosis, early age of onset.
Rai et al, Epilepsia, 2012; Nilsson et al, Epilepsia, 1997; Rafnsson et al, Neuroepidemiology, 2001; Bell et al, Epilepsia, 2009;
Nilsson et al, Epilepsia, 2002; Hesdorffer et al, Ann Neurology, 2006; Hesdoffer and Kanner, Epilepsia, 2009.
How to manage
depression?
• Bring up your concerns to your doctor! Even if
your doctor will not treat your depression,
he/she will connect you to the right resources
for diagnosis and treatment.
• Once you initiate treatment, keep your
treatment providers informed about your
diagnoses and treatments (particularly if
receiving antidepressant medication).
Treatments for
Depression
• Types of treatment include:
* Medications: always ensure your providers know about your diagnoses and treatments as
some antidepressants (not many, but some) can increase risk of seizures. Also, some
antidepressants can interact with your antiepileptic medication. So keep all providers
informed!
* Talk therapy (psychotherapy)
Cognitive behavioral therapy: empirically supported intervention for depression
Project UPLIFT: home-based program using CBT and mindfulness
* For more severe depression, electro-convulsive therapy (ECT) can be a consideration (not
contraindicated in epilepsy, but should be carefully discussed with all your treatment
providers).
* Transcranial magnetic stimulation (TMS) is approved for the treatment of depression, but
effects on seizures are yet not clear (it can rarely cause them).
* Vagal nerve stimulation (VNS) is effective for chronic depression (beyond its effectiveness
for seizures)
Self-Management Programs
for depression in epilepsy
• “Using Practice and Learning to Increase Favorable Thoughts” = UPLIFT1
• 8-week Internet and telephone based program using cognitive
behavioral therapy and mindfulness to treat depression in people with
epilepsy.
• Has demonstrated significant improvement in symptoms of depression
compared to a waitlist control group.
• “Program to Encourage Active Rewarding Lives”= PEARLS2
• 6-8 weeks home-based program focused on brief behavioral techniques
(+ monthly follow-up phone calls for a year).
• Has demonstrated significant improvement in symptoms of depression
compared to usual care.
• For more information on Self-Management Programs:
http://www.epilepsy.com/get-help/managing-your-epilepsy/selfmanagement-programs
1. Thompson et al, Epilepsy & Behavior, 2010; 2. Ciechanowski et al, Epilepsy & Behavior, 2010
Other strategies
• Physician-approved exercise: yoga, pilates,
non-intense physical exercise, etc.
• Diet: consult with nutritionist: proper calorie
intake, fruits, veggies, whole grains, lean
meats
• Relaxation training and deep breathing
• Treatment for sleep disorder
• Epilepsy support groups and activities
Anxiety in epilepsy
• Higher frequency of anxiety in patients with
epilepsy compared to people without epilepsy.
• Some studies find higher rates of anxiety
symptoms in patients with LTLE.
• Anxiety also associated with poorly controlled
seizures.
Raj et al., Epilepsia, 2012; Mellers, “Lishman’s Organic Psychiatry,” 2009;
Altshuler et al., Arch Neurol 1990
Different anxiety
syndromes
• Agoraphobia: safety and avoidance behaviors
• Generalized anxiety disorder (GAD): excessive worries
• Social anxiety disorder: excessive anxiety related to
social encounters, avoidance of social situations.
• Panic disorder: recurrent panic attacks
• Obsessive compulsive disorder: obsessions and
compulsions.
How to recognize
anxiety?
• Learn about symptoms of anxiety
• Self-report questionnaires to identify symptoms of anxiety – but
always discuss what it means with a health care professional.
• Investigate time relationship to seizures: does the anxiety
symptom only happen before, during and/or after a seizure?
Some anxiety symptoms (such as “fear” or “panic” or a “sudden
intrusive thought” may be a symptom of a seizure). Anxiety may
also occur irrespective of seizure occurrence.
• When did anxiety symptoms start? any relationship to
medication changes?, or to change in seizure severity or seizure
characteristics?, or to change in psychosocial situations?
GAD-7
Over the last 2 weeks (or other agreed time period) how often
have you been bothered by any of the following problems?
Not at all
Several
days
More
than half
the days
Nearly
every
day
1. Feeling nervous, anxious or on edge
0
1
2
3
2. Not being able to stop or control worrying
0
1
2
3
3. Worrying too much about different things
0
1
2
3
4. Trouble relaxing
0
1
2
3
5. Being so restless that it is hard to sit still
0
1
2
3
6. Becoming easily annoyed or irritable
0
1
2
3
7. Feeling afraid as if something awful might happen
0
1
2
3
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of
things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Scoring:
0-7: no diagnosis; 8-21: Probable anxiety disorder
Spitzer et al, 2006
Other Anxiety self-report
measures
• Beck Anxiety Inventory (BAI): (Beck, 1990.)
• State-Trait Anxiety Inventory (STAI) - used to
identify anxiety and distinguish from
depressive syndromes (Spielberger, Gorsuch,
Lushene, Vagg, & Jacobs, 1983).
How to manage anxiety?
• Bring up your concerns to your doctor!
• Keep all providers informed.
• Options for treatments include:
• Medications
• Talk therapy (psychotherapy)
• Meditation and biofeedback
Medications for anxiety
• Antidepressants: SSRI’s (selective serotonin reuptake
inhibitors) and SNRI’s (selective norepinephrine and
serotonin reuptake inhibitors) are effective to treat anxiety.
Some older antidepressants (tricyclic antidepressants) can
be helpful too, but they carry a higher risk of seizure. These
medications work long-term (they are NOT to be taken as
needed).
• Benzodiazepines: not recommended due to dependence
concerns and long-term cognitive side effects. Their use as
a rescue medication for prolonged seizures may lead to
inappropriate use.
• Other medications may be used for anxiety, although their
evidence is not as strong (ie, buspirone, gabapentin).
Psychotherapy for anxiety disorders
Cognitive Behavioral Therapy has a wide
application to several anxiety disorders.
•Problem-focused
•Action-oriented
•Behaviorists focus on changing
relationship between stimulus
and behavioral response.
•Cognitive therapists focus on
conscious thoughts as directing
behavior.
•CBT merges both approaches.
•Many self-help books available.
Other strategies
• Physician-approved exercise: yoga, pilates,
non-intense physical exercise, etc.
• Diet: consult with nutritionist: proper calorie
intake, fruits, veggies, whole grains, lean
meats
• Relaxation training and deep breathing
• Treatment for sleep disorder
• Epilepsy support groups and activities
Resources
Epilepsy Foundation
www.epilepsy.com
- local epilepsy foundation of NJ and NY