Risk factors for depression in patients with epilepsy

Psychosocial predictors of depression and anxiety in patients with epilepsy: a systematic review

BACKGROUND

People with epilepsy (PWE) have a high chance of experiencing depression and anxiety disorders over their lifetime. However, those most at risk are unknown. Psychosocial variables have been suggested as potentially important risk factors. A systematic review was conducted in order to critically assess available evidence regarding the psychosocial predictors of depression and anxiety in adults with epilepsy.

METHODS

Electronic databases searched were MEDLINE, PsycINFO and Web of Science. Studies were included if they assessed depressive or anxiety symptoms using a validated questionnaire, and controlled for the role of potentially important epilepsy factors. Eleven studies were identified and assessed for research standards using the Quality Index Scale (QIS).

RESULTS

Ten of the eleven studies found at least one significant predictor of depression and all six studies that assessed anxiety found one or more significant predictors.

LIMITATIONS

Overall QIS score was only 7.5 out of 15, indicating significant design limitations of many included studies. There was also large variability between studies in measures used to assess psychosocial variables.

CONCLUSION

Studies did not support the importance of attributional theory and stigma in the development of depression in epilepsy. There was inconsistent support for the role of illness representations but likely support for the role of stress and self-efficacy. Consistent support was found for the role of coping strategies and perceived social support. Given that psychosocial factors are potentially modifiable, a better understanding of their role in the development of depression in people with epilepsy is urgently needed to guide effective treatments.

Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives

The clinical manifestations of depression in people with epilepsy (PWE) are pleomorphic, often associated with anxiety symptoms and anxiety disorders. The ongoing debate of whether the clinical presentation of depression in PWE is unique to this neurologic disorder is reviewed. Comorbid depression can impact the recruitment of PWE for pharmacologic trials with antiepileptic drugs (AEDs). Yet, the impact of depression on the response of the seizure disorder to pharmacotherapy with AEDs and its impact on worse adverse events may bias the interpretation of the trial findings, particularly when depressed patients are included in the AED trials. PWE have a greater suicidal risk than the general population. This risk is mediated by multiple factors, and recent data from the FDA have imputed a potential pathogenic role to all AEDs. The recognition of patients at risk is reviewed. Yet, the validity of the FDA data has been questioned, and the status of this controversial question is analyzed. As in the case of epilepsy, depression and pain syndromes have a relatively high comorbidity. The negative impact of depression on pain is reminiscent of that of depression in PWE; furthermore, the high comorbidity may be also associated with the existence of common pathogenic mechanisms. Neurologists and in particular, epileptologists establish the diagnosis of psychogenic non-epileptic seizures (PNES) in whom a comorbid depressive disorder is very often identified. The role of depression in the course of PNES and its treatment are discussed. Scarce data are available on the treatment of depression in PWE. Thus, clinicians have had to adopt data from patients with primary depressive disorders. We outline a consensus strategy on the identification and treatment of depressive disorders in adult and pediatric patients with epilepsy.

Screening symptoms of depression and suicidal ideation in people with epilepsy using the Beck depression inventory

OBJECTIVE: To measure the severity of symptoms of depression and suicidal ideation in people with epilepsy (PWE) before and after epilepsy surgery using the Beck Depression Inventory (BDI). We aimed to determine the factors associated to depression in PWE. METHODS: PWE, regardless of epilepsy type, seizure type, duration or frequency of seizures, and AEDs were investigated. The sample (n=468) was divided into two groups: pre-operatory (n=346) and pos-operatory (n=122). RESULTS: Before epilepsy surgery female gender, unemployment and high seizure frequency were associated factors for the occurrence of symptoms of depression. After epilepsy surgery, the only factor associated to high level of depression symptoms was the lack of seizure remission. Suicidal ideation was associated to seizure frequency before and after epilepsy surgery. CONCLUSION: Our results confirm the generally held view that depression is common in PWE and provide further insight to the association of depression with certain socio-demographic and seizure-related factors before and after epilepsy surgery.

Prevalence of psychiatric comorbidities in temporal lobe epilepsy in a Southern Brazilian population

A great prevalence of psychiatric disorders in epilepsy is well demonstrated, although most studies have used unstructured psychiatric interviews for diagnosis. Here we present a study evaluating the prevalence of psychiatric comorbidities in a cohort of Southern Brazilian patients with temporal lobe epilepsy (TLE) using a structured clinical interview. We analyzed 166 patients with TLE regarding neuropsychiatric symptoms through the Structured Clinical Interview for DSM-IV. One hundred-six patients (63.9%) presented psychiatric comorbidities. Mood disorders were observed in 80 patients (48.2%), anxiety disorders in 51 patients (30.7%), psychotic disorders in 14 (8.4%), and substance abuse in 8 patients (4.8%) respectively. Our results agree with literature data where most authors detected mental disorders in 10 to 60% of epileptic patients. This wide variation is probably attributable to different patient groups investigated and to the great variety of diagnostic methods. Structured psychiatric interviews might contribute to a better evaluation of prevalence of psychiatric comorbidities in TLE.

Psychiatric comorbidity, quality of life and social support in epileptic patients

BACKGROUND

Epilepsy is accompanied by many psychiatric disorders and continues to be a disease that disturbs the functioning and quality of life (QOL) of patients.

AIMS

To assess the frequency of psychiatric disorders occurring in epileptic patients, determine depression and anxiety levels, and compare the results with healthy controls. The effect of epilepsy on QOL and the effects of social support on epilepsy were also assessed.

METHODS

50 epileptic patients and 50 controls were compared using the Structured Clinical Interview for DSM-IV (SCID-I), Beck Depression Inventory, Beck Anxiety Scale, Multi-dimensional Scale of Perceived Social Support (MSPSS) and the World Health Organization Quality of Life Assessment-Brief (WHOQOL-Brief).

RESULTS

44% of epileptic patients had psychiatric disorders, with depression being the most common diagnoses (28%). In terms of psychiatric comorbidity, there was a significant difference between the groups. The depression and anxiety scores of epileptic patients were significantly higher and there was no difference between the groups in terms of MSPSS scores. Psychological and physical subscale scores of WHOQOL-Brief were significantly lower in epileptic patients. In the epileptic group, a multi-variate analysis of covariance demonstrated that depression was a significant covariate for physical and psychological domains, anxiety was a significant covariate for psychological domain, social support was a significant covariate for social and environmental domains, and age of epilepsy onset was a significant covariate for physical domain of QOL.

CONCLUSION

Epilepsy needs multi-dimensional analysis because of its chronic nature, frequently accompanying psychiatric disorders, its negative effects on QOL and the important role social support plays. The clinicians' handling of patients at an early stage can play an important role in preventing the negative results of epilepsy.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy

Depression is associated with higher rates of suicide and lower quality of life in individuals with epilepsy. We previously published the 12-month outcome from our randomized clinical trial of PEARLS (Ciechanowski P, Chaytor N, Miller J, et al. Epilepsy Behav. Epub 5 July 2010). The purpose of this study was to determine the long-term effectiveness of PEARLS, a home-based collaborative care intervention consisting of problem-solving treatment, behavioral activation, and psychiatric consultation, in individuals with epilepsy. Patients were randomly assigned to PEARLS (N=40) or usual care (N=40), and assessed at baseline and 6, 12, and 18 months. Patients assigned to PEARLS achieved lower depression severity (P<0.05) (Hopkins Symptoms Checklist-20), lower suicidal ideation (P<0.02), and better emotional well being (QOLIE-31) (P<0.02) over 18 months, compared with patients given the usual care. The PEARLS program significantly reduces depressive symptoms in adults with epilepsy, and this effect is maintained for 18 months after baseline and for more than 1 year after completion of home visits.

PEARLS depression treatment for individuals with epilepsy: a randomized controlled trial

OBJECTIVE

Depression is associated with higher rates of suicide and lower levels of functioning and quality of life in individuals with epilepsy. The objective of this randomized controlled trial was to determine the effectiveness of PEARLS, a home-based program for managing depression in adult individuals with epilepsy and clinically significant acute and chronic depression.

METHODS

Delivered by masters-level counselors, PEARLS is a collaborative care intervention consisting of problem solving treatment, behavioral activation, and psychiatric consultation. Patients were randomly assigned to the PEARLS intervention (N = 40) or usual care (N = 40), and assessed at baseline, 6 months, and 12 months.

RESULTS

Compared with patients who received usual care, patients assigned to the PEARLS intervention achieved lower depression severity (P<0.005) (Hopkins Symptoms Checklist-20) and lower suicidal ideation (P = 0.025) over 12 months.

CONCLUSIONS

The PEARLS program, a community-integrated, home-based treatment for depression, effectively reduces depressive symptoms in adults with epilepsy and comorbid depression.

Neuropsychiatric evaluations of postictal behavioral changes

Postictal behavioral changes (PBCs), including psychosis, aggression, and mood change, are commonly observed in patients with epilepsy. Recognition and description of the clinical manifestations of PBCs would help in understanding and treating patients. Additionally, various quantified objective scales that are widely available in clinical psychiatry could be used to assess the clinical symptoms of PBCs. There are few reports in which objective rating scales have been used to assess neuropsychiatric symptoms in patients with epilepsy. However, there have been a small number of studies on interictal psychosis and depression in which either the Brief Psychiatric Rating Scale or the Hamilton Depression Scale was used. These inventories are likely to be useful for the assessment of PBCs. Other rating scales used for schizophrenia, depression, mania, and aggressive behavior are reviewed here. The author suggests that cross-sectional and longitudinal neuropsychiatric measurement combined with other modalities, including functional neuroimaging, could provide clues to the pathophysiology of PBCs.

Predictors of suicidal ideation in people with epilepsy living in Korea

Background and Purpose

The risk of suicide or suicide attempts is reported higher in people with epilepsy (PWE) than in the general population. Although epileptic, psychiatric, and psychosocial factors are known risk factors for suicide or suicide attempt, no studies have evaluated the predictors of the severity of suicidal ideation-which is a warning sign for suicide attempts-in PWE. Therefore, we measured the severity of suicidal ideation and its risk factors.

Methods

Consecutive PWE who were medicated with antiepileptic drugs (AEDs) and attended epilepsy clinic were included in the study. The subjects completed self-reported questionnaires, which included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Checklist-90-Revised (SCL-90-R), and Scale for Suicide Ideation-Beck (SSI-Beck). We compared the patients' demographic and clinical variables, and BDI, BAI, and SCL-90-R scores with their SSI-Beck score, and used our findings to determine the predictors for suicidal ideation.

Results

In total, 257 PWE were enrolled in the study. SSI-Beck scores correlated strongly with several seizure-related variables, duration of education, IQ, BDI and BAI scores, and nine domains of the SCL-90-R questionnaire. However, the strongest predictor for suicidal ideation was BDI score (β=0.41, p<0.001), followed by several SCL-90-R domains, such as obsessive-compulsive (β=-0.39, p<0.001), depression (β=0.38, p<0.001), hostility (β=0.22, p=0.002), paranoid ideation (β=0.17, p=0.01), and IQ (β=-0.10, p=0.017). These variables explained 59% of the variance in the SSI-Beck score. The seizure-related variables that influenced the BDI score were seizure frequency, duration of education, MRI abnormality, and number of AEDs. However, these variables explained only 18% of the variance in the BDI score.

Conclusions

Major risk factors for suicidal ideation in PWE were depressive and psychiatric symptoms rather than seizure-related variables. Therefore, clinicians should focus on screening for depression and other psychiatric problems and treat them appropriately in order to reduce suicidal behavior in PWE. Since seizure-related variables also exhibited a minor role in determining depressive symptoms, stronger seizure-related risk factors for depression should be sought, such as seizure severity or psychosocial factors, to minimize suicidal behavior.

Individual, seizure-related, and psychosocial predictors of depressive symptoms among people with epilepsy over six months

Depression is the most frequently diagnosed psychiatric disorder among people with epilepsy. A variety of risk factors for depression among people with epilepsy have been identified; however, few studies have examined these risk factors over time. The primary purpose of this study was to explore the relationship between demographic characteristics, seizure-related factors, and psychosocial factors and depressive symptoms over 6 months. Three hundred and nineteen adults with epilepsy completed three surveys at 3-month intervals. Multiple linear regression was used with the baseline variables to predict depressive symptoms at baseline, 3 months, and 6 months. Employment status, social support, and stigma emerged as predictors of depressive symptoms at all three time points. Other factors that predicted depression symptoms in one or two time points were self-management, financial strain, and activity restriction due to seizures. The results indicate that multiple factors influence depressive symptoms among people with epilepsy.

Comparison of personality traits in patients with frontal and temporal lobe epilepsies

The current study sought to characterize and compare personality traits of patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE). Ninety-seven adults with medically intractable epilepsy (TLE n=58, FLE n=39) completed the Personality Assessment Inventory (PAI) as part of routine preoperative investigations. Not surprisingly, both epilepsy groups endorsed significantly more symptoms across PAI clinical scales than the normative sample, most notably on scales assessing Depression and Somatic Complaints. Direct comparison of personality profiles of people with FLE and TLE revealed that FLE was associated with relative elevations on scales assessing emotional lability and relationship difficulties (i.e., Mania, Borderline Features, Antisocial, Stress, and Nonsupport). Although effect sizes were moderate to large, the clinical significance of these differences was questionable (<1 SD). However, results of a logistic regression suggested that the Borderline Features and Anxiety scales have incremental validity in predicting seizure site (FLE vs TLE) above education and duration of recurrent seizures. These results suggest that patients with FLE may exhibit more behavioral traits associated with frontal dysfunction than patients with TLE.

Sociodemographic and clinical factors associated with depression in epilepsy

The impact of mood disorders on patients with epilepsy is an important and growing area of research. If clinicians are adept at recognizing which patients with epilepsy are at risk for mood disorders, treatment can be facilitated and morbidity avoided. We completed a case-control study (80 depressed subjects, 141 nondepressed subjects) to determine the sociodemographic and clinical factors associated with self-reported depression in people with epilepsy. The Patient Health Questionnaire-9 was used to determine clinically significant depression. In multivariate analyses, depressed subjects with epilepsy were significantly less likely than nondepressed subjects to be married or employed and more likely to report comorbid medical problems and active seizures in the past 6 months. Adjusted for all other variables, subjects with epilepsy reporting lamotrigine use were significantly less likely to be depressed (OR=0.4, 95% CI: 0.2-0.8) compared with those not reporting lamotrigine use.

Depression and anxiety in children and adolescents with epilepsy: prevalence, risk factors, and treatment

Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions.

Psychiatric aspects of epilepsy

Patients who have epilepsy face many challenges resulting from their illness and have frequent psychiatric comorbidities. Recognition of these disorders is increasing and is having a positive impact on patients' quality of life. Recent recommendations about a new classification system for psychiatric disorders related specifically to epilepsy and based on the relationship of symptoms to seizures, antiepileptic medications, and EEG changes should further research and treatment. Especially insofar psychiatric syndromes specific to epilepsy can be identified, correlation of clinical phenomena with relatively well-understood pathophysiology in epilepsy will allow advances in the understanding of psychiatric illness. This progress should move the treatment of patients who have epilepsy toward a comprehensive biopsychosocial model that focuses on the whole person rather than simply on the disease process.

A psychosocial self-management program for epilepsy: a randomized pilot study in adults

OBJECTIVE

The goal of the work described here was to develop and pilot a theoretically based self-management intervention in adults with epilepsy.

METHODS

A randomized, controlled trial examined intervention effectiveness of a 6-week psychosocial intervention designed to improve self-efficacy and quality of life for 61 adults with diagnosed epilepsy. Measures included the Quality of Life in Epilepsy-89 inventory (QOLIE-89), the Washington Psychosocial Seizure Inventory (WPSI), a locus of control scale (LOC), and the Epilepsy Self-Efficacy Scale-2000 (ESES). Group differences were examined between groups using analysis of covariance.

RESULTS

There was a significant improvement in the QOLIE-89 Role Limitations-Emotional score in the treatment group at follow-up, but no significant differences in overall quality of life. Strong and significant correlations were observed between outcome measures.

CONCLUSION

Although the intervention had little effect on improving overall quality of life, we observed promising trends in postintervention group comparisons linking self-efficacy and other psychosocial factors with quality of life. Intervention material can be modified for stage-based behavior change and retested in another study.

Major depression in temporal lobe epilepsy with hippocampal sclerosis: clinical and imaging correlates

PURPOSE

Refractory temporal lobe epilepsy (TLE) is often associated with hippocampal sclerosis (HS). Patients with major depression (MD) may also show structural abnormalities in the limbic system. Co-occurrence of TLE with HS and MD is not uncommon. We have investigated the clinical and morphological characteristics of TLE patients in relation to MD.

METHODS

34 TLE patients with HS were assessed at a Comprehensive Epilepsy Programme. All relevant clinical data were obtained, including the history of antecedent events to epilepsy. MD was diagnosed based on detailed psychiatric investigation. MRI was used to measure the volume and tissue signal (T2 relaxometry) of the hippocampus and amygdala. The imaging data were expressed as a percentage of the values obtained in a series of 55 controls.

RESULTS

A history of MD was present in 15 (44%) of 34 patients. Patients with MD had a longer duration of their epilepsy (p<0.05) and a lower frequency of antecedent events (13% with MD, 58% without MD, p<0.05). Both groups had a similar degree of ipsilateral HS (small hippocampal volume, increased hippocampal T2 relaxation time) and demonstrated bilateral amygdaloid atrophy. However, the contralateral amygdala showed lower signal in the presence of MD (97 (9) ms; no MD 103 (8) ms; ANCOVA, p = 0.02).

CONCLUSION

The integrity of the amygdala may influence mood disturbances in TLE patients with HS, as depression was associated with a relative preservation of the contralateral amygdala. In contrast, hippocampal abnormalities were not related to the presence of depression.

Psychiatric events in epilepsy

Psychiatric events are thought to be more frequent in people with epileptic seizures than in the general population. However, inter-ictal psychiatric events attributable to epilepsy remain controversial. The aim of the present study was to evaluate the occurrence of psychiatric events in a population of fairly unselected patients with epilepsy and in the general population, and the correlation between psychiatric complaints and selected demographic and disease characteristics. The survey was part of a multicentre prospective cohort study of everyday life risks conducted in eight European countries and comparing referral children and adults with epilepsy referred to secondary/tertiary centers to age- and sex-matched non-epileptic controls. Nine hundred and fifty-one patients with epilepsy and 909 controls were studied. Each patient and his/her control received a diary to record any accident or illness, with severity, circumstances, causes, consequences, and (for the cases) the possible relation to a seizure. The follow-up period ranged between 1 and 2 years. Fifty-eight psychiatric events occurred in 25 patients (2.6%) and 88 in 19 controls (2.1%). Housewives (9.3%) and unemployed persons (4.1%) were mostly affected. No correlation was found between psychiatric events, demographic and disease characteristics. Our results suggest that people with epilepsy if unselected are not at higher risk for psychiatric disorders than the general population.

The acceleration of amygdala kindling epileptogenesis by chronic low-dose corticosterone involves both mineralocorticoid and glucocorticoid receptors

We have previously demonstrated that low-dose corticosterone (CS) administration, used as a model of the effect of chronic stress, accelerates epileptogenesis in the electrical amygdala kindling rat model of temporal lobe epilepsy (TLE). This current study examined the relative contributions to this effect of mineralocorticoid (MR) and glucocorticoid (GR) subtypes of glucocorticoid receptors. Female non-epileptic wistar rats 10-13 weeks of age were implanted with a bipolar electrode into the left amygdala. Five treatment groups were subjected to rapid amygdala kindling: water-control (n=9), CS treated (6 mg/100 ml added to drinking water; n=9), CS+spironolactone (MR antagonist, 50 mg/kg sc; n=9), CS+mifepristone (GR antagonist, 25 mg/kg sc; n=9), and CS+both antagonists (n=7). Rats were injected with vehicle or the relevant antagonist twice daily for the entire kindling period. Experimental groups differed significantly in the number of stimulations required to reach the 'fully kindled state' (Racine, 1972) ANOVA, F(4,38)=2.73, p=0.04). Amygdala kindling was accelerated in the CS-treated group compared with water controls (mean stimulations for full kindling: 45.2 vs. 86.5, p<0.01). This acceleration was inhibited by both the MR and GR antagonist treatments (mean stimulations: 69.6 and 70.4, p=0.04 and 0.04 vs. CS group, respectively), with the kindling rates in these groups not significantly different from water-treated subjects (p=0.26 and 0.29, respectively). The kindling rates in the MR and GR antagonist treatment groups did not significantly differ from each other (p=0.93), nor from the combined treatment group (mean stimulations: 62.8, p=0.59 and 0.54, respectively). This study demonstrates that activation of both high-affinity (MR) and low-affinity (GR) glucocorticoid receptors are involved in mediating CS-induced acceleration of amygdala kindling epileptogenesis.

Reduced Hippocampal 5HT1A PET Receptor Binding and Depression in Temporal Lobe Epilepsy

PURPOSE

To study the relation of hippocampal 5HT1A receptor binding to symptoms of depression in patients with temporal lobe epilepsy. Depression is common in people with epilepsy, and reduced 5HT1A binding has been reported in patients with primary depressive disorders.

METHODS

We studied 45 patients with temporal lobe epilepsy confirmed by ictal video-EEG recording. Mood was assessed with the Beck Depression Inventory (BDI). Positron emission tomographic measurement of 5HT1A receptors was performed with 18F-FCWAY, a highly specific silent antagonist. 3D-T1-weighted MRI was used to correct for structural atrophy. Receptor distribution volume (V) was corrected for plasma tracer free fraction (f1).

RESULTS

There was a significant inverse relation between ipsilateral hippocampal v/f1 and the BDI. For contralateral hippocampus, there was a nonsignificant trend. Patients with BDI > 20 had significantly lower ipsilateral hippocampal V/f1 than patients in the low and medium groups. There was no significant effect of the presence of mesial temporal sclerosis, focus laterality, or gender on the BDI.

CONCLUSIONS

Our study shows a relationship between hippocampal 5HT1A binding and depressive symptoms measured by the BDI in patients with epilepsy. The findings parallel results in patients with MDD.