Epilepsy coexisting with depression

Frontiers and hotspots in comorbid epilepsy and depression: a bibliometric analysis from 2003 to 2023

Background

Epilepsy ranks among the most common neurological disorders worldwide, frequently accompanied by depression as a prominent comorbidity. This study employs bibliometric analysis to reveal the research of comorbid epilepsy and depression over the past two decades, aiming to explore trends and contribute insights to ongoing investigations.

Methods

We conducted a comprehensive search on the Web of Science Core Collection database and downloaded relevant publications on comorbid epilepsy and depression published from 2003 to 2023. VOSviewer and CiteSpace were mainly used to analyze the authors, institutions, countries, publishing journals, reference co-citation patterns, keyword co-occurrence, keyword clustering, and other aspects to construct a knowledge atlas.

Results

A total of 5,586 publications related to comorbid epilepsy and depression were retrieved, with a general upward trend despite slight fluctuations in annual publications. Publications originated from 121 countries and 636 institutions, with a predominant focus on clinical research. The United States led in productivity (1,529 articles), while Melbourne University emerged as the most productive institution (135 articles). EPILEPSY & BEHAVIOR was the journal with the highest publication output (1,189 articles) and citation count. Keyword analysis highlighted emerging trends, including "recognitive impairment" and "mental health," indicating potential future research hotspots and trends.

Conclusion

This study is one of the first to perform a bibliometric analysis of the 20-year scientific output of comorbid epilepsy and depression. While research has trended upwards, ambiguity in pathogenesis and the absence of standardized diagnostic guidelines remain concerning. Our analysis offers valuable guidance for researchers, informing that this might be a strong area for future collaborations.

The relationship between psychiatric symptoms and the use of levetiracetam in people with epilepsy

Background: Mental health in people with epilepsy (PWE) is often overlooked, especially in developing countries.Purpose: Consequently, the current work had two objectives: (1) to estimate the burden of depression, anxiety, insomnia, and stress, and (2) to examine the association of these psychiatric/psychological symptoms with levetiracetam and other relevant clinical factors in a cohort of Jordanian PWE.Research Design: This is a cross-sectional study. The demographic and clinical data were recorded. Depression was measured by the Patient Health Questionnaire-9 (PHQ-9, Arabic-validated version) and anxiety by the General Anxiety Disorder-7 (GAD-7, Arabic-validated version). The insomnia severity index (ISI-A, Arabic version) was used to assess sleep quality, and the Perceived Stress Scale (PSS-A, Arabic version) was used to measure perceived stress.Study Sample: Data were analyzed from 280 patients, of which 178 (63.6%) received levetiracetam as monotherapy or as adjuvant.Results: Depression was reported in 150 (53.6%), anxiety in 110 (39.3%), insomnia in 131 (46.8%), and clinically significant stress in 211 (75.4%). At univariate analysis, levetiracetam was not associated with psychiatric symptoms. Multivariate logistic regression revealed that severe depressive symptoms were associated with family history (OR = 2.47, 95% CI = 1.42-4.33, P = .001) and seizure type (OR = 1.69, 95% CI = 1.01-2.80, P = .04), severe anxiety symptoms were associated with family history (OR = 1.90, 95% CI = 1.12-3.23, P = .01), severe insomnia was associated with seizure type (OR = 2.16, 95% CI = 1.33-3.5, P = .002) and severe stress was associated with marital status (OR = 2.37, 95% CI = 1.31-4.29, P = .004).Conclusions: The high psychological burden of PWE is a challenging issue that requires attention and prompt action to control its risk factors. Levetiracetam was not associated with psychiatric symptoms in this study.

Pathophysiology to Risk Factor and Therapeutics to Treatment Strategies on Epilepsy

Epilepsy represents a condition in which abnormal neuronal discharges or the hyperexcitability of neurons occur with synchronicity, presenting a significant public health challenge. Prognostic factors, such as etiology, electroencephalogram (EEG) abnormalities, the type and number of seizures before treatment, as well as the initial unsatisfactory effects of medications, are important considerations. Although there are several third-generation antiepileptic drugs currently available, their multiple side effects can negatively affect patient quality of life. The inheritance and etiology of epilepsy are complex, involving multiple underlying genetic and epigenetic mechanisms. Different neurotransmitters play crucial roles in maintaining the normal physiology of different neurons. Dysregulations in neurotransmission, due to abnormal transmitter levels or changes in their receptors, can result in seizures. In this review, we address the roles played by various neurotransmitters and their receptors in the pathophysiology of epilepsy. Furthermore, we extensively explore the neurological mechanisms involved in the development and progression of epilepsy, along with its risk factors. Furthermore, we highlight the new therapeutic targets, along with pharmacological and non-pharmacological strategies currently employed in the treatment of epileptic syndromes, including drug interventions employed in clinical trials related to epilepsy.

The effect of cognitive behavioral therapy on depression of people with epilepsy

BACKGROUND

Depression, a common mental problem frequently detected in people with epilepsy (PWE), is a major factor that decreases the quality of life of PWE. The cognitive behavioral therapy (CBT) is the most commonly used non-pharmacological treatment for depressive disorders. The CBT for PWE with depression has not yet been studied in Korea. This study aimed to evaluate the effects of the CBT on depression in PWE in Korea.

METHOD

This study included 16 PWE with depression who received CBT and 30 control PWE with depression who did not receive CBT. The mean number of CBT sessions per patient was 7.2 in the CBT group. The Beck Depression Inventory-II (BDI-II) and Patient Health Questionnaire-9 (PHQ-9) were administered before and after CBT sessions in the CBT group, whereas PHQ-9 was performed at baseline and follow-up in the control group. The difference in PHQ-9 and BDI-II scores were analyzed between the pre- and post-CBT periods in the CBT group. The difference between baseline and follow-up PHQ-9 scores was compared in the control group.

RESULTS

There was no significant difference in baseline variables between the CBT and control groups. The PHQ-9 score significantly decreased after the CBT sessions in the CBT group (pre-CBT PHQ-9 = 13.56 vs. post-CBT PHQ-9 = 8.56) but it did not change in the control group (Baseline PHQ-9 = 13.83 vs. follow-up PHQ-9 = 14.67). Twelve PWE had undergone four or more CBT sessions with pre-CBT and post-CBT BDI-II. The BDI-II score significantly decreased after CBT sessions (pre-CBT BDI-II = 30.75 vs. post-CBT BDI-II = 21.5). The CBT decreased the sub-field scores of cognitive and physical-emotional factors as well as suicidal ideation, but the score of sleep problems did not significantly improve. The CBT did not significantly change the seizure frequency.

CONCLUSION

The CBT significantly improved depression in Korean PWE. Therefore, it can be considered a treatment tool for depression in PWE. However, a study with more patients and a fixed number of CBT sessions is recommended to generalize this effect.

Quantitative Cross-Sectional Study About the Prevalence of Depression Among Epileptic Patients in Saudi Arabia

BACKGROUND

There are high prevalence of mental health co-morbidities in people with epilepsy, with major depressive disorder being the most common among them.

OBJECTIVE

This study aims to investigate the prevalence of depression among epileptic patients in Saudi Arabia. We also explored some of the sociodemographic and clinical variables associated with depression in epilepsy.

METHODS

This was a cross-sectional analysis executed across the four geographical regions of Saudi Arabia and the sample size is calculated to be 358. Data collection was facilitated through a digital self-administered questionnaire, which consisted of three parts: patients' sociodemographic variables, clinical variables, and patient health questionnaire (PHQ-9) depression score. Data processing and analytical procedures are undertaken using the SPSS software.

RESULTS

Of the participants, 311 responded: 65.6% were females, and 34.4% were males. Approximately 50.5% had a confirmed epilepsy diagnosis and were included in the PHQ-9 depression score analysis. Notably, 84.7% manifested depressive symptoms, with the severe category being predominant at 84.7% and moderate at 3.8%. An intriguing observation was the heightened prevalence among the younger demographic (16 to 24 years), registering at 34.4%, a figure nearly 3% superior to older age brackets.

CONCLUSION

The majority of participants manifested depressive symptoms, with a significant association noted between medication quantity and depression prevalence in epilepsy. It is imperative to broaden the scope of research, encompassing varied methodologies and spanning multiple urban centers, to procure more robust and generalizable conclusions.

Adherence to epilepsy quality indicators in a tertiary referral center

BACKGROUND

Quality indicators play an important role in healthcare quality and patient safety. The aim of this study is to identify specific clinical pharmacy interventions to improve adherence to quality indicators and minimize risks among patients with epilepsy.

MATERIAL AND METHODS

A prospective, two-phase, observational study was conducted in a neurology outpatient clinic of a tertiary university hospital. In the first phase of the study, the rate of adherence to the quality indicators was evaluated with a checklist containing the quality indicators. In the second phase of the study, an expert panel meeting was convened to identify clinical pharmacist interventions to reduce the risks associated with non-adherence. The Fine-Kinney method was used to prioritize risks, and adherence rates with each quality improvement indicator (QI) were calculated.

RESULTS

The study found that adherence rates were highest for QIs involving estimating the number and type of seizures, providing medical treatment or referring patients with evidence of mood disorders to mental healthcare, and co-managing prenatal care for women with epilepsy. The most non-adherence rates were found in QIs involving quality-of-life assessment, daily folate supplementation, and addressing the decreased effectiveness of oral contraception. The annual review of information about educational issues was also poorly provided. An expert panel decided to integrate a clinical pharmacist into the outpatient clinic to improve medication adherence, side-effect assessment, drug interaction assessment, patient education, lifestyle-modification education, depression/suicide-related behavior screening, quality-of-life assessment, and effectiveness evaluation of oral contraceptives for female patients using enzyme-inducing ASM.

CONCLUSION

The study shows that medication adherence, assessment of side effects, drug interactions, and patient education are inadequately provided by neurologists in patients with epilepsy. Clinical pharmacists have a crucial role in reducing potential risks of non-adherence with quality indicators. By integrating clinical pharmacy services into routine epilepsy care processes, the quality of care can be improved. Future studies should focus on implementing these interventions and evaluating their impact on patient outcomes.

Stress phenotypes in epilepsy: impact on cognitive functioning and quality of life

Introduction

Drug-resistant epilepsy has been proposed as a chronic stress model. Stress can be measured in terms of chronicity (epilepsy duration) and intensity (comorbidities), with depression and anxiety among the most important comorbidities in epilepsy due to its prevalence and its relationship with cognitive functioning and quality of life. This study aims to establish phenotypes according to how patients face a stressful condition (epilepsy) and examine differences in cognition and quality of life depending on these phenotypes. We hypothesize that there will be an interrelationship between epilepsy duration and negative affectivity, and these variables will influence cognition and quality of life.

Methods

170 patients (82 men and 88 women) underwent a neuropsychological evaluation in which trait anxiety, depression, attention and executive function, verbal and visual memory, language, emotional recognition, and quality of life were assessed. Hierarchical clustering was performed using z-scores for three variables: trait anxiety; depression; and epilepsy duration.

Results

Three clusters were found: vulnerable (high negative affectivity and short duration); resilient (moderate negative affectivity and long duration); and low-impact group (low negative affectivity and short duration). Results show that the vulnerable group had poorer cognitive functioning and quality of life than the other groups. Specifically, the vulnerable group had poorer scores than the low-impact group on verbal memory, visual confrontation naming, and quality of life (except seizure worry). Furthermore, resilient patients had better scores than the low-impact group on cognitive flexibility variables, but lower scores on some quality-of-life subscales (i.e., overall quality of life, emotional well-being, and energy). Finally, the vulnerable group had poorer scores than the resilient group in executive functioning, naming, and quality of life.

Discussion

These results suggest that dealing with stress in patients with epilepsy is related to cognitive performance and quality of life. These findings underline the relevance of considering comorbidities in epilepsy and may be useful for detecting vulnerable or resilient profiles as risk or protective factors for cognitive and quality of life decline.

Supplementation of n-3 PUFAs in Adulthood Attenuated Susceptibility to Pentylenetetrazol Induced Epilepsy in Mice Fed with n-3 PUFAs Deficient Diet in Early Life

The growth and development of the fetus and newborn throughout pregnancy and lactation are directly related to the nutritional status of the mother, which has a significant impact on the health of the offspring. The purpose of this experiment was to investigate the susceptibility of n-3 polyunsaturated fatty acid deficiency in early life to seizures in adulthood. The n-3 PUFAs-deficient mice's offspring were established and then fed with α-LNA diet, DHA-enriched ethyl ester, and DHA-enriched phospholipid-containing diets for 17 days at the age of eight weeks. During this period, animals received intraperitoneal injections of 35 mg/kg of pentylenetetrazol (PTZ) every other day for eight days. The results showed that dietary n-3 PUFA-deficiency in early life could aggravate PTZ-induced epileptic seizures and brain disorders. Notably, nutritional supplementation with n-3 PUFAs in adulthood for 17 days could significantly recover the brain n-3 fatty acid and alleviate the epilepsy susceptibility as well as raise seizure threshold to different levels by mediating the neurotransmitter disturbance and mitochondria-dependent apoptosis, demyelination, and neuroinflammation status of the hippocampus. DHA-enriched phospholipid possessed a superior effect on alleviating the seizure compared to α-LNA and DHA-enriched ethyl ester. Dietary n-3 PUFA deficiency in early life increases the susceptibility to PTZ-induced epilepsy in adult offspring, and nutritional supplementation with n-3 PUFAs enhances the tolerance to the epileptic seizure.

Low quality of life, increased number of anti-seizure drugs, and the lack of caregiver support are associated with internalized stigma in adult Mexican patients with epilepsy

BACKGROUND

People with epilepsy (PWE) have been subject to stigma throughout history, a factor that could compromise their performance in daily life. In Mexico, little is known about the factors that may be affecting internalized stigma.

OBJECTIVE

To evaluate the internalized stigma in adult PWE, its relationship with the quality of life, cognitive and depressive symptomatology, and clinical-demographic characteristics.

MATERIAL AND METHODS

We conducted a cross-sectional study with a consecutive sampling approach in patients with epilepsy treated at the National Institute of Neurology and Neurosurgery Manuel Velasco Suárez (NINNMVS). Sociodemographic and clinical data, depressive symptomatology (Beck's depression inventory, DBI), cognition (MoCA test), quality of life (QOLIE-31 scale), and internalized stigma (King's internalized stigma scale, ISS) were evaluated. Correlations were made between the continuous variables and the ISS to select those with statistical significance and include them in a multiple linear regression model, along with the dummy variables, to explain internalized stigma.

RESULTS

Of 128 patients, 74 (58%) were women; 38% of the patients had more than 20 years of epilepsy evolution. In addition, 39% presented depressive symptoms, and around 60% manifested a possible cognitive impairment. The variables that showed statistical significance concerning the ISS were selected along with dummy variables for multiple linear regression analysis. The resultant model considers the QOLIE-31 total score (β = -0.489), the number of anti-seizure drugs (ASD, β = 0.253), and those patients without caregiver support (β = -0.166) with an adjusted R² value of 0.316.

CONCLUSIONS

A diminishing quality of life, an increased number of ASD, and patients without caregiver support influence a slight to moderate variation of internalized stigma in Mexican PWE. Therefore, it is necessary to continue studying other possible factors that influence internalized stigma to generate effective strategies to reduce its negative effects on PWE.

The Association of Sociodemographic Factors, Postictal Symptoms, and Medical History With Seizure Type in Patients With Epilepsy: A Cross-Sectional Study

Background Approximately 50 million people globally suffer from epilepsy. The prevalence of epilepsy in Saudi Arabia has been reported at 6.5 per 1,000 persons, affecting nearly 1% of the entire population. However, limited data is available in the country regarding the sociodemographic factors affecting epilepsy and its associated postictal symptoms, which may lead to stigmatization and negatively impact patients. Methods A cross-sectional study was conducted at King Abdulaziz University Hospital (KAUH) in a survey format. Ethical approval was obtained from the Research Ethics Committee of the Faculty of Medicine at King Abdulaziz University. The study population included patients with epilepsy who visited King Abdulaziz University Hospital's outpatient neurology clinics from October 2021 to March 2022. Results The study participants' average age at the time of the first seizure was 16.5 years, with patients experiencing seizures as early as within the first year of life and as late as 70 years of age. Patients who had had their first seizure during the first year of life did not have any schooling (p<0.0001) and had learning difficulties (p<0.00001). Focal onset impaired awareness seizures were significantly associated with motor weakness (p=0.023) and mood alterations (p=0.014), while postictal fear, anxiety or panic, and sleep disruption were statistically significant for focal onset aware seizures (p=0.015 and p=0.050). Conclusion This study highlights the sociodemographic differences between patients in Saudi Arabia and in other areas. It may also point to novel findings regarding the postictal symptoms associated with the various seizure types.

Design, Synthesis, and Pharmacology of New Triazole-Containing Quinolinones as CNS Active Agents

Epilepsy and major depressive disorder are the two of the most common central nervous system (CNS) diseases. Clinicians and patients call for new antidepressants, antiseizure medicines, and in particular drugs for depression and epilepsy comorbidities. In this work, a dozen new triazole-quinolinones were designed, synthesized, and investigated as CNS active agents. All compounds reduced the immobility time significantly during the forced swim test (FST) in mice at the dosage of 50 mg/kg. Compounds 3f-3j gave superior performance over fluoxetine in the FST with more reductions of the immobility time. Compound 3g also reduced immobility time significantly in a tail suspension test (TST) at the dosage of 50 mg/kg, though its anti-immobility activity was inferior to that of fluoxetine. An open field test was carried out and it eliminated the false-positive possibility of 3g in the FST and TST, which complementarily supported the antidepressant activity of 3g. We also found that almost all compounds except 3k exhibited antiseizure activity in the maximal electroshock seizure (MES) model at 100 or 300 mg/kg. Compounds 3c, 3f, and 3g displayed the ED₅₀ of 63.4, 78.9, and 84.9 mg/kg, and TD₅₀ of 264.1, 253.5, and 439.9 mg/kg, respectively. ELISA assays proved that the mechanism for the antiseizure and antidepressant activities of compound 3g was via affecting the concentration of GABA in mice brain. The molecular docking study showed a good interaction between 3g and the amino acid residue of the GABA_A receptor. Excellent drug-like properties and pharmacokinetic properties of compound 3a-l were also predicted by Discovery Studio. These findings provided a new skeleton to develop agents for the treatment of epilepsy and depression comorbidities.

Association of depression and epilepsy in Rwanda: A prospective longitudinal study

INTRODUCTION

Depression is the most common psychiatric comorbidity for persons living with epilepsy. In Rwanda, the prevalence of epilepsy and depression are high, with 4,9% and 13.0% respectively. This prospective interventional study aimed to determine the prevalence and incidence of depression and the outcome of persons living with epilepsy (PwE) with depression attending the outpatient neurology department of a tertiary center.

METHODS

Persons living with epilepsy enrolled between February and June 2018 in a screening cohort with a 12-month follow-up. At every 3-month study visit, PwE were screened for depression using the Patient Health Questionnaire (PHQ-9) questionnaire. Any positively screened subject was administered the Hamilton Depression Rating Scale (HDRS) to confirm the diagnosis and severity of depression. Subjects with moderate to severe depression (MSD), were started on treatment and were followed for another year. We describe the prevalence and incidence of depression, baseline characteristics, epilepsy and depression outcomes, and changes in PGI-C.

RESULTS

Of 572 PwE enrolled, 46 were diagnosed with MSD in a twelve-month period, resulting in an incidence of MSD of 32.7/1000 patient-years. The prevalence of any depression and MSD was 14.2% and 4.7%, respectively. Longer epilepsy duration and seizure status at baseline were associated with MSD. Significant improvements in PGI-C and seizure frequency were observed after treatment optimization.

CONCLUSION

The use of PHQ-9 and HDRS proved successful in identifying depression in PwE. Combined treatment of epilepsy and depression resulted in improved outcomes, warranting the implementation of depression screening every six months in daily neurology practice.

Exploring the association between epilepsy and depression: A systematic review and meta-analysis

OBJECTIVE

This study offers meta-analytic data on the potential association between epilepsy and depression especially for the prevalence of depression in epilepsy or vice versa.

METHODS

The relevant studies were searched and identified from nine electronic databases. Studies that mentioned the prevalence and/or incidence of epilepsy and depression were included. Hand searches were also included. The search language was English and the search time was through May 2022. Where feasible, random-effects models were used to generate pooled estimates.

RESULTS

After screening electronic databases and other resources, 48 studies from 6,234 citations were included in this meta-analysis. The period prevalence of epilepsy ranged from 1% to 6% in patients with depression. In population-based settings, the pooled period prevalence of depression in patients with epilepsy was 27% (95% CI, 23-31) and 34% in clinical settings (95% CI, 30-39). Twenty studies reported that seizure frequency, low income, unemployment of the patients, perception of stigma, anxiety, being female, unmarried status, disease course, worse quality of life, higher disability scores, and focal-impaired awareness seizures were risk factors for depression.

CONCLUSION

Our study found that epilepsy was associated with an increased risk of depression. Depression was associated with the severity of epilepsy.

Psychiatric adverse events in three phase III trials of eslicarbazepine acetate for focal seizures

OBJECTIVE

Eslicarbazepine acetate (ESL) is a once-daily (QD), oral anti-seizure medication for the treatment of focal (partial-onset) seizures. Here, we evaluate risk factors for the development of psychiatric treatment-emergent adverse events (TEAEs) in clinical trials of adjunctive ESL in adults with focal seizures.

METHODS

This post-hoc analysis evaluated data pooled from three Phase III, randomized, double-blind, placebo-controlled trials (BIA-2093-301, -302, -304). After an 8-week baseline period, patients were randomized equally to receive placebo, ESL 400 mg (not reported here), 800 mg, or 1200 mg QD (up to 2-week titration; 12-week maintenance; optional open-label extension [OLE]). Incidences of psychiatric TEAEs were evaluated according to three separate criteria: medical history of psychiatric disorders (yes/no); baseline use of psychotropic drugs (yes/no); Montgomery-Åsberg Depression Rating Scale (MADRS) score at baseline (0-6: normal; 7-19: mild depression; 20-34: moderate depression).

RESULTS

The analysis populations comprised 1251 patients for the controlled study period and 1137 patients for the 1-year OLE. Psychiatric TEAE incidence was similar between patients taking ESL and placebo in the controlled and OLE study periods and was not related to ESL dose. Psychiatric TEAEs generally occurred more frequently in patients with a medical history of psychiatric disorders, using psychotropic drugs, or with depressive symptoms than in those without a history, not using psychotropic drugs, or with no depressive symptoms. Depression and anxiety were the most frequently reported psychiatric TEAEs.

SIGNIFICANCE

Overall, in clinical trials of ESL in adults with focal seizures, incidences of psychiatric events were not statistically different between patients taking ESL and placebo, were not related to ESL dose, and generally occurred more frequently in patients with baseline psychiatric symptoms or a history of psychiatric disorders. Long-term exposure to ESL was not associated with a marked increase in the incidence of psychiatric TEAEs.

What are the mental health changes associated with the COVID-19 pandemic in people with medical conditions? An international survey

OBJECTIVES

The COVID-19 pandemic has negatively impacted mental health worldwide but there is paucity of knowledge regarding the level of change in mental health in people with a medical condition (physical/psychiatric). The objectives of this study were (1) to compare the change in mental health in people with and without medical conditions, (2) to assess the change in various types of medical conditions, (3) to evaluate the association between change in mental health and number of comorbidities, and (4) to investigate the influence of receiving treatment and activity limitation imposed by the medical condition(s).

DESIGN

Cross-sectional.

SETTING

Online international survey.

PARTICIPANT

English-speaking adults (age ≥18) were included in the study, with no exclusions based on sex/gender or location. 1276 participants (mean age 30.4, 77.7% female) were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Pre and during COVID-19 pandemic symptoms of anxiety (Generalized Anxiety Disorder-2) and depression (Patient Health Questionnaire-9) were assessed. The Self-Administered Comorbidity Questionnaire was used to collect data regarding medical conditions.Repeated-measures analysis of covariance (objectives 1, 2 and 4) and Pearson's correlation coefficient (objective 3).

RESULTS

50.1% of participants had a medical condition. During the COVID-19 pandemic, compared with people with no medical condition, people with both psychiatric and physical conditions experienced significantly higher symptoms of anxiety (12%, p=0.009) and depression (9.4%, p<0.001). Although not statistically significant, the increase in anxiety and depression occurred across seven major categories of conditions. An association was found between having a higher number of medical conditions with higher anxiety and depression symptoms (r=0.16 anxiety, r=0.14 depression, p<0.001). Receiving treatment and being functionally limited by the disease did not have a significant impact on the amount of change (p>0.05).

CONCLUSIONS

During the COVID-19 pandemic, people who had a combination of psychiatric and physical conditions experienced greater symptoms of anxiety and depression. Patients with chronic diseases may need extra support to address their mental health as a result of the pandemic.

Recent Synergy of Nanodiamonds: Role in Brain-Targeted Drug Delivery for the Management of Neurological Disorders

The aim of the present review article is to summarize the role of nanodiamonds in various neurological diseases. We have taken related literature of making this review article from ScienceDirect, springer, Research gate, PubMed, Sci-finder, etc. The current approaches for treating neurological conditions such as glioblastoma includes chemotherapy or combination anti-retro viral therapy for HIV (human immunodeficiency virus) or use of anti-Alzheimer drugs during cognitive impairment. These approaches can provide only symptomatic relief as they do not target the cause of the disease due to their inability to penetrate the blood brain barrier. On long-term use, they may cause CNS toxicity due to accumulation in the brain. So nanodiamonds could prove as a promising approach in the brain targeting of the bioactive and to treat many neurological disorders such as Alzheimer's disease, Parkinson's disease, brain tumor (glioblastoma), HIV, amyotrophic multiple sclerosis, Huntington disease, stroke (cerebrovascular attack), batten disease, schizophrenia, epilepsy, and bacterial infections (encephalitis, sepsis, and meningitis) due to their ability to penetrate the blood-brain barrier and owing to their excellent surface properties, i.e., nano size and high surface area, ease of functionalization, multiple drug binding, and biocompatibility; they can be useful for brain targeted drug delivery with minimal side effects.

Topiramate and other kainate receptor antagonists for depression: A systematic review of randomized controlled trials

BACKGROUND

Depression is a common disorder that affects patients' quality of life and incurs health system costs. Due to the resistance to treat depression, better understanding of neurophysiology was considered; one of the implications is the glutamatergic system. This study aims to systematically review clinical trials investigating the antidepressant effects of kainate receptor antagonists.

METHODS

The study protocol was registered in PROSPERO (CRD42021213912). Scopus, ISI, Embase, PubMed, Cochrane Library, Google Scholar, and two trial registries were searched for randomized controlled trials on the effectiveness of topiramate, phenobarbital, and other ten barbiturates in depression. The difference with control groups in terms of changing depressive symptoms was the primary outcome.

RESULTS

Nine trials were identified, in which 784 patients were studied. The efficacy of thiopental was comparable to that of imipramine, with fewer side effects. When administered with electroconvulsive therapy, it had fewer to similar effects and fewer side effects than ketamine. Both monotherapy and adjunctive therapy with topiramate were effective and tolerable in treating depressed patients. Phenobarbital had therapeutic effects compared to imipramine and amitriptyline with fewer side effects.

CONCLUSION

Regarding the glutamatergic hypothesis of depression and obtained promising results, further studies of kainate receptor antagonists in high-quality trials are recommended. Given the high prevalence of depression in epileptic patients, more problems with its treatment, and the fact that the studied agents were anticonvulsants, it is recommended that future studies prioritize depressed-epileptic patients.

Nano-Hydrogel for the Treatment of Depression and Epilepsy

This article first combines nano-carrier technology, the electrophysiological mechanism of seizures, and brain targeting technology to prepare new nano-hydrogels. Secondly, through the discharge information generated during the seizure and the electric field responsiveness of the nano-hydrogel, the free drug concentration in the brain area related to the seizure is increased, thereby, limiting the abnormal discharge of the focus to the local area and suppressing it in time. Finally, this article examines the impact of nano-hydrogel on the epilepsy and depression using relevant studies. The experimental observations revealed that the yield of the nano-hydrogel synthesized after 24 h of sapon-free emulsion polymerization was 50 to 70%, the swelling rate was 400 to 1700%, and the viscosity of the 20 mg/mL nano-hydrogel dispersion was 3.9 to 17.0 mPa· s. Furthermore, because the total efficiency was 0.952, the nano-hydrogels have a reduced recurrence rate and a better effect on the depression improvement.

Effect of pharmaceutical care program on depression among women with epilepsy: A randomized controlled trial (IPHIWWE study)

Depression is the most frequent comorbidity of epilepsy, and they are both complex chronic diseases that affect health-related quality of life (HRQOL), especially in women. Pharmaceutical care may contribute significantly to the improvement of HRQOL in women with epilepsy (WWE), with the involvement of the pharmacist in the healthcare team treatments could be optimized and negative outcomes related to medication reduced. This was a randomized controlled trial involving WWE over 18 years of age. The intervention group (IG) received a Pharmaceutical care program consisting of medication review follow-up according to Dáder's method, health education, aids for adherence to treatment, registration of seizures and possible triggers, and therapeutic drug monitoring of anticonvulsants. The control group (CG) received the usual care in the institution. The impact in depression was assessed by changes in the Center for Epidemiologic Studies Depression (CES-D) scale, which was applied both at the first and the last interviews, six months later. One hundred eighty-two WWE entered the study and 144 (79.1%) completed it. At the beginning of the study, 48.95% showed signs of depression, decreasing to 30.43% for the patients in the IG (p-value = 0.0238), while for the patients in the CG it remained at 47.30% (p-value = 0.8693). The Wilcoxon test for comparing the change (Δ) (before-after) in the CES-D scores, between groups, yielded a w = 3138.5, p-value = 0.01802 proving there were statistically significant differences. The study proved that the application of a Pharmaceutical Care program significantly decreases signs of depression in WWE. These results allow us to recommend the implementation of the Pharmaceutical care programs to improve the depression in WWE. Trial registration: Current Controlled Trials ISRCTN46864306 IPHIWWE study.

Case Report: Vortioxetine in the Treatment of Depressive Symptoms in Patients With Epilepsy-Case Series

Epilepsy and depression are both serious and potentially disabling conditions which often coexist-bidirectional relationship between the two disorders has been observed. Comorbidity between depression and epilepsy can be attributed to: underlying common pathophysiological mechanisms, psychiatric side effect of antiepileptic medications and psychological response to stress in people with chronic, neurological condition. Despite high prevalence of depressive symptoms in patients with epilepsy, current evidence of the effectiveness of antidepressant therapy in this group of patients is very limited. Vortioxetine is an antidepressant with multimodal activity, very good treatment tolerability, low risk of inducing pharmacokinetic interactions, relative safety of treatment in patients with somatic comorbidities, low risk of causing: sedation, sexual dysfunctions and metabolic side effects. Vortioxetine seems to be a promising treatment option for depressed patients with cognitive dysfunctions, anhedonia and anxiety. In this case series, we report nine cases of patients with epilepsy and depressive symptoms treated with vortioxetine. Seven cases are patients with secondary focal and generalized epilepsy and two with unclassified epilepsy. Three patients presented with depressive episode in the course of bipolar disorder and six patients had depressive symptoms due to organic mood disorder. The dose range of vortioxetine was between 10 and 20 mg. In all of the presented cases effectiveness and tolerability of treatment were very good. Remission of depressive symptoms was achieved in all patients. No epilepsy seizures after switch to vortioxetine were observed in seven cases. In two patients seizures occurred during the first months of vortioxetine treatment but this most probably was due to suboptimal antiepileptic treatment-satisfactory seizure control was achieved after optimization of antiepileptic pharmacotherapy. Vortioxetine was discontinued in two of the presented cases due to pregnancy planning. The duration of observation period during vortioxetine therapy ranged from 2 to 48 months. In conclusion, vortioxetine can be a promising treatment option in patients with epilepsy and comorbid depressive symptoms.

Prevalence and determinants of depression in patients with epilepsy during the COVID-19 pandemic

Background

Epilepsy is one of the commonest and most serious neurological conditions. It is frequently associated with one or more medical or psychiatric comorbidities. Depression is one of the most common comorbidities. Patients with epilepsy (PWE) are expected to suffer from a high level of depression during the COVID-19 pandemic. This cross-sectional study was applied to 290 PWE. Data was collected by personal interviews with each patient using the Patient Health Questionnaire 9 (PHQ 9) scale for the diagnosis of depression and assessing its severity. We aimed to assess the prevalence and the risk factors of depression in PWE during the COVID-19 pandemic.

Results

We found that 70.3% of PWE suffered from depression. Low financial status, refractory seizures, fear of infection and death by COVID-19, had close relatives died by COVID-19, had a sleep disturbance, a decreased family support, increased seizure rate during the pandemic, increased ER visits during the pandemic, lack of drug adherence, and decreased epilepsy-related follow-up visits during the pandemic were significantly associated with increased risk of depression in PWE during the pandemic.

Conclusions

The COVID-19 pandemic has a serious effect on the psychological and physical well-being of PWE. There was an increased rate of depression during the COVID-19 pandemic in PWE with its subsequent burden on those patients. So, these patients are in a high need of care and support during the pandemic.

Epileptic disorders in Becker and Duchenne muscular dystrophies: a systematic review and meta-analysis

Dystrophin alterations in the brain have been associated with an increased risk of epilepsy in Becker and Duchenne muscular dystrophies (BMD and DMD). Moreover, an association between the mutation site and the risk of epilepsy is not ruled out. The aim of this systematic review and meta-analysis was to estimate the prevalence of epilepsy in BMD and DMD populations and to establish a possible association between the site of mutation in the dystrophin gene and the risk of epilepsy. Systematic searches of Medline, Scopus, Web of Science, and Cochrane Library were conducted to identify relevant studies published from inception to January 2022. Observational studies of participants with BMD/DMD estimating the prevalence of epilepsy were included. The main outcome was the prevalence of epilepsy, and the secondary outcome was the prevalence ratio considering genotype. A random effects meta-analysis was performed for the prevalence of epilepsy. Eight studies were included in the systematic review and meta-analysis. The prevalence of epilepsy was 7% (95% CI 3-11%) in BMD, 5% (95% CI 2-8%) in DMD, and 5% (95% CI 3-7%) in the overall estimate. No association was observed between mutation site and the prevalence of epilepsy. BMD/DMD is strongly associated with the prevalence of epilepsy, with a higher prevalence in BMD/DMD populations than in the general population, probably owing to alterations in Dp427. The current evidence does not support the hypothesis that Dp140 or Dp71 affect epilepsy risk.

Social Isolation and Associated Factors in Chinese Adults With Epilepsy: A Cross-Sectional Study

Objective: We aimed to determine the prevalence of social isolation and associated factors among adults with epilepsy in northeast China. Methods: A cohort of consecutive patients with epilepsy (PWE) from the First Hospital of Jilin University (Changchun, China) was recruited. Demographic and clinical data for each patient were collected during a face-to-face interview. Social isolation was measured using the Berkman-Syme Social Network Index (SNI), and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Quality of Life in Epilepsy Inventory (QOLIE-31) were also administered. Multivariate logistic regression analyses were used to determine the factors associated with social isolation in PWE. Results: A total of 165 patients were included in the final analysis. The mean SNI score was 2.56 (SD: 1.19), and 35 patients (21.2%) were socially isolated. In multivariate logistic regression analysis, higher depressive symptom levels (OR = 1.15, 95% CI: 1.003-1.318, P = 0.045) and poorer quality of life (OR = 0.967, 95% CI: 0.935-0.999, P = 0.047) emerged as independent factors associated with social isolation in PWE. Conclusion: Social isolation is common and occurs in approximately one-fifth of PWE. Social isolation is significantly associated with depressive symptoms and poor quality of life in PWE. Patients need to be encouraged to actively integrate with others and reduce social isolation, which may help improve their quality of life.

Perceived stigma, discrimination and psychological problems among patients with epilepsy

OBJECTIVE

The current study sought to investigate the effects of perceived stigma and discrimination on epilepsy patients' psychological problems, such as depression, anxiety, and quality of life.

STUDY DESIGN

A purposive sampling technique was used in this cross-sectional study.

MATERIALS AND METHODS

The sample consisted of 186 patients with epilepsy. The Stigma Scale, Depression Anxiety Stress Scale, and Quality of life in Epilepsy-10 were used to measure the study variables.

RESULTS

Findings showed that both the perception of stigma and discrimination have a significant positive correlation with depression as well as anxiety. Stigma is a significant positive predictor of depression and anxiety at [F (1, 184) = 27.8, 15.92, p < 0.001, 0.001, respectively] and explains 12.7 and 7.5% variance that could be attributed to Stigma. Stigma is also a significant predictor of quality of life at [F (1, 184) = 16.10, p < 0.001] and explains the 7.5% variance that could be attributed to Stigma. Results also indicate that discrimination is a significant positive predictor of depression and anxiety at [F (1, 184) = 32.39, 19.91, p < 0.001] and explains 15 and 9.8 % variance, respectively, that could be attributed to Stigma. However, stigma negatively predicts quality of life at [F (1, 184) = 20.34, p < 0.001] and explains 10 % variance. Non-significant differences were found in all the demographic variables (i.e., gender, socio-economic status, and disease duration), except the quality of life was significantly high among individuals with high Socio-economic status.

CONCLUSIONS

Stigma is significantly higher in epileptic patients and has a detrimental effect on the patient's quality of life, recovery, and prognosis. Thus, there is undoubtedly a need to address psychological issues, most notably the stigma associated with illnesses. Psychologists, psychiatrists, other physicians, and care givers of epileptic patients must pay close attention to the stigma in this patient population.

Evaluation of knowledge levels and attitudes of health management department students about epilepsy disease; a cross-sectional study

AIM

We aimed to evaluate the knowledge levels and attitudes of the students of the Department of Health Management about epilepsy.

METHOD

This descriptive and cross-sectional study was conducted with the voluntary participation of 238 health management department students in their first and third years of study who were registered at the Faculty of Health Sciences summer school exam. We collected the data through a research questionnaire form and the Epilepsy Knowledge and Attitude Scales.

RESULTS

Girls accounted for 66.6% (n = 157) all participants, 53.4% of them were 1st year (n = 127), whereas 46.6% (n = 111) were third-year students. Their mean age was 19.97 ± 1.46 years. Among these participants, 52.9% grew in the province (n = 126), 20.6% were smoking, 5% had epilepsy, and 36.6% had relatives with epilepsy. The mean epilepsy knowledge scale score was 5.64 ± 4.41 and the mean epilepsy attitude scale score was 52.55 ± 9.98. The third-year students' epilepsy knowledge score was significantly higher than their first-year counter parts (p < 0.001). We found no statistically significant difference between the first and third-year participants in attitude scores (p = 0.907). A moderate positive correlation was found between the students' knowledge level scores about epilepsy and their total attitude scores (r = 0.405, p < 0.001). The female students had a more positive attitude toward epilepsy and higher scores on the epilepsy knowledge scale than their male counterparts (p = 0.001, p = 0.005, respectively). Students who knew someone with epilepsy had higher epilepsy knowledge and attitude scale scores than those who did not (p = 0.001, p = 0.005 respectively).

CONCLUSION

The epilepsy knowledge levels and attitude scale scores of health management students were found to be low. Third-year students were found to have higher knowledge levels than first-year students but there was no statistically significant difference between their attitude scores. More education opportunities should be provided for students of the Department of Health Management about this common chronic disease.

Point prevalence of depression in persons with active epilepsy and impact of methodological moderators: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to determine the pooled prevalence of depression in persons with epilepsy and assess the methodological moderators affecting the prevalence estimates.

METHODS

Five electronic databases PubMed, The Cochrane Library, EMBASE, WHO Global Index Medicus, and Clinicaltrial.gov were searched for studies reporting prevalence of depression in PWE ≥ 18 years of age in any setting.

RESULTS

Out of 13,873 studies, after deduplication and screening, 56 studies with 10,527 PWE met the eligibility criteria. The overall pooled prevalence of depression in PWE was 32% (95%confidence interval [CI] 28-35%) and significant heterogeneity (Chi-square = 1171.53, p = 0.00; τ² = 0.02; I² = 94.36%). Prevalence has doubled in the recent years (16% in 2000-2005 vs. 35% in 2016-2020), was higher in Asia than in Europe (coefficient 0.899, 95%CI: 0.809-0.999; p = 0.049). Among assessment methods, prevalence was highest in HAM-D scale (54%, 95%CI: 27-82%) and lowest in MINI (22%, 95%CI: 19-26%). Sensitivity analysis also corroborated findings when MINI was excluded (35%, 95%CI: 31-38%).

CONCLUSIONS

A significant proportion of PWE have depression. Though there is substantial heterogeneity due to various methodological moderators, it is unlikely to affect the routine screening of PWE for depression. Use of a screening tool should be based on ease of administration, and cutoff selection should ensure identification of minimal depression as well.

Depression severity mediates the impact of perceived stigma on quality of life in patients with epilepsy

OBJECTIVE

To determine whether and the extent to which depression severity mediates the impact of perceived stigma on quality of life in patients with epilepsy (PWE).

METHODS

A consecutive cohort of 165 PWE was invited to participate in this study. Each participant completed the Kilifi Stigma Scale of Epilepsy (KSSE), Depression Inventory for Epilepsy (NDDI-E), and Quality of Life in Epilepsy Inventory (QOLIE-31). Mediation analysis was employed to assess whether depression severity mediates the relationship between perceived stigma and quality of life.

RESULTS

Perceived stigma was positively associated with depression severity and negatively associated with quality of life in PWE. The mediation analysis confirmed that perceived stigma had an indirect effect on the quality of life through the mediating variable of depression severity in PWE (B = -0.576, SE = 0.097, Bootstrap95% CI = -0.784 to -0.405). The indirect effects of perceived stigma on quality of life through depression severity accounted for 57.7% of the total effects of perceived stigma on quality of life.

CONCLUSION

This study provided evidence that depression severity mediates the impact that perceived stigma has on quality of life, indicating that assessment of and interventions targeting depression may be appropriate for PWE.

Response to sertraline and antiepileptic drugs in pentylenetetrazole kindling in rats

Anti-epileptic drugs (AEDs) are the mainstay of epilepsy treatment but these may be a potential risk factor for behavioral disturbances particularly depression which requires treatment. In this study, the effect of antidepressant sertraline (SRT) in combination with AEDs sodium valproate (SV) and levetiracetam (LEV) on seizures, cognitive impairment and oxidative stress in rats was evaluated. After administration of 24th injection of pentylenetetrazole (PTZ), 77.8% rats were kindled. Administration of SRT showed no protective effect on kindling development while SV was 100% protective. With LEV 42.9% were kindled. On combining SRT with SV or LEV 25% and 20% rats were kindled. A significant increase in latency to reach platform zone in Morris water maze(MWM), and increased transfer latencies in Elevated plus maze(EPM) was observed in PTZ kindled rats as compared to normal control on day 49 and when LEV was combined with SRT. In EPM test, however none of the drug treatments had any effect on transfer latencies except LEV pretreated kindled group. In Passive avoidance (PA) test, kindling was associated with a significant decrease in retention time(p = 0.018) while LEV and SV had no effect. The PTZ kindled rats showed significantly higher malondialdehyde(MDA) levels in brain hippocampus(p = 0.0286) while both SRT and SV were associated with significantly lower MDA levels as compared to kindled control group. In case of glutathione (GSH), kindling had no significant effect. The use of sertraline for depression in persons with epilepsy on AEDs needs to be carefully evaluated and monitored due to likelihood of individual variation.

Exploring the mechanisms of action of the antidepressant effect of the ketogenic diet

The ketogenic diet (KD) is characterized by a diet ratio of 4:1 fat to non-fat energy sources. For decades KD has been successfully used to control seizures in epilepsy patients. Investigations into its mechanism of action suggest that it may have an effect on the metabolic, nervous, immune, and digestive systems. In this review, we postulate that KD may also improve depressive symptoms - for that, we highlight the similarities between depression and epilepsy, describe the extent to which body systems involved in both conditions are affected by the KD, and ultimately hypothesize how KD could improve MDD outcomes. Research into animal models and human patients have reported that KD can increase mitochondrial biogenesis and increase cellular resistance to oxidative stress both at the mitochondrial and genetic levels. Its effect on neurotransmitters alters cell-to-cell communication in the brain and may decrease hyperexcitability by increasing Gamma Aminobutyric Acid (GABA) and decreasing excitatory neurotransmitter levels. Its anti-inflammatory effects are mediated by decreasing chemo- and cytokine levels, including TNF-alpha and IL-1 levels. Finally, KD can alter gut microbiota (GM). Certain strains of microbiota predominate in major depressive disorder (MDD) when compared to healthy individuals. Recent evidence points to Bacteroidetes as a potential treatment predictor as it seems to increase in KD treatment responders for epilepsy. Each of these observations contributes to the presumed modulatory effects of KD on mood and supports its potential role as antidepressant.

Prevalence of depression and suicidal ideation in persons with epilepsy during the COVID-19 pandemic: A longitudinal study from India

OBJECTIVES

COVID-19 pandemic has disrupted healthcare services for chronic disorders such as epilepsy. In this study, the impact of COVID-19 pandemic on persons with epilepsy (PWE) with regard to their seizure control, depression status, and medication adherence was assessed.

METHODS

After ethical clearance, 449 PWE who had been previously evaluated for depression at All India Institute of Medical Sciences (AIIMS), New Delhi, India, were telephonically revaluated using Mini International Neuropsychiatric Interview and surveyed for source of medication and medication adherence over past 6 months. The prevalence and the association of depression, suicidality, and seizures during pandemic with different PWE variables were determined.

RESULTS

Out of 449 PWE, 70.6% responded. 19.9% were diagnosed positive for depression as per MINI while suicidal ideation was observed in 5.4%. Seventy six (23.9%) PWE reported seizures during pandemic. The incidence was greater in females, unemployed, previously uncontrolled epilepsy, polytherapy, altered use of medications, and depressed PWE. Seizure during pandemic, increased seizure frequency, previous history of depression, and altered use of medications were all significantly associated with depression during COVID-19 pandemic (2.6-95%CI, 1.45-4.73; 1.9-95%CI, 1.01-3.57; 8.8-95%CI, 4.54-17.21; 2.9-95%CI, 1.19-7.24), and polytherapy (2.9-95%CI, 0.92-9.04), seizures during pandemic (3.9-95%CI, 1.45-10.53) and previous history of depression and suicidality, were related with suicidal ideation.

CONCLUSION

COVID-19 pandemic-induced disruptions can be detrimental for PWE, and restoring services to the precovid levels as well as putting appropriate continuity plans in place for care of PWE should be a priority.

Depressive symptoms in patients with epilepsy and clinically associated features in a single tertiary center

Although depressive symptoms are the most common psychiatric comorbidity in epilepsy, they remain underestimated and untreated in a large proportion of patients. The purpose of this study was to evaluate depression severity and related clinical features in people with epilepsy using a well-reliable self-report index of mood, the Beck Depression Inventory-II (BDI-II). One-hundred seventeen adult patients with epilepsy were recruited from a tertiary epilepsy center and completed the BDI-II. A single-item analysis of the 21 questions of the BDI-II was computed and differences between women and men in each depressive symptom were evaluated. Correlation and regression analyses were used to identify clinical features associated with the severity of depression. Results showed gender differences in some items, with women reporting overall higher depression severity than men. The most common symptoms regarded domains of sleeping patterns, tiredness, and loss of energy. Regression evidence suggested that being female, having an epilepsy duration < 10 years, as well as being treated with psychotropic drugs and reporting generalized seizure, were associated with higher depression severity. Despite its cross-sectional nature, this study reinforces the importance of investigating and possibly treating depressive symptoms in adult patients with epilepsy, since they negatively impact well-being, daytime activities, and sleep. Further studies identifying pharmacological and non-pharmacological treatments for depression in epilepsy need to be planned.

Low-dose clozapine-related seizure: A case report and literature review

BACKGROUND

Treatment-resistant schizophrenia is a severe form of schizophrenia characterized by poor response to at least two antipsychotic drugs and is typically treated with clozapine. However, clozapine lowers the epileptic threshold, leading to seizures, which are severe side effects of antipsychotics that result in multiple complications. Clozapine-related seizures are generally considered to be dose-dependent and especially rare in the low-dose (150-300 mg/d) clozapine treated population. Due to clinical rarity, little is known about its clinical characteristics and treatment.

CASE SUMMARY

A 62-year-old Chinese man with a 40-year history of treatment-resistant schizophrenia presented to the Emergency Department with symptoms of myoclonus, consciousness disturbance and vomiting after taking 125 mg clozapine. Upon admission, the patient had a suddenly generalized tonic-clonic seizure lasting for about half a minute with persistent disturbance of consciousness, fever, cough and bloody sputum, which was considered to be low-dose clozapine-related seizure. After antiepileptic and multiple anti-infection treatments, the patient was discharged without epileptic or psychotic symptoms.

CONCLUSION

Our aim is to highlight the early prevention and optimal treatment of clozapine-related seizure through case analysis and literature review.

Stress-Associated Molecular and Cellular Hippocampal Mechanisms Common for Epilepsy and Comorbid Depressive Disorders

The review discusses molecular and cellular mechanisms common to the temporal lobe epileptogenesis/epilepsy and depressive disorders. Comorbid temporal lobe epilepsy and depression are associated with dysfunction of the hypothalamic-pituitary-adrenocortical axis. Excessive glucocorticoids disrupt the function and impair the structure of the hippocampus, a brain region key to learning, memory, and emotions. Selective vulnerability of the hippocampus to stress, mediated by the reception of glucocorticoid hormones secreted during stress, is the price of the high functional plasticity and pleiotropy of this limbic structure. Common molecular and cellular mechanisms include the dysfunction of glucocorticoid receptors, neurotransmitters, and neurotrophic factors, development of neuroinflammation, leading to neurodegeneration and loss of hippocampal neurons, as well as disturbances in neurogenesis in the subgranular neurogenic niche and formation of aberrant neural networks. These glucocorticoid-dependent processes underlie altered stress response and the development of chronic stress-induced comorbid pathologies, in particular, temporal lobe epilepsy and depressive disorders.

Therapeutic Targets for the Treatment of Comorbidities Associated with Epilepsy

One of the most common neurological disorders, which occurs among 1% of the population worldwide, is epilepsy. Therapeutic failure is common with epilepsy and nearly about 30% of patients fall in this category. Seizure suppression should not be the only goal while treating epilepsy but associated comorbidities, which can further worsen the condition, should also be considered. Treatment of such comorbidities such as depression, anxiety, cognition, attention deficit hyperactivity disorder and, various other disorders which co-exist with epilepsy or are caused due to epilepsy should also be treated. Novel targets or the existing targets are needed to be explored for the dual mechanism which can suppress both the disease and the comorbidity. New therapeutic targets such as IDO, nNOS, PAR1, NF-κb are being explored for their role in epilepsy and various comorbidities. This review explores recent therapeutic targets for the treatment of comorbidities associated with epilepsy.

Relationships among illness representations and depressive symptom severity in predominantly African-American and Caribbean-American people with epilepsy

Objective: Depression is the most common psychiatric comorbidity among people with epilepsy (PWE) and tends to be more prevalent among people of color (POC) and those with intractable seizures. However, the extent to which illness-related perceptions are associated with depressive symptom severity among POC with intractable seizures is unclear. Method: This cross-sectional study examined relationships among illness representations and self-rated depressive symptoms in 55 PWE (M Age = 41; 61.8% female) with intractable seizures (M seizures per month = 2) who identified as Black/African-American (52.7%), Black/Caribbean-American (27.3%), and/or Hispanic/Latino (21.8%). Epilepsy-related illness perceptions were assessed with the Illness Perception Questionnaire-Revised and depression was measured via the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Results: Nearly half of the sample (41.8%) scored above the NDDI-E depression cut-off. PWE endorsing more severe depressive symptoms indicated that their epilepsy had more negative consequences, was hard to comprehend, was insufficiently controlled by treatment, and had a negative emotional impact (p's ≤ 0.02). Controlling for sex, these four illness representations accounted for 48% of the variance in depression severity. Interestingly, participants with probable major depressive episodes were more likely to endorse several psychological causes of seizures compared to non-depressed PWE. Conclusions: Worse depression symptom severity was associated with negative illness perceptions and a tendency to attribute one's epilepsy to psychological causes. Future research is needed to understand how the relationship between negative illness perceptions and depression symptoms unfold over time and whether interventions aimed at modifying illness representations reduce psychological distress in diverse PWE.

Impact of Stress on Epilepsy: Focus on Neuroinflammation-A Mini Review

Epilepsy, one of the most common neurological disorders worldwide, is characterized by recurrent seizures and subsequent brain damage. Despite strong evidence supporting a deleterious impact on seizure occurrence and outcome severity, stress is an overlooked component in people with epilepsy. With regard to stressor duration and timing, acute stress can be protective in epileptogenesis, while chronic stress often promotes seizure occurrence in epilepsy patients. Preclinical research suggests that chronic stress promotes neuroinflammation and leads to a depressive state. Depression is the most common psychiatric comorbidity in people with epilepsy, resulting in a poor quality of life. Here, we summarize studies investigating acute and chronic stress as a seizure trigger and an important factor that worsens epilepsy outcomes and psychiatric comorbidities. Mechanistic insight into the impact of stress on epilepsy may create a window of opportunity for future interventions targeting neuroinflammation-related disorders.

How Antidepressant Drugs Affect the Antielectroshock Action of Antiseizure Drugs in Mice: A Critical Review

Depression coexists with epilepsy, worsening its course. Treatment of the two diseases enables the possibility of interactions between antidepressant and antiepileptic drugs. The aim of this review was to analyze such interactions in one animal seizure model-the maximal electroshock (MES) in mice. Although numerous antidepressants showed an anticonvulsant action, mianserin exhibited a proconvulsant effect against electroconvulsions. In most cases, antidepressants potentiated or remained ineffective in relation to the antielectroshock action of classical antiepileptic drugs. However, mianserin and trazodone reduced the action of valproate, phenytoin, and carbamazepine against the MES test. Antiseizure drug effects were potentiated by all groups of antidepressants independently of their mechanisms of action. Therefore, other factors, including brain-derived neurotrophic factor (BDNF) and glial-derived neurotrophic factor (GDNF) modulation, should be considered as the background for the effect of drug combinations.

Sex differences in anxiety in patients with epilepsy: Status and risk factors analysis

OBJECTIVES

Evidence has indicated that there may be sex differences in the prevalence of and risk factors for anxiety in patients with epilepsy (PWE). The prevalence and risk factors for anxiety in male and female PWE in Northeast China were investigated.

METHODS

A consecutive cohort of patients with epilepsy (PWE) from the First Hospital of Jilin University was recruited. Anxiety symptoms were assessed using the 7-item Generalized Anxiety Disorder-7 questionnaire (GAD-7; Chinese version). Multivariate logistic regression analyses were used to confirm independent risk factors for anxiety in male and female patients.

RESULTS

Anxiety was prevalent in 28.2% (n = 162) of the total sample of patients, in 23.2% (n = 79) of males, and in 35.5% (n = 83) of females. Younger age (P = 0.033), higher seizure frequency over the last year (P = 0.003), and higher C-NDDI-E scores (P = 0.001) were risk factors for anxiety in males with epilepsy. Only higher C-NDDI-E scores (P = 0.001) had an independent effect on the risk of anxiety in females with epilepsy.

CONCLUSION

Anxiety is a common psychiatric comorbidity among PWE. There were sex differences in the prevalence and risk factors for anxiety in patients.

A systematic literature review of recommendations for referral to specialty care for patients with epilepsy

OBJECTIVE

In epilepsy, patients who receive appropriate care receive treatment that differs substantially from those that do not. Given the need for a more detailed assessment of the role of specialty referral in the care of patients with epilepsy, this systematic literature review identified epilepsy care guidelines and recommendations that specifically address when and why people with epilepsy should be referred to specialty care.

METHODS

This study identified recent (in the last 10 years) publications that made best-practice recommendations for referring people with epilepsy to a neurologist or epileptologist. We searched six databases in December 2018: MEDLINE (PubMed), Cochrane Library, ProQuest, Web of Science, CINAHL (Ebsco), Scopus (Elsevier). Search terms included "Epilepsy" OR "Seizures," "Guideline" OR "Practice Parameter," and "Referral."

RESULTS

The 15 full-text articles identified included formal guidelines, summaries of these guidelines, or professional commentary that builds upon existing guidelines. Most of these publications came from the U.K and its National Institute for Health and Care Excellence. Overall, the included recommendations for referral varied considerably both for new-onset and refractory epilepsy. Although these recommendations were not consistent, it is reasonable to refer patients following the failure of 2 anti-seizure medication (ASM) trials.

SIGNIFICANCE

Guidelines and informal recommendations are not consistent regarding best practices for specialty care referral for patients with epilepsy. These guidelines and recommendations should consider the context of care in real-world settings and suggest pragmatic approaches that optimize seizure control and functioning.

Depression in persons with epilepsy: A comparative study of different tools in Indian population

OBJECTIVE

Depression is an important co-morbidity in persons with epilepsy (PWE) and its timely identification is essential. The aim of the study was to assess and compare the psychometric properties of potentially suitable screening tools of depression in PWE in a tertiary care setting in India.

METHODS

After ethical clearance, 449 PWE above 18 years of age, on anti-seizure drugs (ASDs), attending epilepsy clinic in neurology outpatient department (OPD) of All India Institute of Medical Sciences, New Delhi, India, were recruited and evaluated for depression using different tools namely: Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), Patient Health Questionnaire (PHQ-9) and Hamilton Depression Rating Scale (HAM-D). Mini International Neuropsychiatric Interview (MINI: Module A, version 6.0.0) was used as reference standard. The association if any of depression with PWE variables was also determined.

RESULTS

A variable percentage of PWE were positive for depression- 40.1% with MINI, 40.5% with NDDI-E, 44.3% with HAM-D and 45.4% with PHQ-9. Suicidal ideation was present in 4.5% of PWE. The sensitivity and specificity of scales using MINI as a reference standard were found to be maximal at scores ≥5, ≥8 and >11 for PHQ-9, HAM-D, and NDDI-E, respectively. The ROC analysis revealed a statistically significant difference among NDDI-E and PHQ-9 (p = 0.0268). Polytherapy in PWE had significant association with risk of depression (p < 0.01) and female PWE had 1.5 times the odds of depression as compared with males (95% CI, 1.02-2.2).

CONCLUSION

All the tools used in this study were found to be appropriate for use in PWE if cut-off points are validated. The choice of tool can be based on the clinical setting.

Predicting mood decline following temporal lobe epilepsy surgery in adults

OBJECTIVE

To develop a model to predict the probability of mood decline in adults following temporal lobe resection for the treatment of pharmacoresistant epilepsy.

METHODS

Variable selection was performed on 492 patients from the Cleveland Clinic using best subsets regression. After completing variable selection, a subset of variables was requested from four epilepsy surgery centers across North America (n = 100). All data were combined to develop a final model to predict postoperative mood decline (N = 592). Internal validation with bootstrap resampling was performed. A clinically significant increase in depressive symptoms was defined as a 15% increase in Beck Depression Inventory-Second Edition score and a postoperative raw score > 11.

RESULTS

Fourteen percent of patients in the Cleveland Clinic cohort and 22% of patients in the external cohort experienced clinically significant increases in depressive symptoms following surgery. The final prediction model included six predictor variables: psychiatric history, resection side, relationship status, verbal fluency score, age at preoperative testing, and presence/absence of malformation of cortical development on magnetic resonance imaging. The model had an optimism-adjusted c-statistic of .70 and good calibration, with slight probability overestimation in higher risk patients.

SIGNIFICANCE

Clinicians can utilize our nomogram via a paper tool or online calculator to estimate the risk of postoperative mood decline for individual patients prior to temporal lobe epilepsy surgery.

Evaluation of reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E)

INTRODUCTION

Major depression is common among people with epilepsy (PWE), but it is underdiagnosed. The aim of the present study was to assess the reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E) as a screening tool for major depression in patients with epilepsy.

METHOD

A total of 210 patients suffering from epilepsy have been assessed using the NDDI-E and the Beck Depression Inventory-II (BDI-II) with no difficulty in understanding or answering the Persian version of the questionnaire. Patients identified as depressed under BDI-II underwent a psychiatric evaluation to confirm depression according to 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) criteria.

RESULT

According to the BDI-II and the ICD-10 criteria, major depression was diagnosed in 75 patients (32% men, 68% women). Cronbach's α coefficient was 0.826, suggesting a very good internal consistency. The receiver operating characteristic analysis showed an area under the curve of 0.90 (95% confidence interval [CI] = 0.86-0.94, standard error [SE]: 0.02, p < 0.001). A cutoff of ≥14 resulted in an 83% sensitivity, an 80% specificity, a 70.1% positive predictive value, and an 88.6% negative predictive value. A significant and positive correlation between the P-NDDI-E and the BDI-II was shown (Spearman's ρ = 0.604, p < 0.001).

DISCUSSION

The P-NDDI-E could be used as a reliable and valid instrument in detecting major depression in PWE.

Non-clinical toxicity of (+)-limonene epoxide and its physio-pharmacological properties on neurological disorders

The compound (+)-limonene epoxide has antioxidant, anxiolytic, and antihelminthic properties. However, investigations to determine its long-term exposure were not performed. We investigated the systemic toxicological profile after chronic exposure as well as the antidepressant and antiepileptic potentialities of (+)-limonene epoxide on mice. Initially, we evaluated acute toxicity on Artemia salina nauplii and cytotoxicity on mice erythrocytes and peripheral blood mononuclear cells (PBMC). Aftterwards, mice were chronically treated for 120 days by gavage with (+)-limonene epoxide (25, 50, and 75 mg/kg/day) and this exposure was assessed by pathophysiological measurements. For antidepressant and anticonvulsivant analysis, we performed the forced swimming and tail suspension protocols and pentylenetetrazol- and picrotoxin-induced seizures, respectively. (+)-Limonene epoxide showed a LC50 value of 318.7 μg/mL on A. salina shrimps, caused lysis of red blood cells at higher concentrations only but did not show cytotoxicity on PMBC, which suggests pharmacological safety if plasma concentrations do not exceed 100 μg/mL. Macroscopic, hematological, clinical chemistry, and nutritional changes were not detected, though focal areas of hepatic necrosis, inflammatory infiltrate, and karyolysis have been detected at 75 mg/kg/day. The compound inhibited the developing of pentylenetetrazol- and picrotoxin-induced seizures, decreased deaths, and reduced immobility times, mainly at 75 mg/kg. So, it reversed reserpine effects, suggesting antidepressant effects should be linked to serotonergic and/or adrenergic transmission. It is feasible that (+)-limonene epoxide plays a benzodiazepine-like anticonvulsive action and may be also recommended as an antidote for poisonings caused by central depressants.

Pharmacogenomic Biomarkers and Their Applications in Psychiatry

Realizing the promise of precision medicine in psychiatry is a laudable and beneficial endeavor, since it should markedly reduce morbidity and mortality and, in effect, alleviate the economic and social burden of psychiatric disorders. This review aims to summarize important issues on pharmacogenomics in psychiatry that have laid the foundation towards personalized pharmacotherapy and, in a broader sense, precision medicine. We present major pharmacogenomic biomarkers and their applications in a variety of psychiatric disorders, such as depression, attention-deficit/hyperactivity disorder (ADHD), narcolepsy, schizophrenia, and bipolar disorder. In addition, we extend the scope into epilepsy, since antiepileptic drugs are widely used to treat psychiatric disorders, although epilepsy is conventionally considered to be a neurological disorder.

Synthesis of ring-opened derivatives of triazole-containing quinolinones and their antidepressant and anticonvulsant activities

Based on the potent antidepressant and anticonvulsant activities of the triazole-containing quinolinones reported in our previous work, a series of ring-opened derivatives of them were designed, synthesized in this work. Their antidepressant and anticonvulsant activities were screened using the forced swimming test (FST) and the maximal electroshock seizure test (MES), respectively. The results showed that compounds 4a, 5a, 6c-6e, 6g-6i, and 7 led to significant reductions in the accumulated immobility time in the FST at a dose of 50 mg/kg. Especially compound 7 exhibited higher levels of efficacy than the reference standard fluoxetine in the FST and the tail suspension test. The results of an open field test excluded the possibility of central nervous stimulation of 7, which further confirmed its antidepressant effect. Meanwhile, compounds 6a-6i and 7 showed different degrees of anticonvulsant activity in mice at the doses range from 300 to 30 mg/kg in the MES. Among them, compounds 6e and 7 displayed the ED₅₀ of 38.5 and 32.7 mg/kg in the MES, and TD₅₀ of 254.6 and 245.5 mg/kg, respectively. No one showed neurotoxicity at the dose of 100 mg/kg. The preliminary investigation forward to their mechanism indicated that regulation of GABAergic system might contribute to their anticonvulsive and anti-depressive action.

The P2X7 receptor in activated microglia promotes depression- and anxiety-like behaviors in lithium -pilocarpine induced epileptic rats

Depressive and anxious behaviors are the most common psychiatric symptoms of epilepsy, and may aggravate the epileptic condition and affect the patient's quality of life. Accumulating data obtained from both experimental animal models and patients have convincingly shown a critical role of P2X7 receptor (P2X7R) during depression and anxiety. Our study showed for the first time that the P2X7R is involved in promoting depression- and anxiety-like behaviors in lithium pilocarpine-induced epileptic rats. More importantly, direct anti-depressive and anti-anxiety effects were produced by the P2X7R antagonist Brilliant Blue G (BBG) is in this study, and the effect was similar to that of the classic anti-depressant and anti-anxiety drug fluoxetine. We also found that BBG did not affect the development of spontaneous recurrent seizures (SRS) and had a neuroprotective effect via inhibition of microglial activation after status epilepticus (SE). Thus, our data provide evidence that the P2X7R in activated microglia promotes depression- and anxiety-like behaviors in lithium-pilocarpine induced epileptic rats. Since previous studies have indicated that some anti-depression and anti-anxiety drugs may exacerbate seizures, our data support that the P2X7R is a promising therapeutic target for epilepsy associated with depression and anxiety.

Effects of a remotely delivered group-format epilepsy self-management program on adverse health outcomes in vulnerable people with epilepsy: A causal mediation analysis

BACKGROUND

People with epilepsy frequently experience negative health events (NHEs), such as emergency room visits or hospitalizations for epilepsy-related complications despite significant advances in care. We developed a novel remotely delivered group-format epilepsy self-management program ("Self-management for people with epilepsy and a history of negative health events"; SMART). In a 6-month randomized controlled trial (RCT), SMART participants had significant decreases in NHEs, as well changes in attitudes and behaviors compared to a wait-list (Sajatovic et al., 2018). This secondary analysis from the RCT characterizes the indirect causal effects of SMART on NHE improvements that may be mediated by specific improvements in self-management, self-efficacy, social support, quality of life, and depression symptom severity.

METHODS

Participants were adults with epilepsy and a NHE in the prior 6 months. There were 60 participants in each RCT arm (SMART versus wait-list) and assessments were conducted at baseline, 10 weeks and 24 weeks. The outcome was a binary variable measuring NHE improvement at week 24. A counterfactual-based mediation framework was used to determine whether improvements or changes in attitudes and behaviors at specific time points or across the study period, mediated the impact of SMART on NHE improvements.

RESULTS

At week 24, SMART contributed to significant improvements in NHEs compared to those in wait-list (odds ratio = 3.2, p = 0.015). SMART was significantly associated with improvements and changes in aspects of self-management, self-efficacy, quality of life, and depression symptom severity at week 10, and significant improvements between baseline and week 24 in overall self-management and quality of life. Mediation analyses demonstrated that a portion of the effect (∼20-30 %; p < 0.05) of SMART on NHE improvement was also indirectly mediated by early improvements in depression symptom severity and quality of life.

CONCLUSIONS

This mediation analysis of the SMART intervention demonstrates that in addition to its direct effect on improving NHEs in people with epilepsy, early improvements in depression symptom severity and quality of life indirectly mediated ∼20-30 % of the intervention's effect. These results demonstrate the promise of self-management approaches as a key component of an optimal healthcare model for people with epilepsy, particularly those with a recent history of NHEs.

Mood variations and personality traits in patients with epilepsy over the course of their menstrual cycle

INTRODUCTION

The incidence of mood disorders and psychopathology is more frequent in patients with epilepsy (PWE) than in the general population. Also, it has been reported that PWE suffer more seizures during certain phases of their menstrual cycle (MC). Still, limited information exists regarding the relationship between the physical and emotional changes during the MC in PWE. Therefore, in this study, we aimed to evaluate the mood and personality traits of PWE during their MC and to compare them with controls.

METHODS

A cohort of 22 PWE and nine controls was gathered. All the participants underwent psychiatric, electroencephalographic, and gynecological evaluations.

RESULTS

Overall, PWE scored higher in depression compared with controls (p < 0.05), PWE also obtained higher scores for the personality traits of neuroticism and self-isolation (p < 0.05). During the evaluation of the symptoms of premenstrual syndrome (PMS), PWE were more symptomatic during the early follicular (EF) phase in comparison with the rest of the phases of their MC, whereas the control group showed the known premenstrual pattern of symptoms during the late luteal (LL) phase. The frequency of seizures (40.6%) and electroencephalographic abnormalities (34.8%) was also higher during the EF phase of the MC when compared with the other phases of the MC (p < 0.05).

CONCLUSIONS

The results of this study suggest that unlike the PMS present in women without epilepsy, PWE appear to show a "menstrual syndrome" that consists of similar mood changes and physical symptoms. This arrangement of symptoms seems to have an impact on the increase in seizure activity.