Effect of levetiracetam on depression and anxiety in adult epileptic patients

Population pharmacokinetics of levetiracetam in Chinese adult epilepsy patients with varying renal function: exposure simulation and individualized dosing adjustments

Levetiracetam (LEV) has become a first-line treatment option for various types of epilepsy with a broad spectrum of efficacy and favorable pharmacokinetic profile. We aimed to develop a population pharmacokinetic (PPK) model for LEV and devise a model-based dosing guideline specific to Chinese adult epilepsy patients. Employing Phoenix NLME 7.0 software, we utilized the first-order conditional estimation and extended least squares method to establish the PPK model. The PK of LEV was effectively characterized using a one-compartment model. Monte Carlo simulations were then performed to generate dosing guidelines suitable for various patient groups. The Bayesian feedback method was employed to develop the clinical individual predictive model. Data from 80 Chinese adult patients yielded 148 LEV plasma concentrations for analysis. In the final model, the absorption rate constant was fixed at 2.44. The apparent volume of distribution and the apparent clearance (CL/F) had population typical values of 35.34 L and 3.24 L/h, respectively. CL/F of LEV was significantly influenced by creatinine clearance (CrCL), identified as a major covariate. Monte Carlo simulations indicated that regimens of 0.5 g, 0.75 g, 1.0 g, 1.5 g, 2.0 g, 2.5 g, and 3.5 g twice daily were associated with the highest probability of target attainment (PTA) in patients with different renal function levels. Accordingly, a user-friendly dose recommendation was formulated for these patients. The individual predictive model accurately matched the observed concentrations and managed to guide the personalized dose adjustment. The PPK model linked CL/F to CrCL. Model-based simulations suggest that higher dosage adjustments may be necessary for those with augmented renal function. The developed clinical individual predictive model could effectively guide personalized dose adjustments, potentially reducing the need for frequent drug concentration measurements.

Navigating the depths: A comprehensive narrative review on depression in people with epilepsy

Epilepsy presents a significant global health challenge, impacting millions worldwide. Alarmingly, over half of individuals living with epilepsy (PWE) also face concurrent medical conditions, with psychiatric complications, particularly depression, standing out as prevalent issues. The relationship between epilepsy and depression is complex and bidirectional, with approximately a quarter of adults with epilepsy receiving a diagnosis of depression. This complexity underscores the challenges in diagnosing depression in epilepsy patients, hindered by overlapping symptoms and distinct manifestations of depression in this population. Our review highlights that the use of most antidepressant pharmacotherapies does not increase the risk of seizure occurrences. On the contrary, compelling evidence suggests that such treatments may even decrease seizure frequency, offering hope for patients. In addition to pharmacology, non-pharmacological interventions are emerging as vital alternatives, enriching the therapeutic landscape. However, despite these promising avenues, a significant gap in our understanding persists, characterized by a lack of comprehensive, prospective research. Our review rigorously explores the latest pathophysiological insights linking depression and epilepsy while critically evaluating contemporary treatment paradigms for individuals grappling with these comorbid conditions. By focusing on the most current developments, this review aims to equip clinicians with cutting-edge knowledge, fostering a more nuanced and effective approach to managing the intricate interplay between epilepsy and comorbid depression.

The differential effect of levetiracetam on memory and anxiety in rats

OBJECTIVE

One of the newest antiseizure medication is levetiracetam (LEV). It might be effective in various indications, not only related to convulsions. Central nervous system disorders are common during anticonvulsant therapy. The aim of this study was to assess the effect of LEV on various types of memory and anxiety in rats.

METHODS

Adult male Wistar rats (n = 58) were given LV p.o. as a single (100 mg/kg or 500 mg/kg) or repeated doses (300 mg/kg). The effect of the drug on memory was assessed in the Morris water maze (MWM) (spatial memory), the passive avoidance (PA) (emotional memory) and the novel object recognition (NOR) (recognition memory). The anxiety was evaluated in the elevated plus maze (EPM).

RESULTS

LEV administered as repeated doses disturbed the long-term recognition memory in NOR and locomotor activity in EPM. A single dose affected emotional memory in PA. LEV did not alter spatial memory in MWM.

CONCLUSIONS

LEV may cause memory and locomotor disturbances, but some of these adverse effects seem to be temporary and limited to the effect of acute dose.

Symptoms of Depression and Anxiety in Adults with High-Grade Glioma: A Literature Review and Findings in a Group of Patients before Chemoradiotherapy and One Year Later

Simple Summary

High-grade glioma (HGG) is the most severe type of brain cancer. At different stages of the disease, affected persons are at high risk of symptoms of depression and anxiety. If undiagnosed and untreated, these symptoms might become severe and compromise the patient’s quality of life. Improved knowledge on the prevalence, mechanisms and clinical risk factors underlying the etiology of depression and anxiety in this population is required. This may help to increase awareness on the importance of integrating consistent assessment of mood symptoms with the clinical follow-up and provide insights for developing personalized psychosocial interventions.

Abstract

High-grade glioma (HGG) is associated with several external and internal stressors that may induce mood alterations at all stages of the disease. Symptoms of depression and anxiety in persons with glioma have multifactorial etiology and require active follow-up. We reviewed the literature data on the prevalence, mechanisms likely involved in the etiology of mood alterations in persons with HGG and psychosocial interventions found beneficial in treating these symptoms. We also investigated the prevalence and clinical variables that could increase the risk of depression and anxiety symptoms in a group of patients with HGG at two disease time-points: after surgery, before and 1 year after chemoradiotherapy. Literature findings revealed complex mechanisms underlying these symptoms and highlighted the importance of providing early access to palliative care. Our results show a high rate of anxiety and depression symptoms in the first stage of the disease and increased concomitance of these symptoms at the 1-year follow-up. Depression and anxiety symptoms at 1 year after the end of chemoradiotherapy were associated with the presence of symptoms at the first stage of the disease and tumor progression. Antiepileptic drugs and corticosteroid intake did not increase the risk of depressive and anxious symptoms among patients. Active management of mood alterations is an essential part of the care and contributes to patients’ well-being and quality of life.

Integration of postmortem amygdala expression profiling, GWAS, and functional cell culture assays: neuroticism-associated synaptic vesicle glycoprotein 2A (SV2A) gene is regulated by miR-133a and miR-218

Recent genome-wide studies have begun to identify gene variants, expression profiles, and regulators associated with neuroticism, anxiety disorders, and depression. We conducted a set of experimental cell culture studies of gene regulation by micro RNAs (miRNAs), based on genome-wide transcriptome, proteome, and miRNA expression data from twenty postmortem samples of lateral amygdala from donors with known neuroticism scores. Using Ingenuity Pathway Analysis and TargetScan, we identified a list of mRNA-protein-miRNA sets whose expression patterns were consistent with miRNA-based translational repression, as a function of trait anxiety. Here, we focused on one gene from that list, which is of particular translational significance in Psychiatry: synaptic vesicle glycoprotein 2A (SV2A) is the binding site of the anticonvulsant drug levetiracetam ((S)-α-Ethyl-2-oxo-1-pyrrolidineacetamide), which has shown promise in anxiety disorder treatments. We confirmed that SV2A is associated with neuroticism or anxiety using an original GWAS of a community cohort (N = 1,706), and cross-referencing a published GWAS of multiple cohorts (Ns ranging from 340,569 to 390,278). Postmortem amygdala expression profiling implicated three putative regulatory miRNAs to target SV2A: miR-133a, miR-138, and miR-218. Moving from association to experimental causal testing in cell culture, we used a luciferase assay to demonstrate that miR-133a and miR-218, but not miR-138, significantly decreased relative luciferase activity from the SV2A dual-luciferase construct. In human neuroblastoma cells, transfection with miR-133a and miR-218 reduced both endogenous SV2A mRNA and protein levels, confirming miRNA targeting of the SV2A gene. This study illustrates the utility of combining postmortem gene expression data with GWAS to guide experimental cell culture assays examining gene regulatory mechanisms that may contribute to complex human traits. Identifying specific molecular mechanisms of gene regulation may be useful for future clinical applications in anxiety disorders or other forms of psychopathology.

Gender Differences in Associated and Predictive Factors of Anxiety and Depression in People With Epilepsy

PURPOSE

Comorbid anxiety and depression in people with epilepsy (PWE) are highly prevalent and contribute to low quality of life (QOL) and may even lead to poor outcomes of epilepsy. Among the various factors that affect these negative emotional comorbidities, possible gender differences remain poorly understood and are often neglected. This research aimed to determine whether there are discrepancies in the incidence and influence factors of anxiety and depression between men and women with epilepsy in a hospital in northwest China.

METHODS

A total of 158 adult PWE (female: N = 65; 41.1%) completed self-report questionnaires, including the Self-rating Anxiety Scale (SAS), the Self-rating Depression Scale (SDS), the Chinese version of the Quality of Life in Epilepsy-31 (QOLIE-31) inventory and the Pittsburgh Sleep Quality Inventory (PSQI). The comparison between male and female PWE was made by regression analysis.

RESULTS

For the prevalence of anxiety and depression in PWE, no gender difference was found in this study. However, the moderating factors of psychiatric comorbidities were significantly different between men and women: male PWE with comorbid anxiety were more likely to be affected by sleep quality, while anxiety symptoms in female PWE were closely associated with the frequency of seizures. Education years and QOL social function were significant indicators of depression in male PWE but not in female PWE. The important and common predictor for anxiety and depressive symptoms in PWE was QOL energy/fatigue, with male patients being more affected.

CONCLUSION

For the PWE included in this study, the incidence of comorbid anxiety and depression in PWE was similar for men and women, but the moderating factors affecting comorbid anxiety and depressive disorders differed between genders: male PWE were more likely to be affected by psychosocial factors, while female PWE were more influenced by epilepsy itself. This exploration suggests that gender-specific health care should be considered in epilepsy therapy to improve the psychiatric condition and QOL of PWE, and different treatments should be conducted for male and female PWE to prevent negative emotional comorbidities.

Association between anxiety and clinical outcomes in Chinese patients with myocardial infarction in the absence of obstructive coronary artery disease

BACKGROUND

Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) accounts for approximately 5% - 6% of acute myocardial infarction (AMI) patients. Anxiety symptoms are common in patients with coronary artery disease (CAD), and are associated with a poor prognosis. However, the association between anxiety and MINOCA outcomes is less clear.

HYPOTHESIS

Anxiety will be associated with clinical outcomes in patients with MINOCA.

METHODS AND RESULTS

Between November 2014 and December 2016, 620 hospitalized patients with MINOCA were recruited from a single center. Within 7 days of coronary angiography, anxiety was assessed using the Zung Self-Rating Anxiety Scale. The primary endpoint was all-cause mortality; secondary endpoint was any major adverse cardiovascular event (MACE). After 3 years, 87 deaths and 151 MACE had occurred. Kaplan-Meier curves indicated the unadjusted rates of all-cause mortality (log-rank P = .045) and MACE (log-rank P = .023) were significantly higher in the anxiety group compared with the control group of patients without anxiety. Multivariate Cox regression analysis showed that clinically significant anxiety was an independent prognostic factor for all-cause mortality as well as MACE (hazard ratio [HR] = 1.547; 95% confidence interval [CI], 1.006-2.380; P = .047; HR = 1.460; 95% CI, 1.049-2.031; P = .025; respectively).

CONCLUSIONS

Anxiety is significantly and independently associated with an increased risk of all-cause mortality and MACE in patients with MINOCA.

Antiepileptic drug therapy in the elderly: a clinical pharmacological review

Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.

Associated and predictive factors of quality of life in patients with temporal lobe epilepsy

OBJECTIVE

Identifying the factors that are correlated with and predictive of reduced quality of life (QOL) is essential to optimize the treatment of epilepsy and the management of comorbidities.

METHODS

We analyzed the independent associations between the Quality of Life in Epilepsy-31 (QOLIE-31) inventory and the demographic, clinical, psychiatric, and cognitive variables of 47 consecutive patients with temporal lobe epilepsy (TLE). Predictors of the correlated variables were analyzed by multiple linear regression analysis.

RESULTS

The QOLIE-31 total score was positively correlated with occupational status and Mini-Mental State Examination (MMSE) scores (r = 0.290 and 0.295, respectively; P < 0.05) and negatively correlated with the duration of seizures, adverse effects of antiepileptic drugs (AEDs), and the Pittsburgh Sleep Quality Inventory (PSQI), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS) scores (r = -0.357, 0.321, 0.328, -0.672, and -0.565, respectively; P < 0.05; P < 0.01 for the SAS and SDS). In the final multivariate regression model, anxiety, long durations of seizures, adverse effects of AEDs, and depression explained approximately 60.6% (adjusted R² = 0.606, R coefficient = 0.800) of the QOLIE-31 overall score variance.

CONCLUSION

Anxiety, long durations of seizures, adverse effects of AEDs, and depression were significant predictors of QOL, and these variables had relatively high prediction capacities for the overall QOLIE-31 in the regression model. Comorbid anxiety is the most powerful negative determinant of the QOLIE-31.

Psychological features and quality of life in 50 adult patients with epilepsy and their caregivers from the Lecco epilepsy center, Italy

Epilepsy is one of the most common neurological disorders. To the best of our knowledge, in Italy, the relationship between patients' and caregivers' psychological state has rarely been analyzed. Thus, we sought to evaluate both the psychological state of patients with epilepsy and that of their caregivers and the interrelationship between them. We also assessed the existing relation between psychological features and some clinical and demographic information, such as number of antiepileptic drugs (AEDs), epilepsy duration and education level of patients and their caregivers. We enrolled in the study 50 consecutive adult patients attending the epilepsy clinic of "A. Manzoni" Hospital and their caregivers. Both patients and their caregivers were administered Hospital Anxiety and Depression Scale (HADS) and 36-item Short-Form Health Survey (SF-36). Anxiety, depression and quality of life values of both patients and their caregivers did not differ significantly from the normative samples. No statistically significant correlation between epilepsy duration and patients' and caregivers' psychological features was found. Patients which took more than one AED reported lower values of "Vitality" (p <.05) and "Social Functioning" (p <.05) than their own caregivers. Caregivers with higher education level presented lower "Vitality" values than caregivers with lower education level (p <.05). Patients with pharmacoresistant seizures reported lower values of "Mental Health" than patients with non-pharmacoresistant seizures (p <.05). In this context, the role of coping mechanisms by patients and caregivers may explain apparently unexpected findings and suggests that strategies aimed at reinforcing them may be effective in selected cases. Therefore, while the severity of epilepsy may have an impact on the psychological state of adult patients with epilepsy and their caregivers, our results highlight the role of multidimensional determinants, including stigma. Further studies are needed to identify the factors related to epilepsy, patients, caregivers, treatments, and the environment that may be modifiable in order to improve self-perceived QoL.

Targeted Self-Management of Epilepsy and Mental Illness for individuals with epilepsy and psychiatric comorbidity

OBJECTIVES

Serious mental illness is disproportionately common in people with epilepsy and contributes to complications and mortality. Few care approaches specifically target individuals who have epilepsy and severe mental illness. We used an iterative process to refine an existing intervention and tested the novel intervention, Targeted Self-Management for Epilepsy and Mental Illness (TIME) in individuals with epilepsy and comorbid mental illness (E-MI).

METHODS

The TIME intervention was developed with input from a community advisory board and then tested for feasibility, acceptability, and preliminary efficacy in people with E-MI, using a 16-week prospective, randomized controlled design comparing TIME (N=22) vs. treatment as usual (TAU, N=22). Primary outcome was change in depressive symptoms, assessed by the Montgomery Asberg Depression Rating Scale (MADRS). Secondary assessments included global psychiatric symptom severity, seizure frequency, sleep patterns, quality of life, stigma, social support, and self-efficacy.

RESULTS

There were 44 individuals enrolled, mean age 48.25 (SD=11.82) with 25 (56.8%) African-Americans. The majority (N=31, 70.5%) were unemployed, and most (N=41, 95.5%) had annual income <U.S. $25,000. With respect to study retention, there were 36 individuals (18 in TIME, 18 in TAU) assessed at 12weeks and 35 individuals (19 in TIME, 16 in TAU) assessed at 16weeks. There was a significant effect for MADRS (p=0.036; effect size of 0.70), with lower MADRS at 16weeks in TIME, while TAU MADRS did not change. Differences between most secondary measures were not statistically significant.

SIGNIFICANCE

The TIME intervention engages individuals to actively participate in self-management and can reduce depression in E-MI. Given the high morbidity and mortality associated with epilepsy complicated by serious mental illness, additional research is needed to better identify how TIME might be implemented in routine care settings.

Efficacy and safety of conversion to monotherapy with eslicarbazepine acetate in adults with uncontrolled partial-onset seizures: a randomized historical-control phase III study based in North America

Objective

To assess the efficacy and safety of eslicarbazepine acetate (ESL) as monotherapy in North American patients with partial‐onset seizures (POS).

Methods

This multicenter, randomized, double‐blind “withdrawal to monotherapy” study used historical control data as the comparator. Adults with POS medically uncontrolled by one to two antiepileptic drugs gradually converted to ESL monotherapy. Following an 8‐week baseline period, patients were randomized 2:1 to receive ESL 1,600 mg (n = 128) or 1,200 mg QD (n = 65) for 18 weeks. The primary end point was the proportion of patients meeting predefined exit criteria (signifying worsening seizure control). Treatment was considered effective if the 95% upper confidence limit (UCL) for the Kaplan‐Meier estimated exit rate was lower than the exit rate threshold calculated from the historical control (65.3%).

Results

Kaplan‐Meier estimated exit rates were: ESL 1,600 mg, 28.7% (95% CI 21.2–38.1%) and 1,200 mg, 44.4% (32.5–58.3%). The difference between doses was not significant (p = 0.07). For both doses, the 95% UCLs for the exit rate were ˂65.3%; ESL monotherapy was considered superior to the historical control. There was no statistically significant increase in the risk of study exit related to carbamazepine use. Nine (7.6%) and five patients (8.3%) remained seizure‐free during the 10‐week monotherapy period, while taking ESL 1,600 and 1,200 mg, respectively. The reductions in median standardized seizure frequency (seizures per 28 days) between baseline and the 18‐week treatment period were: ESL 1,600 mg, 42% and 1,200 mg, 31%. Treatment‐emergent adverse events (TEAEs) occurring in ≥10% of patients were dizziness, headache, fatigue, somnolence, nausea, and nasopharyngitis. The TEAE most frequently leading to discontinuation was hyponatremia (2.1%).

Significance

ESL was efficacious and well tolerated as monotherapy in North American patients, and led to a reduction in seizure frequency. Exit rates for ESL 1,600 and 1,200 mg QD were superior to the historical control; the difference in exit rates between doses was not statistically significant.

Apparent dose-dependent levetiracetam-induced de novo major depression with suicidal behavior

Levetiracetam (LEV) is a novel antiepileptic drug (AED) approved for the adjunctive treatment of generalized and partial seizures. LEV has no clinically significant drug interactions and has limited adverse effects. The psychiatric adverse effects of LEV include de novo psychosis, affective disorder, and aggression. LEV-induced suicidal behavior has been reported infrequently with a past history of affective disorders. The authors report an apparent dose/concentration-dependent LEV-induced de novo major depression with near fatal suicide attempt in a patient without prior history of affective disorder. Psychiatric evaluation with emphasis on historic/current affective disorders, impulsive-aggressive behaviors, and assessment of risk factors for suicidal behaviors is indicated in treating patients with epilepsy with LEV. Clinicians should consider therapeutic drug monitoring to optimize therapeutic LEV treatment.

Anxiety and adverse coronary artery disease outcomes in Chinese patients

OBJECTIVES

To investigate the impact of anxiety on the prognosis of coronary artery disease (CAD) in patients of Chinese Han ethnicity and to explore the correlation between anxiety and the severity of coronary atherosclerosis.

METHODS

Between June 2007 and May 2009, 1007 hospitalized patients with CAD diagnosed by coronary angiography were recruited. The anxiety symptoms were investigated within 2 days after coronary angiography or percutaneous coronary intervention, using the Zung Self-Rating Anxiety Scale. The severity of coronary atherosclerosis was assessed using the modified Gensini score. One and a half years after discharge, the participants were evaluated at the outpatient clinic or by telephone. The primary outcome was the composite of all-cause death and nonfatal myocardial infarction (MI).

RESULTS

A total of 917 (91.1%) patients were evaluated during a mean follow-up period of 17 months. Thirty-five deaths (26 of cardiovascular and 9 of other causes) and 5 nonfatal MIs occurred. The Zung Self-Rating Anxiety Scale score assessed during hospitalization was significantly and independently associated with the Gensini score (β = 1.35, p < .001). Adjusted Cox proportional hazards models showed that anxiety symptoms predicted all-cause death and nonfatal MI (adjusted hazard ratio = 2.43, 95% confidence interval = 1.24-4.75, p = .009).

CONCLUSIONS

Anxiety was independently associated with the severity of coronary atherosclerosis and predicted worse outcome in patients with CAD of Chinese Han ethnicity.

Psychosocial difficulties in people with epilepsy: a systematic review of literature from 2005 until 2010

The aims of this paper are to identify factors that influence the psychosocial difficulties (PSDs) that persons with epilepsy experience in their everyday life, to describe their onset and the way they evolve over time, and to analyze the determinants of changes over time and other related variables. Electronic databases were searched for studies published in English between January 2005 and May 2010, and information from thirteen studies was extracted. The most frequent PSDs found in people with epilepsy were depressive symptoms, memory functions, quality of life, anxiety, stigma, locus of control, cognitive functions in general, and emotional functions in general. It can be stated that patients' life areas are affected by cognitive, emotional, and psychological problems. However, the majority of studies focus on isolated PSDs or on the effects of a specific determinant in the course of epilepsy, leaving some gaps that could encourage further research.

Tsukamurella sp. E105 as a new biocatalyst for highly enantioselective hydrolysis of ethyl 2-(2-oxopyrrolidin-1-yl) butyrate

A new bacterial strain, E105, has been introduced as a biocatalyst for the enantioselective hydrolysis of ethyl (R,S)-2-(2-oxopyrrolidin-1-yl) butyrate, (R,S)-1, to (S)-2-(2-oxopyrrolidin-1-yl) butyric acid, (S)-2. This strain was isolated from 60 soil samples using (R,S)-1 as the sole carbon source. The isolate was identified as Tsukamurella tyrosinosolvens E105, based on its morphological characteristics, physiological tests, and 16S rDNA sequence analysis. The process of cell growth and hydrolase production for this strain was then investigated. The hydrolase activity reached its maximum after cultivation at 200 rpm and 30 °C for 36 h. Furthermore, the performance of the enantioselective hydrolysis of (R,S)-1 was studied. The optimal reaction temperature, initial pH, substrate concentration, and concentration of suspended cells were 30 °C, 6.8, 10 and 30 g/l (DCW), respectively. Under these conditions, a high conversion (>45 %) of the product (S)-2 with an excellent enantiomeric excess (ee) (>99 %), and a satisfied enantiomeric ratio (E) (>600) as well were obtained. This study showed that the bacterial isolate T. tyrosinosolvens E105 displayed a high enantioselectivity towards the hydrolysis of racemic ethyl 2-(2-oxopyrrolidin-1-yl) butyrate.

Beneficial and adverse psychotropic effects of antiepileptic drugs in patients with epilepsy: a summary of prevalence, underlying mechanisms and data limitations

Antiepileptic drugs (AEDs) can have both beneficial and adverse psychotropic effects. They act on neurotransmitter systems, neuronal ion permeability and other targets, although the exact mechanisms are not generally fully elucidated. A systematic review of the literature reveals evidence for both positive and negative effects on depression, anxiety, aggression, psychosis and sleep in patients with epilepsy. Topiramate, vigabatrin, levetiracetam, tiagabine and zonisamide have been associated primarily with adverse psychotropic effects, whilst gabapentin, pregabalin, lacosamide and lamotrigine, in particular, have demonstrated a more beneficial psychotropic profile, especially with regard to affective symptoms. This review, however, identifies specific methodological issues with studies that have reported on the psychotropic effects of AEDs, suggesting that some of the findings might be inconclusive or unreliable because of confounding factors, particularly the presence of psychiatric history. More rigorous double-blind, randomized, placebo-controlled trials on larger numbers of patients with epilepsy, with clear inclusion/exclusion criteria, that are specifically designed to investigate psychotropic changes are more likely to produce results that inform clinical practice and direct future research.

Psychiatric symptoms and quality of life in patients with drug-refractory epilepsy receiving adjunctive levetiracetam therapy

Background and Purpose

Levetiracetam (LEV) is a new antiepileptic drug that has been found to be effective as an adjunctive therapy for uncontrolled partial seizures. However, the results of several studies suggested that LEV has negative psychotropic effects, including irritability, aggressiveness, suicidality, and mood disorders. We investigated the impact of adjunctive LEV on psychiatric symptoms and quality of life (QOL) in patients with drug-refractory epilepsy (DRE) and determined the risk factors provoking psychiatric adverse events.

Methods

A 24-week, prospective, open-label study was conducted. At enrollment, we interviewed patients and reviewed their medical charts to collect demographic and clinical information. They were asked to complete self-report health questionnaires designed to measure various psychiatric symptoms and QOL at enrollment and 24 weeks later.

Results

Seventy-one patients were included in the study, 12 patients (16.9%) of whom discontinued LEV therapy due to serious adverse events including suicidality. The risk factor for premature withdrawal was a previous history of psychiatric diseases (odds ratio 4.59; 95% confidence interval, 1.22-17.32). LEV intake resulted in significant improvements in Beck Anxiety Inventory score (p<0.01) and some domains of the Symptom Checklist-90-Revised, such as somatization (p<0.05), obsessive-compulsiveness (p<0.05), depression (p<0.05), and anxiety (p<0.05). These improvements were not related to the occurrence of seizure freedom. The Quality of Life in Epilepsy Inventory-31 overall score and subscale scores, such as seizure worry (p<0.01), overall QOL (p<0.05), emotional well-being (p<0.05), energy-fatigue (p<0.05), and social function (p<0.05), also improved.

Conclusions

Adjunctive LEV in patients with DRE is likely to improve psychiatric symptoms and QOL. Clinicians should be well aware of the psychiatric histories of patients to prevent them from developing serious adverse events related to LEV.

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.

Anticonvulsants in the treatment of major depressive disorder: an overview

Major depressive disorder (MDD) is highly prevalent, potentially disabling, and sometimes fatal. Antidepressants (ADs) have improved its treatment, but incomplete response, sustained morbidity, recurrences, agitation, substance abuse, excess medical mortality, and suicide remain unsolved problems among mood disorder patients. AD treatment itself sometimes induces adverse behavioral responses. Several anticonvulsants (ACs) used to treat bipolar disorder (BPD) might also be of value for MDD. Accordingly, we reviewed published reports on ACs for MDD, identifying studies by computerized searches. We excluded reports dealing only with BPD patients or with sedatives, classified trials by design quality, and evaluated treatment of acute episodes and recurrences of adult MDD. We found 36 reports involving 41 relevant trials of carbamazepine (12 trials), valproate (11), lamotrigine (9), gabapentin (3), topiramate (3), phenytoin (2), and tiagabine (1). They include 9 blinded, controlled trials (of 28-70 days), involving carbamazepine (3 trials), lamotrigine (3), phenytoin (2), or topiramate (1) as primary treatments (5) or AD adjuncts (4). Some of these trials, as well as 7 of lesser quality, suggest benefits of carbamazepine, lamotrigine, and valproate, mainly as adjuncts to ADs. Another 20 anecdotes or small trials further suggest that these ACs might be useful as AD adjuncts-specifically to treat irritability or agitation in MDD. Overall, these reports provide suggestive evidence of beneficial effects of carbamazepine, lamotrigine, and valproate that require further study, especially for long-term adjunctive use, particularly in patients with recurring MDD with prominent irritability or agitation.

Differential effects of levetiracetam, carbamazepine, and lamotrigine on reproductive endocrine function in adults

Animal studies have shown endocrine changes after levetiracetam treatment. The present study investigated reproductive and sexual function in patients with epilepsy (aged 18-45) treated with levetiracetam (LEV: 30 men/26 women), carbamazepine (CBZ: 63 men/30 women), or lamotrigine (LTG: 37 men/40 women) monotherapy and in healthy controls (36 men/44 women). In women, no endocrine changes were observed during LEV treatment, whereas steroid hormone-binding globulin levels were greater and progesterone levels lower in women using CBZ. Dehydroepiandrosterone sulfate levels were higher and androstenedione levels lower in LTG-treated women. Arizona Sexual Experience Scale scores, which were significantly lower in females using LTG or LEV, suggesting they have better sexual function than CBZ users and controls. In men, no drug-specific hormonal pattern was observed after LEV treatment. Male patients in all treatment groups had lower androstenedione and free testosterone. Those using CBZ had lower free androgen indices and dehydroepiandrosterone sulfate levels, and higher steroid hormone-binding globulin, follicle-stimulating hormone, and luteinizing hormone levels. Arizona Sexual Experience Scale scores for men were similar in all groups. In conclusion, LEV treatment apparently has no drug-specific sexual or endocrine side effects in men or women in this age group.

Levetiracetam extended release and levetiracetam immediate release as adjunctive treatment for partial-onset seizures: an indirect comparison of treatment-emergent adverse events using meta-analytic techniques

The safety profiles of once-daily adjunctive levetiracetam (LEV) extended release (XR) (1000mg/day) and adjunctive LEV immediate release (IR) (500mg twice daily) were compared using data from three randomized, placebo (PBO)-controlled phase III clinical trials in patients with partial-onset seizures. MedDRA 9.0 treatment-emergent adverse events (TEAEs) were indirectly compared using meta-analytic techniques, including calculation of risk difference (RD) and mixed-effects analysis. Statistical significance was set at 10% alpha risk, the normative value for these analyses. Data from 555 patients older than 16 (204 LEV IR, 70 LEV XR, 281 PBO) were analyzed. Following adjustment for incidence of placebo TEAEs, LEV XR showed statistically significantly lower rates of TEAEs than LEV IR across nervous system disorders (RD=-18%, P=0.03), psychiatric disorders (RD=-11%, P=0.08), and metabolism and nutrition disorders (RD=-3%, P=0.08). Among nervous system disorders, the RD for headache favored LEV XR (RD=-11%, P=0.08). These results suggest that adjunctive LEV XR may be associated with a lower incidence of nervous system, psychiatric, and nutritional and metabolic TEAEs as compared with LEV IR. However, this difference was observed at a broad scale and not at a specific TEAE level except for headache.

A prospective pilot study of levetiracetam for body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted.

OBJECTIVE

This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD.

METHODS

Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures.

RESULTS

In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated.

CONCLUSION

Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.