Interictal psychiatric comorbidities of drug-resistant focal epilepsy: Prevalence and influence of the localization of the epilepsy

Factors affecting psychiatrist hesitation towards epilepsy care and care for patients with epilepsy transitioning from pediatric to adult care: A survey by the Japanese Society of General Hospital Psychiatry

OBJECTIVE

This study was undertaken by the Epilepsy Subcommittee of the Japanese Society of General Hospital Psychiatry (JSGHP) to explore the challenges faced by psychiatrists in treating epilepsy and the difficulties encountered during the transition of patients with epilepsy (PWE) from pediatric to adult care.

METHODS

An online survey targeting 1,980 JSGHP-affiliated psychiatrists was conducted from May to July 2022. The participants were asked to complete a questionnaire on epilepsy care. We analyzed the factors associated with participant hesitancy to treat epilepsy and their professional characteristics.

RESULTS

Responses were obtained from 545 of the 1,980 solicited psychiatrists (response rate: 27.5 %). The mean number of years of clinical experience in psychiatry was 20.9 ± 10.3 years. A majority of the psychiatrists were hesitant toward treating epilepsy (89.2 %) and managing the transition of PWE from pediatric services to adult care (83.3 %). Logistic regression analysis showed that the absence of hesitation toward epilepsy treatment was significantly associated with years of clinical experience in psychiatry (OR: 1.05, p = 0.002), being a board-certified epileptologist (OR: 4.36, p = 0.037), having colleagues who are specialists in epilepsy care that may be consulted in the workplace (OR: 2.12, p = 0.027), and general confidence in managing PWE transition from pediatric to adult care (OR 3.54, p < 0.001). Confidence in managing the transition was positively correlated with being a board-certified psychiatrist of the Japanese Society of Psychiatry and Neurology (OR: 4.55, p = 0.048), being a board-certified psychiatrist of the JSGHP (OR: 1.75, p = 0.034), treating six or more PWE per month (OR: 3.54; 95 % CI, p < 0.001), and overall confidence in treating epilepsy (OR: 3.38, p < 0.001).

CONCLUSIONS

Alleviation of reluctance to providing epilepsy care and managing the process of transition are correlated; however, the factors influencing each are distinct. To reduce resistance to epilepsy treatment, enhancing the knowledge of epilepsy and creating an environment conducive to consultations are essential. Improving transition-related outcomes, having substantial psychiatric expertise, and increasing opportunities to treat PWE are of great significance. The integration of these approaches may enable psychiatrists to alleviate hesitancy towards epilepsy care and enhance both treatment and transitional care modalities.

Resective epilepsy surgery and its impact on depression in adults: a systematic review, meta-analysis, and implications for future research

BACKGROUND

How epilepsy surgery influences the bidirectional relationship of epilepsy and depression remains poorly defined.

METHOD

For a better understanding of this question, we conducted a systematic review and meta-analysis of risk ratio on depression prevalence before and after epilepsy surgery, using Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Three databases were comprehensively screened for all studies assessing depression before and after resective surgery in adult epileptic patients until 8 October 2022. Studies were included if depression was assessed before and after epilepsy surgery regardless of the time of follow-up. A total of 1917 studies were screened for eligibility and 91 full-texts up for inclusion; 35 studies were finally included, 25 studies and 2563 patients were included in main meta-analysis and 10 for exploratory analysis. Risk of bias was assessed using Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) from Cochrane. To derive the pooled depression rates before and after surgery, a meta-analysis with inversed-variance was performed using random-effects logistic models with Peto's correction and a 95% CI. Heterogeneity was assessed with Cochran's Q-test along with its derived measure of inconsistency I2.

RESULTS

Overall, the depression rates before and after resective epilepsy surgery were 0.70 (0.53 to 0.91) 95% CI, suggesting that the rate of depression at last follow-up evaluation tends to decrease after Resective Epilepsy Surgery (RES). Subgroup analysis suggest a positive long-term effect appears with a significant lower rates of depression already 6 months (0.61 (0.38 to 0.98)), after surgery which is maintained over time after 1 year (0.53 (0.31 to 0.90)), and after 2 years (0.62 (0.42 to 0.92)).

CONCLUSION

This important finding should be taken in consideration before resective surgery for drug-resistant epilepsies. However, prospective studies should be conducted to characterise which patient, at the individual level, might be at risk of de novo or worsening of depression.

PROSPERO REGISTRATION NUMBER

CRD42022355386.

Prevalence and associated factors of psychiatric comorbidities in epilepsy in the Casablanca-Settat region of Morocco: A cross-sectional study

OBJECTIVE

To determine the estimated prevalence of anxiety, depression, and anxiety-depression syndrome (ADS) and to identify the associated factors in Moroccan people with epilepsy (PWE).

METHOD

A cross-sectional study was conducted among adult PWE (June 2021-December 2022) in the Casablanca-Settat region. PWE were interviewed by completing a questionnaire collecting sociodemographic and clinical data. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). Out of 21 points, a score ≥8 is in favor of considerable anxiety/depression symptoms and a sum of the two scores ≥15 indicates the presence of ADS. Data were analyzed using Statistical Package for Social Sciences (SPSS) 21.0. p-values ≤0.05 were considered statistically significant and logistic regression was performed to determine the associated factors.

RESULTS

Among 294 PWE, the median age was 39 years (interquartile range [IQR]: 25.75-54.00). The median anxiety, depression, and ADS scores were 8 (IQR: 5.00-10.00), 7 (IQR: 4.00-10.00), and 15 (IQR: 10.00-20.00), respectively. Anxiety, depression, and ADS were revealed in 51.4%, 44.9%, and 51.0% of PWE, respectively. Depression was the only predictor for anxiety (aOR = 24.20; 95%CI: 12.45-47.01). Antiseizure polytherapy (aOR = 3.35; 95%CI: 1.72-6.54) and anxiety (aOR = 24.04; 95%CI: 12.12-47.67) were the factors associated with depression. The risk of ADS was increased by female gender (aOR = 2.83; 95%CI: 1.68-4.78), antiseizure polytherapy (aOR = 2.75; 95%CI: 1.62-4.65), structural epilepsy (aOR = 1.73; 95%CI: 1.01-2.94), and the presence of concomitant conditions with epilepsy (aOR = 1.96; 95%CI: 1.16-3.31).

SIGNIFICANCE

Our study reports high psychiatric comorbidity prevalence in epilepsy, which supports the bidirectional link hypothesis. Associated factors found are important in the prognosis and prevention.

PLAIN LANGUAGE SUMMARY

The neural mechanisms underlying epilepsy tend to expose PWE to psychiatric disorders. Our study aims to quantify the rate of psychiatric comorbidities and their predictive factors in Moroccan PWE. The estimated prevalences of significant symptoms of anxiety, depression, and ADS were 51.4%, 44.9%, and 51.0%, respectively. Depression was the predictor of anxiety. Antiseizure polymedication and anxiety were the associated factors with depression. The risk of SAD was increased by female gender, antiseizure polymedication, structural epilepsy, and concomitant diseases with epilepsy. Our results are important for considering the psychiatric aspect of PWE and improving their care and quality of life.

The relationship of psychiatric comorbidities and symptoms, quality of life, and stigmatization in patients with epilepsy

OBJECTIVE

Research around the frequency of psychiatric diseases and psychosocial consequences caused by seizures and stigmatization in patients with epilepsy is important, in terms of multidimensional evaluation of the condition, increasing quality of life, and controlling the frequency of seizures. This prospective study aimed to evaluate relationship between comorbid psychiatric diseases and clinical and sociodemographic data, patients' quality of life and perceived stigma in patients with epilepsy.

METHODS

In this prospective single-center study, we evaluated clinical and demographic data, and characteristics of epilepsy. We used the Symptom Check List 90-Revised (SCL-90-R) as a screening test for psychiatric comorbidities and the Mini International Neuropsychiatric Interview (MINI) test for patients who had an SCL90-R general symptom index (GSI) score of ≥1. The frequency of psychiatric comorbidities, the association between comorbid psychiatric disorders and quality of life, and the level of stigmatization in patients with epilepsy was assessed using the Quality of Life in Epilepsy Inventory (QOLIE-10) and Perceived Stigma Scale.

RESULTS

SCL90-R GSI scores of ≥1 were found in 122 of 300 patients. Psychiatric comorbidities were found in 24.8% (n = 69) of patients with epilepsy in the MINI test, major depression was found in 16.9 %, (n = 47), and generalized anxiety disorder was the most common (5.7 %, n = 16). The number of anti-seizure medications (p = 0.007), high seizure frequency (p = 0.01), seizure in previous 12 months (p = 0.003), history of epilepsy surgery (p = 0.032) and psychiatric disease (p < 0.001), and high perceived stigma (p < 0.001) and QOLIE-10 (p < 0.001) scores were all correlated with psychiatric comorbidities.

CONCLUSIONS

According to the results of our study, an important correlation was determined between psychiatric comorbidities and a history of psychiatric disease, poor quality of life, and high perceived stigma scores in patients with epilepsy. This suggests that screening patients for comorbid psychiatric conditions in epilepsy outpatient clinics is critical, as is establishing a strong collaboration with the psychiatry clinic, to reduce psychosocial issues and the economic burden of stigmatization and improve quality of life.

[The relationship between immunological and psychopathological characteristics in patients with focal epilepsy depending on the profile of interhemispheric asymmetry]

OBJECTIVE

To identify the possible influence of cellular immunity parameters and neurobiological variables (frequency of seizures of various semiotics and their severity) on comorbid psychopathological symptoms depending on the profile of interhemispheric asymmetry in patients with focal forms of epilepsy.

MATERIAL AND METHODS

The study included 92 patients with epilepsy (38 men, 54 women, mean age 38.7+8.45 years). Focal temporal lobe epilepsy was diagnosed in 36 patients, focal frontal lobe epilepsy in 16 patients, and temporal-frontal lobe epilepsy in 40 patients. For each type of seizure, severity was assessed according to the National Seizure Severity Scale (NHS3). The mental status of patients was assessed using the SCL-90 self-report questionnaire. The Annette scale was used to assess the profile of interhemispheric asymmetry. The number of different clusters of lymphocytes was studied, including the number of T-lymphocytes (CD3+), T-helpers (CD3+CD4+), T-cytotoxic (CD3+CD8+), T-NK (natural killers CD3+CD16+CD56+), B-lymphocytes (CD3-CD19+), as well as immunoregulatory index (CD4/CD8 ratio). In order to identify any possible relationships between neurobiological and immune variables, on the one hand, and the SCL-90 constructs, on the other hand, a separate correlation analysis of Spearman ranks within the left-handed group and the right-handed group was carried out.

RESULTS

We revealed the differences between groups of patients with epilepsy with right and left profiles of hemispheric asymmetry regarding the relationship between the frequency of seizures, their severity and accompanying psychopathological variables, on the one hand, and between immunity indices and psychopathological constructs, on the other hand. It has been established that neurobiological and immune variables in left-handers can determine the psychopathological structure of the comorbid mental disorder.

CONCLUSION

Prediction of concomitant psychopathological syndromes in patients with epilepsy on the basis of clinical data and data on immunity is quite possible, but only in left-handed patients.

Interictal Dysphoric Disorder: A disorder with distinct nosography or atypical symptomatology of mood disorders in people with epilepsy? Results from a systematic review

INTRODUCTION

Mood disorders are the most frequent comorbidities in people with epilepsy. The term Interictal Dysphoric Disorder (IDD) has been used to describe a condition where at least three out of eight symptoms must be present for diagnosis. Symptoms are grouped into three symptom clusters of four "labile depressive" symptoms (anergia, depressed mood, insomnia, and pain), two "labile affective" symptoms (anxiety and fear), and two specific symptoms (euphoric moods and paroxysmal irritability), which are described and can be present in people with epilepsy. There is debate about whether IDD is a distinct disease, or if it is simply a special manifestation of mood disorders in epilepsy. For instance, it may represent an atypical presentation of depression in this population.

METHODS

We conducted a systematic review of the literature in 3 databases with the terms "Interictal Dysphoric Disorder" and "mood disorder". A total of 130 articles were selected and, after removing the duplicated applying eligibility criteria, 12 articles were included.

RESULTS

Six articles showed positive evidence for the validation of IDD as an independent nosological entity; in contrast, five articles reported inconclusive findings regarding the question; one explicitly questioned significant differences between IDD and mood disorders as nosological constructs. The data available and presented in this systematic review is insufficient to confirm IDD as a distinct diagnostic category. Nevertheless, it is worth noting other researchers have found some validity in this concept, highlighting the strong connection between mood disorders and epilepsy.

CONCLUSION

Further research in this area is needed, and additional systematic reviews focusing on other aspects of the construct, such as neurobiological mechanisms, may prove to be helpful.

The CLDN5 gene at the blood-brain barrier in health and disease

The CLDN5 gene encodes claudin-5 (CLDN-5) that is expressed in endothelial cells and forms tight junctions which limit the passive diffusions of ions and solutes. The blood-brain barrier (BBB), composed of brain microvascular endothelial cells and associated pericytes and end-feet of astrocytes, is a physical and biological barrier to maintain the brain microenvironment. The expression of CLDN-5 is tightly regulated in the BBB by other junctional proteins in endothelial cells and by supports from pericytes and astrocytes. The most recent literature clearly shows a compromised BBB with a decline in CLDN-5 expression increasing the risks of developing neuropsychiatric disorders, epilepsy, brain calcification and dementia. The purpose of this review is to summarize the known diseases associated with CLDN-5 expression and function. In the first part of this review, we highlight the recent understanding of how other junctional proteins as well as pericytes and astrocytes maintain CLDN-5 expression in brain endothelial cells. We detail some drugs that can enhance these supports and are being developed or currently in use to treat diseases associated with CLDN-5 decline. We then summarise mutagenesis-based studies which have facilitated a better understanding of the physiological role of the CLDN-5 protein at the BBB and have demonstrated the functional consequences of a recently identified pathogenic CLDN-5 missense mutation from patients with alternating hemiplegia of childhood. This mutation is the first gain-of-function mutation identified in the CLDN gene family with all others representing loss-of-function mutations resulting in mis-localization of CLDN protein and/or attenuated barrier function. Finally, we summarize recent reports about the dosage-dependent effect of CLDN-5 expression on the development of neurological diseases in mice and discuss what cellular supports for CLDN-5 regulation are compromised in the BBB in human diseases.

Psychiatric co-morbidity of drug-resistant epilepsy in Veterans

OBJECTIVE

Psychiatric conditions are frequently co-morbid in epilepsy and studies examining Veterans with epilepsy suggest this population may present with unique psychiatric and clinical features Drug-resistant epilepsy (DRE) may confer a greater risk of psychiatric dysfunction; however, there is a paucity of literature documenting this. To expand our clinical understanding of Veterans with DRE, we assessed a comprehensive Veterans Health Administration (VHA)-wide sample, describing psychiatric conditions, medications, and healthcare utilization.

METHODS

Psychiatric and hospitalization data were collected on 52,579 Veterans enrolled in VHA healthcare between FY2014-2ndQtr.FY2020 from the VHA Corporate Data Warehouse administrative data. Data examined include psychiatric diagnosis, psychotropic medication use, and utilization of hospital services.

RESULTS

At least one psychiatric diagnosis was present in 70.2% of patients, while 49.8% had two or more diagnoses. Depression (51.7%), posttraumatic stress disorder (PTSD) (38.8%), and anxiety (38.0%) represented the most common psychiatric co-morbidities. Psychiatric medication use was present in 73.3%. Emergency room (ER) visits were highest in those with suicidality (mean 14.9 visits), followed by bipolar disorder (10.3), and schizophrenia (12.1). Psychiatric-related hospitalizations were highest for schizophrenia (mean 2.5 admissions) and bipolar disorder (2.3). Females had more psychiatric diagnoses (2.4 vs. 1.6, p < 0.001), psychiatric medications (3.4 vs. 2.3, p < 0.001), and ER utilization than males (6.9 vs. 5.5, p < 0.001).

SIGNIFICANCE

A substantial psychiatric burden exists among Veterans with DRE. Compared to prior epilepsy literature, results suggest that Veterans with DRE evidence more prevalent psychiatric comorbidity, emergency care usage, and inpatient psychiatric admissions. Females were especially impacted, with greater rates of psychiatric conditions and treatment. Considering the relationship of psychiatric comorbidities in epilepsy with psychosocial functioning and quality of life, our findings highlight the need for screening and provision of services for those with DRE.

Optimization of Therapy in Patients with Epilepsy and Psychiatric Comorbidities: Key Points

Psychiatric disorder comorbidity in patients with epilepsy (PWE) is very frequent with a mean percentage prevalence of up to 50% and even higher. Such a high frequency suggests that epilepsy and psychiatric disorders might share common pathological pathways. Various aspects contribute in making the matter very complex from a therapeutic point of view. Some antiseizure medications (ASMs), namely valproic acid, carbamazepine, and lamotrigine, have mood-stabilising effects and are routinely used for the treatment of bipolar disorder in patients who do not have epilepsy. Pregabalin and, to a lesser extent, gabapentin, exerts anxiolytic effects. However, several ASMs, in particular levetiracetam, topiramate, and perampanel, may contribute to psychiatric disorders, including depression, aggressive behaviour, and even psychosis. If these ASMs are prescribed, the patient should be monitored closely. A careful selection should be made also with psychotropic drugs. Although most of these can be safely used at therapeutic doses, bupropion, some tricyclic antidepressants, maprotiline, and clozapine may alter seizure threshold and facilitate epileptic seizures. Interactions between ASMs and psychotropic medication may make it difficult to predict individual response. Pharmacokinetic interactions can be assessed with drug monitoring and are consequently much better documented than pharmacodynamic interactions. Another aspect that needs a careful evaluation is patient adherence to treatment. Prevalence of non-adherence in PWE and psychiatric comorbidities is reported to reach values even higher than 70%. A careful evaluation of all these aspects contributes in optimizing therapy with a positive impact on seizure control, psychiatric wellbeing, and quality of life.

Long-term seizure, psychiatric and socioeconomic outcomes after frontal lobe epilepsy surgery

OBJECTIVE

Resective surgery for selected individuals with frontal lobe epilepsy can be effective, although multimodal outcomes are less established than in temporal lobe epilepsy. We describe long-term seizure remission and relapse patterns, psychiatric comorbidity, and socioeconomic outcomes following frontal lobe epilepsy surgery.

METHODS

We reviewed individual data on frontal lobe epilepsy procedures at our center between 1990 and 2020. This included the presurgical evaluation, operative details and annual postoperative seizure and psychiatric outcomes, prospectively recorded in an epilepsy surgery database. Outcome predictors were subjected to multivariable analysis, and rates of seizure freedom were analyzed using Kaplan-Meier methods. We used longitudinal assessment of the Index of Multiple Deprivation to assess change in socioeconomic status over time.

RESULTS

A total of 122 individuals with a median follow-up of seven years were included. Of these, 33 (27 %) had complete seizure freedom following surgery, with a further 13 (11 %) having only auras. Focal MRI abnormality, histopathology (focal cortical dysplasia, cavernoma or dysembryoplastic neuronal epithelial tumor) and fewer anti-seizure medications at the time of surgery were predictive of a favorable outcome; 67 % of those seizure-free for the first 12 months after surgery never experienced a seizure relapse. Thirty-one of 50 who had preoperative psychiatric pathology noticed improved psychiatric symptomatology by two years postoperatively. New psychiatric comorbidity was diagnosed in 15 (13 %). Persistent motor complications occurred in 5 % and dysphasia in 2 %. No significant change in socioeconomic deciles of deprivation was observed after surgery.

SIGNIFICANCE

Favorable long-term seizure, psychiatric and socioeconomic outcomes can be seen following frontal lobe epilepsy surgery. This is a safe and effective treatment that should be offered to suitable individuals early.

Factors not considered in the study of drug-resistant epilepsy: Psychiatric comorbidities, age, and gender

In basic research and clinical practice, the control of seizures has been the most important goal, but it should not be the only one. There are factors that remain poorly understood in the study of refractory epilepsy such as the age and gender of patients and the presence of psychiatric comorbidities. It is known that in patients with drug-resistant epilepsy (DRE), the comorbidities contribute to the deterioration of the quality of life, increase the severity, and worsen the prognosis of epilepsy. Some studies have demonstrated that patients diagnosed with a co-occurrence of epilepsy and psychiatric disorders are more likely to present refractory seizures and the probability of seizure remission after pharmacotherapy is reduced. The evidence of this association suggests the presence of shared pathogenic mechanisms that may include endocrine disorders, neuroinflammatory processes, disturbances of neurotransmitters, and mechanisms triggered by stress. Additionally, significant demographic, clinical, and electrographic differences have been observed between women and men with epilepsy. Epilepsy affects the female gender in a greater proportion, although there are no studies that report whether refractoriness affects more females. The reasons behind these sex differences are unclear; however, it is likely that sex hormones and sex brain differences related to chromosomal genes play an important role. On the other hand, it has been shown in industrialized countries that prevalence of DRE is higher in the elderly when compared to youngsters. Conversely, this phenomenon is not observed in developing regions, where more cases are found in children and young adults. The correct identification and management of these factors is crucial in order to improve the quality of life of the patients.

Interleukin-17A Mediates Hippocampal Damage and Aberrant Neurogenesis Contributing to Epilepsy-Associated Anxiety

Anxiety disorder is one of the most common comorbidities in temporal lobe epilepsy (TLE), but its neurobiological mechanisms remain unclear. Here we identified a novel target, interleukin-17A (IL-17A), which can contribute to TLE-associated anxiety. Epileptic seizures were induced in 6-week-old IL-17A wild-type (WT) and knockout (KO) mice by pilocarpine injection. To evaluate anxiety level, we subjected mice to open field and elevated plus maze (EPM) tests and measured the time animals spent in center zone or open arms. Epileptic IL-17A WT mice showed thigmotaxis and reluctance to stay in open arms, whereas IL-17A KO mice spent more time in the center area and open arms, suggesting alleviated anxiety in epilepsy. Histological assessments revealed that hippocampal neuronal death as evaluated by Fluoro-Jade B staining was significantly reduced in IL-17A KO mice. Moreover, at 6 weeks after pilocarpine-induced status epilepticus, the number of hilar ectopic granule cells was also markedly decreased by IL-17A deficiency without a difference in the proliferation of neural progenitors or the generation of newborn neurons in the dentate gyrus. Taken together, our data demonstrated that IL-17A deletion mitigates TLE-associated anxiety behavior, possibly via the hippocampal neuroprotection and the reduction of seizure-induced aberrant neurogenesis.

Anticipatory anxiety of seizures is associated with ictal emotional distress and amygdala onset seizures

OBJECTIVE

Anxiety disorders are a frequent psychiatric condition in patients with epilepsy. Anticipatory Anxiety of Seizures (AAS) is described as a daily persistent fear, or excessive worry of having a seizure. AAS seems to be related to "subjective ictal anxiety" reported by patient. The current study aimed to assess the association between objective ictal features and the presence of AAS.

METHODS

Ninety-one patients with drug-resistant focal epilepsy underwent a standardized psychiatric assessment, specific for epilepsy, and a pre-surgical long term video-EEG or stereoelectroencephalography (SEEG). We compared seizures semiology and epilepsy features of patients with AAS (n=41), to those of patients without AAS (n=50). We analyzed emotional and motor behavior ictal signs as well as ictal consciousness. We further assessed amygdala ictal involvement in seizures recorded with SEEG (n=28).

RESULTS

AAS was significantly associated with the presence of ictal emotional distress: negative emotional behavior (p<0.01) and negative emotion, explicitly reported to examiner during record (p=0.015), regardless of the ictal level of consciousness. Among the patients recorded with SEEG, we found a significant involvement of amygdala within the seizure onset zone (p<0.01) for patients with AAS.

SIGNIFICANCE

Higher risk of developing AAS is associated with seizures expressing negative emotional symptoms, independently of ictal consciousness level. Persistent interictal fear of seizures might be viewed as the consequence of a reinforcement of the emotional networks secondary to amygdala involvement in seizures of temporal origin. Physicians should screen for AAS not only to assess the impact of epilepsy on daily life, but also as an interictal biomarker of ictal semiology and emotional network involvement at seizure onset.

Beyond Seizure Control: Treating Comorbidities in Epilepsy via Targeting of the P2X7 Receptor

Epilepsy is one of the most common chronic diseases of the central nervous system (CNS). Treatment of epilepsy remains, however, a clinical challenge with over 30% of patients not responding to current pharmacological interventions. Complicating management of treatment, epilepsy comes with multiple comorbidities, thereby further reducing the quality of life of patients. Increasing evidence suggests purinergic signalling via extracellularly released ATP as shared pathological mechanisms across numerous brain diseases. Once released, ATP activates specific purinergic receptors, including the ionotropic P2X7 receptor (P2X7R). Among brain diseases, the P2X7R has attracted particular attention as a therapeutic target. The P2X7R is an important driver of inflammation, and its activation requires high levels of extracellular ATP to be reached under pathological conditions. Suggesting the therapeutic potential of drugs targeting the P2X7R for epilepsy, P2X7R expression increases following status epilepticus and during epilepsy, and P2X7R antagonism modulates seizure severity and epilepsy development. P2X7R antagonism has, however, also been shown to be effective in treating conditions most commonly associated with epilepsy such as psychiatric disorders and cognitive deficits, which suggests that P2X7R antagonisms may provide benefits beyond seizure control. This review summarizes the evidence suggesting drugs targeting the P2X7R as a novel treatment strategy for epilepsy with a particular focus of its potential impact on epilepsy-associated comorbidities.

Quality of life study for caregivers of people with uncontrolled focal-onset seizures

AIM

The aim of this study was to capture and measure the impact of caregiving for an adult with uncontrolled drug-resistant focal-onset seizures (FOS) on the caregivers' quality of life (QoL), and to quantify the costs of productivity losses associated with providing informal care in this patient population.

METHODS

An online survey, which included the EQ-5D-5L, CarerQol-7D and the Work Productivity and Activity Impairment: Specific-Health Problem (WPAI:SHP) questionnaires, was administered to caregivers of individuals with uncontrolled drug-resistant FOS in the United Kingdom (UK), France, Spain, Germany, Italy, and Sweden.

RESULTS

The study included 345 caregivers. Most were males, aged between 25 and 34 years old whose caring responsibilities took between 15 and 24 h per week. The caregivers' mean EQ-5D-5L score was 0.6, with 95% confidence intervals (CI) of [0.58, 0.63], whilst the mean CarerQol-7D score was 72.61 [70.46, 74.76]. Caregivers' mental health was the most substantially affected aspect of their QoL. In addition, most caregivers reported deriving some or a lot of fulfilment out of their caregiving tasks. The WPAI:SHP showed that the mean percentage of work impairment due to caregiving responsibilities was 63%, [59.75, 66.26]. The mean annualised costs of productivity losses per caregiver were estimated at €14,872 [€11,908; €17,888].

LIMITATIONS

One limitation consisted in the use of an online survey instead of a face-to-face interview. However, the medical terms were clearly explained, and examples were provided to help participants to give accurate responses. Another limitation was that the respondents self-reported as caregivers. Efforts were made to mitigate this weakness by using screener questions.

CONCLUSION

This study found that providing informal care for people with uncontrolled drug-resistant FOS had a negative impact on caregivers' QoL, with mental health being affected the most. However, caregivers found their role fulfilling and had support with their caring tasks.

Predictors of Comorbid Anxiety Symptoms After a New Diagnosis of Epilepsy: A Prospective 12-Month Follow-Up Observation

Objectives: We aimed to identify the factors contributing to comorbid anxiety symptoms over a 12-month follow-up period in Chinese adults with newly diagnosed epilepsy. Methods: Adult patients with newly diagnosed epilepsy (PWNDE) were recruited from First Hospital, Jilin University. Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 questionnaire (GAD-7; Chinese version) at 12 months. Multivariate stepwise logistic regression analysis was employed to identify the predictors for anxiety symptoms at 12 months. Results: A total of 157 PWNDE completed the study and were included in the final analysis. The percentage of participants with anxiety symptoms significantly decreased from 31.2% at baseline to 23.6% at 12 months (p = 0.027). Multivariate stepwise logistic regression analysis indicated that depressive symptoms at baseline [odds ratio (OR) 3.877 (95% confidence interval (CI) 1.683-8.933); P = 0.001] and the number of antiseizure medications (ASMs) during the follow-up period [OR 2.814 (95% CI 1.365-5.803); P = 0.005] were independent factors contributing to comorbid anxiety symptoms at 12 months. Conclusion: Depressive symptoms at baseline and the number of ASMs during the follow-up period were significant predictors of comorbid anxiety symptoms 12 months after a diagnosis of epilepsy.

Anxiety and Depression in Newly Diagnosed Epilepsy: A Matter of Psychological History?

Purpose: Anxiety and depression are highly prevalent in patients with epilepsy (PWE), and these symptoms can even precede the onset of the pathology. We aimed to define the prevalence of anxiety and depressive symptoms at the time of the epilepsy diagnosis and the factors related to their presence in newly diagnosed adult patients.

Methods: One hundred and twelve newly diagnosed patients were assessed, usually in the week after diagnosis. Patients were untreated at this time. We used the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, cut-off ≥15) and the Generalized Anxiety Disorder 7-Item scale (GAD-7, cut-off >7). A semi-structured interview was conducted to collect sociodemographic and epilepsy data and patients' psychiatric history. We first compared patients with and without anxiety symptoms, then patients with and without depressive symptoms.

Results: According to the GAD-7 scale, the prevalence of anxiety symptoms at the time of diagnosis was 35%. Patients with anxiety symptoms had significantly more psychiatric history (26%, p = 0.001) and more history of psychological trauma (51%, p = 0.003) than patients with no anxiety symptoms. According to the NDDI-E scores, the prevalence of depressive symptoms at the time of the diagnosis was 11%. Patients with depressive symptoms had significantly more psychiatric history (43%, p < 0.001) and more history of psychological trauma (65%, p = 0.007) than patients with no depressive symptoms. No difference between groups was found for other sociodemographic variables (age and gender), epilepsy characteristics (number of seizures prior to diagnosis, time from first seizure to diagnosis, type of epilepsy, and localization in focal epilepsy), or neurological comorbidities.

Conclusions: Anxiety symptoms are common whereas depressive symptoms are less prevalent at the time of diagnosis. It appears essential to be aware of anxiety and depression in newly diagnosed epileptic patients. They should be screened and routinely monitored, especially those patients with a history of psychological trauma and/or psychiatric disorders. Longitudinal follow-up is required to identify whether these factors and anxiety and depression themselves have an impact on the future course of care.

Invasive Electrophysiology for Circuit Discovery and Study of Comorbid Psychiatric Disorders in Patients With Epilepsy: Challenges, Opportunities, and Novel Technologies

Intracranial electroencephalographic (iEEG) recordings from patients with epilepsy provide distinct opportunities and novel data for the study of co-occurring psychiatric disorders. Comorbid psychiatric disorders are very common in drug-resistant epilepsy and their added complexity warrants careful consideration. In this review, we first discuss psychiatric comorbidities and symptoms in patients with epilepsy. We describe how epilepsy can potentially impact patient presentation and how these factors can be addressed in the experimental designs of studies focused on the electrophysiologic correlates of mood. Second, we review emerging technologies to integrate long-term iEEG recording with dense behavioral tracking in naturalistic environments. Third, we explore questions on how best to address the intersection between epilepsy and psychiatric comorbidities. Advances in ambulatory iEEG and long-term behavioral monitoring technologies will be instrumental in studying the intersection of seizures, epilepsy, psychiatric comorbidities, and their underlying circuitry.

ATP and adenosine-Two players in the control of seizures and epilepsy development

Despite continuous advances in understanding the underlying pathogenesis of hyperexcitable networks and lowered seizure thresholds, the treatment of epilepsy remains a clinical challenge. Over one third of patients remain resistant to current pharmacological interventions. Moreover, even when effective in suppressing seizures, current medications are merely symptomatic without significantly altering the course of the disease. Much effort is therefore invested in identifying new treatments with novel mechanisms of action, effective in drug-refractory epilepsy patients, and with the potential to modify disease progression. Compelling evidence has demonstrated that the purines, ATP and adenosine, are key mediators of the epileptogenic process. Extracellular ATP concentrations increase dramatically under pathological conditions, where it functions as a ligand at a host of purinergic receptors. ATP, however, also forms a substrate pool for the production of adenosine, via the action of an array of extracellular ATP degrading enzymes. ATP and adenosine have assumed largely opposite roles in coupling neuronal excitability to energy homeostasis in the brain. This review integrates and critically discusses novel findings regarding how ATP and adenosine control seizures and the development of epilepsy. This includes purine receptor P1 and P2-dependent mechanisms, release and reuptake mechanisms, extracellular and intracellular purine metabolism, and emerging receptor-independent effects of purines. Finally, possible purine-based therapeutic strategies for seizure suppression and disease modification are discussed.

Sex Differences in the Epilepsies and Associated Comorbidities: Implications for Use and Development of Pharmacotherapies

The epilepsies are common neurologic disorders characterized by spontaneous recurrent seizures. Boys, girls, men, and women of all ages are affected by epilepsy and, in many cases, by associated comorbidities as well. The primary courses of treatment are pharmacological, dietary, and/or surgical, depending on several factors, including the areas of the brain affected and the severity of the epilepsy. There is a growing appreciation that sex differences in underlying brain function and in the neurobiology of epilepsy are important factors that should be accounted for in the design and development of new therapies. In this review, we discuss the current knowledge on sex differences in epilepsy and associated comorbidities, with emphasis on those aspects most informative for the development of new pharmacotherapies. Particular focus is placed on sex differences in the prevalence and presentation of various focal and generalized epilepsies; psychiatric, cognitive, and physiologic comorbidities; catamenial epilepsy in women; sex differences in brain development; the neural actions of sex and stress hormones and their metabolites; and cellular mechanisms, including brain-derived neurotrophic factor signaling and neuronal-glial interactions. Further attention placed on potential sex differences in epilepsies, comorbidities, and drug effects will enhance therapeutic options and efficacy for all patients with epilepsy. SIGNIFICANCE STATEMENT: Epilepsy is a common neurological disorder that often presents together with various comorbidities. The features of epilepsy and seizure activity as well as comorbid afflictions can vary between men and women. In this review, we discuss sex differences in types of epilepsies, associated comorbidities, pathophysiological mechanisms, and antiepileptic drug efficacy in both clinical patient populations and preclinical animal models.

The prevalence of depressive and anxiety symptoms in Polish epilepsy patients - The context of pharmaco-resistance

PURPOSE

Patients with epilepsy (PWE) are at a higher risk of experiencing depressive and anxiety symptoms than the general population; these symptoms are more prevalent in patients with drug-resistant epilepsy (DRE) compared to those with non-drug-resistant epilepsy (NDRE). The aim of the present study was to compare the level of reported depressive and anxiety symptoms in patients with DRE and patients with NDRE and to examine the relationships between demographic and epilepsy-related variables and severity of depression and anxiety symptoms.

MATERIAL AND METHODS

A total of 193 adult PWE, divided into a DRE group (n = 87), and an NDRE group (n = 106), completed the Beck Depression Inventory (BDI) and the Stat-Trait Anxiety Inventory (STAI-Sand STAI-T). Data analysis included sociodemographic and disease-related variables such as the type of epilepsy syndrome, age at onset of disease, and duration of the disease.

RESULTS

The DRE group presented a higher score of BDI than the NDRE group (p = 0.04). Age correlated with the score of STAI-S in the NDRE group (r = 0.22). Sex was the only significant predictor of the score of STAI-T in the NDRE group. Men from the DRE group presented higher scores in BDI, STAI-S, and STA-T compared with the NDRE group.

CONCLUSIONS

Patients with DRE reported more severe depressive symptoms than patients with NDRE. In NDRE patients, the level of anxiety, considered as a state, was correlated with age. Sex was a significant predictor of the level of anxiety in DRE patients. Pharmaco-resistance was significantly associated with severity of depression and anxiety in male patients.

Systematic Literature Review of Psychiatric Comorbidities in Adults with Epilepsy

Background and Purpose

Mental illness is disproportionately common in people with epilepsy (PWE). This systematic literature review identified original research articles that reported the prevalence of psychiatric comorbidities based upon clinical assessments in a sample of PWE and assessed the clinical features of the populations found in studies included in our review of mental health comorbidity.

Methods

The included articles were written in English and published from 2008 to 2018, and focused on adults aged ≥18 years who had psychiatric diagnoses determined in clinical assessments, such as those found in medical records, clinician psychiatric evaluations, structured diagnostic interviews, and mental health screening questionnaires specific for a psychiatric disorder. The primary outcome was the prevalence of psychiatric comorbidities as a percentage of the total sample of PWE. Additional data included the overall sample size, mean age, epilepsy type, study design, and method of diagnosis. A modified Newcastle Ottawa Scale was used to assess the quality of the studies. All 23 articles that were consistent with the inclusion criteria were related to observational studies.

Results

Mood disorders and anxiety disorders were the most common psychiatric comorbidities, with prevalence rates of 35.0% and 25.6%, respectively. Major depressive disorder was the most common mood disorder, with a prevalence of 24.2%. Post-traumatic stress disorder (PTSD) had the highest reported prevalence among anxiety disorders, at 14.2%, followed by general anxiety disorder at 11.1%. Other comorbidities included psychosis (5.7%), obsessivecompulsive disorder (3.8%), schizophrenia (1.7%), bipolar disorder (6.2%), and substance abuse (7.9%). The pooled prevalence of suicidality, as reported for two studies, was 9.3%. Temporal lobe epilepsy (TLE) was associated with higher levels of psychiatric comorbidity. Two (8.7%) of the 23 studies compared psychiatric comorbidities in TLE with that of extratemporal lobe epilepsy (ETLE), and one of these two studies found that depression was more common in TLE (53.8%) than in ETLE (25%). Regarding seizure types, partial seizures were associated with a higher prevalence of depression vs generalized seizures.

Conclusions

This systematic literature review of recent original research found a relatively high prevalence of mental health comorbidities in PWE. Mood and anxiety disorders are the most common comorbidities, while psychotic spectrum conditions such as schizophrenia and bipolar disorder are much rarer. The prevalence of comorbidity may vary with the epilepsy type and treatment responsiveness. These findings suggest that screening tools for depression and anxiety should be included as part of the training for epilepsy care, while resources for other relatively common conditions such as PTSD and substance abuse disorders should be readily available to neurology specialists who treat PWE.

Lactation in large litters influences anxiety, memory, and spreading depression in adult male rats that were chronically subjected to a non-convulsive pilocarpine dose

Objectives: Unfavorable lactation influences brain excitability and behavioral reactions in adults. Administration early in life of the cholinergic agonist, pilocarpine, even at non-convulsive doses, alters the brain excitability-related phenomenon known as cortical spreading depression (CSD), and produce anxiogenic-like behavior. However, the influence of unfavorable lactation on the CSD- and memory-effects of pilocarpine administration late in life has not been investigated. Herein, we analyzed the ponderal, electrophysiological (CSD), and behavioral effects of chronic treatment with a non-convulsive dose of pilocarpine, in adult rats suckled under favorable and unfavorable conditions.Methods: Wistar rats were suckled in litters with 9 or 15 pups (groups L₉ and L₁₅, respectively). A very low dose of pilocarpine (45/mg/kg/day) was chronically administered in mature rats from postnatal day (PND) 69-90. Behavioral tests occurred at PND91 [elevated plus maze (EPM)], PND93 [open field (OF)], and PND94-95 [object recognition memory (ORM)]. CSD was recorded between PND96-120.Results: Pilocarpine-treated rats performed worse in the anxiety and memory tests, and displayed lower CSD propagation velocity when compared with saline-treated controls. In addition, L₁₅ rats showed an increase in the distance traveled and a decrease in the immobility time in the EPM, impaired ORM, and accelerated CSD propagation when compared with L₉ rats (p ≤ 0.05).Discussion: These data suggest that sub-convulsive pilocarpine treatment in adult rats can affect behavioral and excitability-related reactions. In addition, unfavorable lactation increases the ambulatory effects of pilocarpine. Further studies should investigate the possible cholinergic molecular mechanisms involved in these effects.

Depression and Anxiety in the Epilepsies: from Bench to Bedside

PURPOSE OF REVIEW

Depression and anxiety substantially contribute to interictal disability in patients with epilepsy (PWE). This review summarizes current studies that shed light on mechanisms of comorbidity.

RECENT FINDINGS

Mounting epidemiological data implicate shared risk factors for anxiety/depression and seizure propensity, but these remain largely elusive and probably vary by epilepsy type. Within PWE, these symptoms appear to be associated with unique genetic, neuropathological, and connectivity profiles. Temporal lobe epilepsy has received enormous emphasis particularly in preclinical studies of comorbidity, where candidate neurobiological mechanisms underlying bidirectionality have been tested without psychopharmacological confounds. Depression and anxiety in epilepsy reflect dysfunction within broadly distributed limbic networks that may be the cause or consequence of epileptogenesis. In refractory epilepsy, seizures and/or certain anticonvulsants may distort central emotional homeostatic mechanisms that perpetually raise seizure risk. Developing future safe and effective combined anticonvulsant-antidepressant treatments will require a detailed understanding of anatomical and molecular nodes that pleiotropically enhance seizure risk and negatively alter emotionality.

Effectiveness and safety of perampanel as early add-on treatment in patients with epilepsy and focal seizures in the routine clinical practice: Spain prospective study (PERADON)

OBJECTIVE

Perampanel (PER) has been shown to be effective as an adjunctive therapy for controlling refractory focal-onset seizures (FOS). However, the information as early add-on for the treatment of FOS in the clinical practice is still scarce and must be further assessed.

METHODS

An observational prospective study was conducted to evaluate the effectiveness of early add-on PER, assessed as 50% responders (seizure frequency reduced by at least 50% during the last 3 months as compared with baseline) rate at 6 and 12 months, in patients with FOS in the routine clinical practice of Spain.

RESULTS

One hundred and thirteen patients (mean age: 40.3 years, 51.3% male) with FOS received PER as early add-on (1st add-on: 37.2% and 2nd: 62.8%) for a mean exposure of 11 months (mean PER dose: 6.3 mg/day at month 12). At 6 months, 50.4% and 20.4% of the patients were responders and seizure-free (respectively) relative to baseline (3 months prior to PER initiation), and at 12 months, 68.1% and 26.5% of the patients were responders and seizure-free (respectively), relative to baseline (3 months prior to PER initiation). The retention rate at 6 and 12 months was 83.2% and 80.5%, respectively. The percentage of seizure-free patients at 12 months was significantly (p = 0.033) higher when PER was added as first vs. second add-on. The number of concomitant antiepileptic drugs (AEDs) was significantly reduced from baseline to 6 and 12 months (p = 0.001). Treatment was simplified in 23.9% of patients at the end of the observation period. Drug-related adverse events (AEs), most mild or moderate, were reported in 30.1% of patients, with irritability (8%) and dizziness (7.1%) as the most frequent ones.

CONCLUSIONS

This is the first observational, prospective study to evaluate efficacy and safety of early adjunctive treatment with PER in patients with focal epilepsy at 12 months. Perampanel demonstrated a good efficacy and safety profile when used at a median dose of 6 mg/day, regardless of the combination with other AEDs. Adverse events were mild or moderate, with dizziness being the most frequent one.

The Relationship Between Epilepsy and Anxiety Disorders

PURPOSE OF REVIEW

The current review aims at providing an overview of relevant aspects of anxiety symptoms and anxiety disorders (AD) in adults patients with epilepsy (PWE).

RECENT FINDINGS

Firstly, the appropriate diagnosis of type of anxiety symptoms and AD in PWE will be presented. Anxiety symptoms are often peri-ictal and classified in relation to their temporal occurrence to seizures. Anxiety symptoms are of three types: preictal (preceding a seizure), ictal (presenting as part of the seizure symptoms and signs), and postictal (occurring within 72 h of a seizure). AD are diagnosed in the interictal period and occur independently of seizures. Four specific AD in PWE can be objectified: anticipatory anxiety of epileptic seizures (AAS), seizure phobia, epileptic social phobia, and epileptic panic disorder. Secondly, the bidirectional pathophysiological relationship between anxiety and epilepsy will be described. Anxiety is a trigger for seizures in some patients, and the notion of stress and arousal is essential to understand the relationship between anxiety and seizure. Moreover, seizures arising from the limbic network especially involving amygdala, which may express fear-related semiology, provide insight into the pathophysiology of AD comorbidities. Thirdly, the methods of screening for AD and anxiety symptoms will be detailed. Fourthly, the pharmacological and psychobehavioral management of anxiety symptoms and AD in PWE will be presented. Arousal-based approaches for preictal and ictal symptoms and anxiety-based approaches for postictal and interictal symptoms will be presented. Despite lack of evidence-based approaches, it is recognized that management of epilepsy is not only about controlling seizures, but also depends heavily on detecting, correctly diagnosing, and appropriately managing anxiety symptoms and AD comorbidities, in order to maximize quality of life. Improving self-control and self-efficacy is of fundamental importance in the management of PWE. Further rigorously designed studies focusing on anxiety symptoms and AD are essential to improve the overall care of PWE.