Rapid detection of major depression in epilepsy: a multicentre study

Evaluating depression in Indonesian adolescents with epilepsy: Comprehensive validation and reliability assessment of the neurological disorders depression inventory-epilepsy for youth Indonesian version (NDDI-E-Y[ID])

OBJECTIVES

Epilepsy is a common chronic neurological disorder in pediatrics. Depression is an often underdetected comorbidity in childhood epilepsy. This study aimed to adapt the Neurological Disorders Depression Inventory-Epilepsy for Youth (NDDI-E-Y) to the Indonesian language and population, as well as to validate the Indonesian version of NDDI-E-Y (NDDI-E-Y[ID]).

METHODS

This three-stage study comprised instrument translation, cultural verification, and content validity testing (first stage), pilot testing (second stage), followed by concurrent validity and reliability testing (third stage) of the NDDI-E-Y(ID). Validation was done against the Centre for Epidemiologic Studies Depression Scale - Revised (CESD-R). Content validity, assessed by six experts, was quantified using the content validity index for items (I-CVI) and scale (S-CVI). Participants were adolescents aged 12-17 years diagnosed with any type of epilepsy who completed both instruments. Concurrent validity was evaluated using Spearman's correlation and reliability was measured using Cronbach's alpha.

RESULTS

The first stage produced a culturally appropriate NDDI-E-Y(ID). Thirty healthy adolescents and 10 adolescents with epilepsy participated in the second stage. In the third stage, another group of 30 adolescents with epilepsy took part. We obtained I-CVI and S-CVI values averaging 1. The NDDI-E-Y(ID) showed a positive and significant correlation with CESD-R (Spearman's rho = 0.671, p < 0.001). A Cronbach's alpha of 0.928 reflected a high internal consistency.

SIGNIFICANCE

Based on the results, the NDDI-E-Y(ID) was found to be a valid and reliable screening instrument for detecting depression in youth with epilepsy.

PLAIN LANGUAGE SUMMARY

Depression is an under-recognized problem in youth with epilepsy. Currently available depression screening tools are in English, making it less suitable for detection purposes in Indonesia. This study developed and validated the Indonesian version of the NDDI-E-Y, a depression screening tool for youth with epilepsy.

Screening for depression in patients with epilepsy: same questions but different meaning to different patients

PURPOSE

Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items.

METHODS

Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients' characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression.

RESULTS

Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status.

CONCLUSION

PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics.

Risk of suicide and suicide-related events in subjects treated with antiseizure medications

INTRODUCTION

In the United States, it is reported that 1.4% of the general population commits suicide. It has been postulated that antiseizure medications (ASMs) can lead to the development of suicidal ideation and suicidal behavior; however, this risk is still very low and has yet to be precisely established.

AREAS COVERED

This narrative review evaluates the risk of suicide-related events (SREs) in subjects taking ASMs for various neurological disorders. Screening tools for suicidal ideation and suicidal behavior are also discussed. References for this article were found using PubMed/MEDLINE.

EXPERT OPINION

Although some ASMs can be associated with SREs, this is not yet clearly established. The mechanisms involved in suicide risk in subjects taking ASMs are multifactorial. The bidirectional relationship between depression and epilepsy, as well as other associations, should be kept in mind when interpreting any impact of ASMs in PWE. Screening for SREs, close monitoring of subjects taking ASMs are the most appropriate strategies to minimize suicide risk. More efforts should be made to achieve accurate risk stratification through prognostic models that could be applied to subjects taking ASMs. Studies exploring the association between ASMs and suicide should consider ASMs individually and control for prior SREs.

Proceedings of the 2022 "Lifestyle Intervention for Epilepsy (LIFE)" symposium hosted by Cleveland Clinic

Lifestyle interventions are strategies used to self-manage medical conditions, such as epilepsy, and often complement traditional pharmacologic and surgical therapies. The need for integrating evidence-based lifestyle interventions into mainstream medicine for the treatment of epilepsy is evident given that despite the availability of a multitude of treatments with medications and surgical techniques, a significant proportion of patients have refractory seizures, and even those who are seizure-free report significant adverse effects with current treatments. Although the evidence base for complementary medicine is less robust than it is for traditional forms of medicine, the evidence to date suggests that several forms of complementary medicine including yoga, mindfulness meditation, cognitive behavioral therapy, diet and nutrition, exercise and memory rehabilitation, and music therapy may have important roles as adjuncts in the treatment armamentarium for epilepsy. These topics were discussed by a diverse group of medical providers and scientists at the "Lifestyle Intervention for Epilepsy (LIFE)" symposium hosted by Cleveland Clinic. PLAIN LANGUAGE SUMMARY: There are many people with epilepsy who continue to have seizures even though they are being treated with medication or brain surgery. Even after seizures stop, some may experience medication side effects. There is research to suggest that certain lifestyle changes, such as yoga, mindfulness, exercise, music therapy, and adjustments to diet, could help people with epilepsy, when used along with routine treatment. Experts discussed the latest research at the "Lifestyle Intervention for Epilepsy (LIFE)" symposium hosted by Cleveland Clinic.

Screening for depression in patients with epilepsy: What are the benefits for physicians and patients in the real-life setting

OBJECTIVE

Screening for depression in people with epilepsy (PWE) is highly recommended in order to avoid underdiagnosis, misdiagnosis, or delayed diagnosis of this highly impacting comorbidity. Here we evaluated the impact of reporting and suggesting depression via the Beck Depression Inventory (BDI) on medical decision-making, and thereby the value of a depression screening for good medical practice.

METHODS

Of 445 BDI data sets, PWE with scores indicating moderate (BDI 19-29) to severe depressive disorder (BDI >29) were extracted and clinical reports were retrospectively reviewed regarding decisions on antidepressants, anti-seizure medications (ASMs), and non-pharmaceutical interventions.

RESULTS

Sixty-four PWE (14%; 56% female; mean age 39.7 years) showed elevated BDI scores, with 40 (63%) categorized as moderate depression and 24 (37%) as severe depression. Thirty-nine percent of PWE already had a pre-existing diagnosis of depression and 53% left the clinic with the diagnosis of depression, half of them with antidepressants. High depression scores were associated with any intervention in 53%, interventions with potentially mood affecting ASM in 19%, treatment with antidepressants in 11%, and non-pharmaceutical interventions in 41%. Non-pharmaceutical interventions were related to BDI scores. Changes of potentially mood-affecting ASMs were more frequent in PWE with moderate scores, and introduction of antidepressants appeared as a trend related to higher depression scores.

SIGNIFICANCE

The finding of an only weak relation between high depression scores, diagnoses of depression, and treatment consequences questions the diagnosis and treatment pathway and the clinical value of the BDI screening in PWE. Prospective standard procedures need to be established for depression diagnosis and treatment including follow-up evaluations of the validity of the diagnosis and effectiveness of the decisions taken.

Validity of the MoCA as a cognitive screening tool in epilepsy: Are there implications for global care and research?

OBJECTIVE

This study evaluated the diagnostic performance of a widely available cognitive screener, the Montreal cognitive assessment (MoCA), to detect cognitive impairment in older patients (age ≥ 55) with epilepsy residing in the US, using the International Classification of Cognitive Disorders in Epilepsy (IC-CoDE) as the gold standard.

METHODS

Fifty older adults with focal epilepsy completed the MoCA and neuropsychological measures of memory, language, executive function, and processing speed/attention. The IC-CoDE taxonomy divided participants into IC-CoDE Impaired and Intact groups. Sensitivity and specificity across several MoCA cutoffs were examined. Spearman correlations examined relationships between the MoCA total score and clinical and demographic variables and MoCA domain scores and individual neuropsychological tests.

RESULTS

IC-CoDE impaired patients demonstrated significantly lower scores on the MoCA total, visuospatial/executive, naming, language, delayed recall, and orientation domain scores (Cohen's d range: 0.336-2.77). The recommended MoCA cutoff score < 26 had an overall accuracy of 72%, 88.2% sensitivity, and 63.6% specificity. A MoCA cutoff score < 24 yielded optimal sensitivity (70.6%) and specificity (78.8%), with overall accuracy of 76%. Higher MoCA total scores were associated with greater years of education (p = 0.016) and fewer antiseizure medications (p = 0.049). The MoCA memory domain was associated with several standardized measures of memory, MoCA language domain with category fluency, and MoCA abstraction domain with letter fluency.

SIGNIFICANCE

This study provides initial validation of the MoCA as a useful screening tool for older adults with epilepsy that can be used to identify patients who may benefit from comprehensive neuropsychological testing. Further, we demonstrate that a lower cutoff (i.e., <24) better captures cognitive impairment in older adults with epilepsy than the generally recommended cutoff and provides evidence for construct overlap between MoCA domains and standard neuropsychological tests. Critically, similar efforts in other regions of the world are needed.

PLAIN LANGUAGE SUMMARY

The Montreal cognitive assessment (MoCA) can be a helpful tool to screen for cognitive impairment in older adults with epilepsy. We recommend that adults 55 or older with epilepsy who score less than 24 on the MoCA are referred to a neuropsychologist for a comprehensive evaluation to assess any changes in cognitive abilities and mood.

Post-epileptic seizure posttraumatic stress Disorder: A mediation analysis

OBJECTIVE

Previous studies investigated the varying prevalence of post-epileptic seizure posttraumatic stress disorder (PS-PTSD). The current study aimed first to compare the profiles of patients with and without PS-PTSD and, second, to study the interaction between other past traumatic experiences, subjective ictal anxiety, psychiatric comorbidities, and PS-PTSD in people with epilepsy (PWE).

METHODS

We conducted an observational study, investigating past traumatic experiences and PS-PTSD through standardized scales (CTQ-28, LEC-5 and PCL-5). We used semi-structured interviews and validated psychometric scales (NDDIE for depression and GAD-7 for anxiety) to collect data on general psychiatric comorbidities. We also assessed epilepsy specific psychiatric symptoms (interictal and peri-ictal). We performed a mediation analysis through PROCESS for SPSS to evaluate the effect of history of past trauma and subjective ictal anxiety on PS-PTSD through interictal depression and anxiety symptoms.

RESULTS

We enrolled 135 PWE, including 35 patients with PS-PTSD (29.5 %). Patients with PS-PTSD had significantly higher depression (12.87 vs 10; p = 0.005) and anxiety (7.74 vs 5.01; p = 0.027) scores and higher prevalence of peri-ictal psychiatric symptoms, compared to patients without PS-PTSD. The relationship between other past traumatic experiences and PS-PTSD was totally mediated by interictal depression and anxiety. We found a significant indirect effect of interictal anxiety symptoms on the path between subjective ictal anxiety and PS-PTSD.

SIGNIFICANCE

Our results showed that patients with PS-PTSD have a more severe psychopathological profile (more peri ictal and inter ictal depressive and anxiety symptoms). Both inter ictal and subjective ictal anxiety appear to have a significant role in PS-PTSD.

Quality of life during usual epilepsy care for anxiety or depression symptoms: Secondary patient-reported outcomes in a randomized trial of remote assessment methods

BACKGROUND AND OBJECTIVES

Anxiety and depression are highly prevalent and impactful in epilepsy. American Academy of Neurology quality measures emphasize anxiety and depression screening and quality of life (QOL) measurement, yet usual epilepsy care QOL and anxiety/depression outcomes are poorly characterized. The main objective was to assess 6-month QOL, anxiety and depression during routine care among adults with epilepsy and baseline anxiety or depression symptoms; these were prespecified secondary outcomes within a pragmatic randomized trial of remote assessment methods.

METHODS

Adults with anxiety or depression symptoms and no suicidal ideation were recruited from a tertiary epilepsy clinic via an electronic health record (EHR)-embedded process. Participants were randomized 1:1 to 6 month outcome collection via patient portal EHR questionnaires vs. telephone interview. This report focuses on an a priori secondary outcomes of the overall trial, focused on patient-reported health outcomes in the full sample. Quality of life, (primary health outcome), anxiety, and depression measures were collected at 3 and 6 months (Quality of Life in Epilepsy-10, QOLIE-10, Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory-Epilepsy). Change values and 95 % confidence intervals were calculated. In post-hoc exploratory analyses, patient-reported anxiety/depression management plans at baseline clinic visit and healthcare utilization were compared with EHR-documentation, and agreement was calculated using the kappa statistic.

RESULTS

Overall, 30 participants (15 per group) were recruited and analyzed, of mean age 42.5 years, with 60 % women. Mean 6-month change in QOLIE-10 overall was 2.0(95 % CI -6.8, 10.9), and there were no significant differences in outcomes between the EHR and telephone groups. Mean anxiety and depression scores were stable across follow-up (all 95 % CI included zero). Outcomes were similar regardless of whether an anxiety or depression action plan was documented. During the baseline interview, most participants with clinic visit EHR documentation indicating action to address anxiety and/or depression reported not being offered a treatment(7 of 12 with action plan, 58 %), and there was poor agreement between patient report and EHR documentation (kappa=0.22). Healthcare utilization was high: 40 % had at least one hospitalization or emergency/urgent care visit reported and/or identified via EHR, but a third (4/12) failed to self-report an EHR-identified hospitalization/urgent visit.

DISCUSSION

Over 6 months of usual care among adults with epilepsy and anxiety or depression symptoms, there was no significant average improvement in quality of life or anxiety/depression, suggesting a need for interventions to enhance routine neurology care and achieve quality of life improvement for this group.

Factors influencing quality of life in extratemporal lobe epilepsy and mesial temporal lobe epilepsy: a cross-sectional study using medical records

Objective

This study aimed to examine differences in factors influencing quality of life (QOL) in people with extratemporal lobe epilepsy (ETLE) and mesial temporal lobe epilepsy (MTLE).

Methods

We obtained data from the medical records of 84 (47 ETLE and 37 MTLE) people with epilepsy. The data included age, sex, employment, seizure frequency, number of antiseizure medication (ASM), Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) score, and Quality of Life in Epilepsy Inventory-31 (QOLIE-31) score. Multiple regression analyses were performed using QOLIE-31 as the dependent variable and age, sex, employment, seizure frequency, number of ASM, and NDDI-E score as the independent variables in ETLE or MTLE.

Results

From the results of the multiple regression analyses, QOLIE-31 in ETLE was associated with NDDI-E (β = -0.757, p < 0.001) and employment (β = 0.388, p = 0.008). Meanwhile, QOLIE-31 in MTLE was associated with NDDI-E (β = -0.625, p < 0.001), employment (β = 0.396, p = 0.041), and number of ASMs (β = -0.399, p = 0.018).

Conclusion

Overall, our findings indicate that the number of ASMs is potentially an influence on QOL of MTLE but similar effect is not observed in ETLE.

Rehabilitation in patients with newly diagnosed epilepsy: A controlled, 1-year follow-up study on a specialized inpatient rehabilitation program

OBJECTIVES

To evaluate the efficacy of a specialized inpatient rehabilitation program in patients with newly diagnosed epilepsy (NDE), who had been referred within 1 year after diagnosis.

METHODS

We performed an open, prospective, controlled study comparing a 1-year follow-up assessment of patients with NDE after completing a rehabilitation program at an epilepsy center (rehabilitation group) with a control group of patients with similar epilepsy duration, but without rehabilitation in the first year after diagnosis. Primary outcome measures comprised emotional adaptation to epilepsy, depression and anxiety; and secondary outcome measures were overall quality of life (QoL), overall health, perceived restrictions because of epilepsy, level of information about epilepsy, and employment status.

RESULTS

Comparison of the admission data of 74 rehabilitation group patients (mean age and SD 47.7 ± 13.0 years) with the pre-rehabilitation assessment of 56 control patients (45.5 ± 12.1 years) revealed no significant differences concerning sociodemographic and health data. Comparison of the follow-up assessment of the rehabilitation group and the pre-rehabilitation assessment of the control group showed significantly better values for the rehabilitation group on emotional adaptation to epilepsy (p = .003), overall QoL (p = .006) and overall health (p = .011), perceived restrictions because of epilepsy, and subjective level of information about epilepsy (both p's < .001). There were no statistically significant differences concerning depression and anxiety or employment status (all p's > .50). One year after rehabilitation, patients in the rehabilitation group were more often seizure-free and less often on sickness absence than control group patients (both p's < .001).

SIGNIFICANCE

Since reduced QoL shortly after diagnosis of NDE is associated with seizure recurrence, an early identification of patients with a greater need for support seems important. This epilepsy-related rehabilitation program showed lasting effects on several aspects of adaptation to epilepsy and QoL.

Microglia as a Game Changer in Epilepsy Comorbid Depression

As one of the most common neurological diseases, epilepsy is often accompanied by psychiatric disorders. Depression is the most universal comorbidity of epilepsy, especially in temporal lobe epilepsy (TLE). Therefore, it is urgently needed to figure out potential mechanisms and the optimization of therapeutic strategies. Microglia play a pivotal role in the coexistent relationship between epilepsy and depression. Activated microglia released cytokines like IL-6 and IL-1β, orchestrating neuroinflammation especially in the hippocampus, worsening both depression and epilepsy. The decrease of intracellular K+ is a common part in various molecular changes. The P2X7-NLRP3-IL-1β is a major inflammatory pathway that disrupts brain network. Extra ATP and CX3CL1 also lead to neuronal excitotoxicity and blood-brain barrier (BBB) disruption. Regulating neuroinflammation aiming at microglia-related molecules is capable of suspending the vicious mutual aggravating circle of epilepsy and depression. Other overlaps between epilepsy and depression lie in transcriptomic, neuroimaging, diagnosis and treatment. Hippocampal sclerosis (HS) and amygdala enlargement (AE) may be the underlying macroscopic pathological changes according to current studies. Extant evidence shows that cognitive behavioral therapy (CBT) and antidepressants like selective serotonin-reuptake inhibitors (SSRIs) are safe, but the effect is limited. Improvement in depression is likely to reduce the frequency of seizure. More comprehensive experiments are warranted to better understand the relationship between them.

Validation of the Seizure-Related Impact Assessment Scale (SERIAS): a study protocol

INTRODUCTION

This study aims to validate the Seizure-Related Impact Assessment Scale (SERIAS). This novel patient-reported outcome measure (PROM) compares the 'trade-off' between seizures and treatment-related adverse effects, and measures epilepsy disability qualitatively and quantitively. It fills an important gap in PROMs for epilepsy clinical trials and practice.

METHODS AND ANALYSIS

Adults with epileptologist-confirmed epilepsy from two Australian Epilepsy Centres are being recruited. People with functional seizures, or who are unable to self-complete English-language validated instruments are excluded. Participants providing informed consent are invited to complete questionnaires at baseline, 3 and 6 months later. SERIAS includes five questions that ask about the number of days per month that seizures or treatment-related adverse effects partially or fully impact work/home/school and family/social/non-work activities, as well as a visual analogue scale regarding epilepsy-related disability. SERIAS is completed alongside seven internationally validated instruments measuring treatment-related adverse effects, mood disorders and quality of life. Target recruitment is n=100, ensuring>50 people complete all questionnaires at all timepoints. Comprehensive psychometric analysis will be performed. Convergent validity will be investigated using bivariate correlations with relevant measures. Reliability will be investigated using Cronbach's alpha, McDonald's omega and test-retest correlation coefficients. SERIAS will be a novel PROM for epilepsy clinical trials and practice.

ETHICS AND DISSEMINATION

Multisite ethics approval was granted by the Alfred Health Ethics Committee (HREC 17/23). Results of this study will be disseminated through publication in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

ACTRN12623000599673.

The effect of 20-minute mindful breathing exercise on psychological well-being in epilepsy: A pilot randomized controlled trial

INTRODUCTION

Depression and anxiety are prevalent in epilepsy patients, but psychiatric or psychological services may not be accessible to all patients. This study aimed to determine the effectiveness of the 20-minute mindful breathing on the psychological well-being of PWE using an instructional video.

METHOD

This was a pilot, assessor-blinded, randomized controlled trial. The intervention group received a guided video and was briefed to perform the exercise twice a week for two weeks while the waitlist control group only received the video upon completion of the study. The subjects were assessed at three-time points (T0: Baseline, T1: 2 weeks after the intervention, T2: 4 weeks after intervention), using the Neurological Disorders Depression Index (NDDI-E), General Anxiety Disorder (GAD-7), Quality of Life in Epilepsy Inventory (QOLIE-31) and Mindfulness Attention Awareness Scale (MAAS).

RESULTS

Twenty patients were recruited, with 10 in the intervention and waitlist-control groups. Compared with the waitlist-control group, participants in the intervention group showed significant improvement in NDDI-E at T1 (p = 0.022) but not at T2 (p = 0.056) and greater improvement in GAD-7 at T1 and T2 but not statistically significant. The QOLIE-31 overall score in the intervention group has significantly improved at T1 (p = 0.036) and T2 (p = 0.031) compared to the waitlist-control group. For MAAS, the intervention group also had an increased score at T2 (p = 0.025).

CONCLUSION

The 20-minute mindfulness breathing exercise has an immediate effect in improving depression and quality of life among people with epilepsy.

Impact of depressive symptoms on adverse effects in people with epilepsy on antiseizure medication therapy

OBJECTIVE

We studied the impact of depressive symptoms on adverse effects (AEs) in people with epilepsy (PWE) on antiseizure medication (ASM) therapy. An effect of depression on the AE burden has already been reported. We studied the correlation of various depressive symptoms with specific AEs to assess which AEs are especially prone to being confounded by particular depressive symptoms.

METHODS

PWE filled in a variety of questionnaires including the "Neurological Disorder Depression Inventory for Epilepsy" (NDDI-E), "Emotional Thermometers 4" (ET4) and "Liverpool Adverse Events Profile" (LAEP). Depression was defined by a NDDI-E score > 13. Depressive symptoms consisted of NDDI-E and ET4 items. Discriminant analysis identified those AEs (=LAEP items) that were most highly influenced by depression. Logistic regression analysis yielded correlations of different depressive symptoms with specific AEs.

RESULTS

We included 432 PWE. The strongest discriminators for depression were the LAEP items "Depression", "Nervousness/agitation," and "Tiredness". Out of all depressive symptoms "Everything I do is a struggle" most strongly correlated with total LAEP score (odds ratio [OR] = 3.1) and correlated with all but one LAEP item. Other depressive symptoms correlated to varying degrees with total LAEP and item scores. The number of ASMs, lack of seizure remission, and female gender correlated with high LAEP scores.

SIGNIFICANCE

To the best of our knowledge, we are the first to show that various depressive symptoms correlate with specific LAEP items. This information can be helpful for quick evaluation of whether the reporting of different LAEP items may be confounded by particular depressive symptoms. This is relevant because changes in therapy may differ depending on if AEs are confounded by depressive symptoms. Simply reporting a particular depressive symptom may give a clue to whether specific AEs are confounded by depression. Our findings confirm the importance of screening for depression in all PWE.

PLAIN LANGUAGE SUMMARY

In this study we measured depressive disorder and side effects caused by medication used to treat epilepsy with self-reported questionnaires in a cohort of people with epilepsy. We found depressive disorder to influence the perception of side effects that are caused by drugs used to treat epilepsy. This knowledge can help to identify if the reporting of side effects is influenced by depression. Treating depression may help to reduce side effects and may thus increase the tolerability of anti-epileptic medication. People who tolerate their medication are more likely to take it and are thus less likely to develop epileptic seizure.

Anticipatory anxiety of seizures in epilepsy: A common, complex, and underrecognized phenomenon?

The diagnosis of epilepsy is associated with loss of predictability, which invariably results in the fear of when and if future seizures will occur. For a subset of patients with epilepsy (PWE), there may be a pathological persistent fear of seizure occurrence, resulting in limitations to daily activities through avoidant behaviors. Paradoxically, the research of anticipatory anxiety of seizures (AAS; also referred to as seizure phobia) has been practically nonexistent and, not surprisingly, this condition remains underrecognized by clinicians. The available data are derived from three small case series of patients followed in tertiary epilepsy centers. In this study, we review the available data on the reported clinical manifestations of AAS in PWE, and of the potential role of variables associated with it, such as personal and family psychosocial and psychiatric history and epilepsy-related variables. In addition, we review the need for the creation of screening tools to identify patients at risk of AAS and discuss potential treatment strategies, which could be considered as part of the comprehensive management for PWE.

A multicenter, matched case-control analysis comparing burden of illness among patients with tuberous sclerosis complex related epilepsy, generalized idiopathic epilepsy, and focal epilepsy in Germany

BACKGROUND

Depending on the underlying etiology and epilepsy type, the burden of disease for patients with seizures can vary significantly. This analysis aimed to compare direct and indirect costs and quality of life (QoL) among adults with tuberous sclerosis complex (TSC) related with epilepsy, idiopathic generalized epilepsy (IGE), and focal epilepsy (FE) in Germany.

METHODS

Questionnaire responses from 92 patients with TSC and epilepsy were matched by age and gender, with responses from 92 patients with IGE and 92 patients with FE collected in independent studies. Comparisons were made across the main QoL components, direct costs (patient visits, medication usage, medical equipment, diagnostic procedures, ancillary treatments, and transport costs), indirect costs (employment, reduced working hours, missed days), and care level costs.

RESULTS

Across all three cohorts, mean total direct costs (TSC: €7602 [median €2620]; IGE: €1919 [median €446], P < 0.001; FE: €2598 [median €892], P < 0.001) and mean total indirect costs due to lost productivity over 3 months (TSC: €7185 [median €11,925]; IGE: €3599 [median €0], P < 0.001; FE: €5082 [median €2981], P = 0.03) were highest among patients with TSC. The proportion of patients with TSC who were unemployed (60%) was significantly larger than the proportions of patients with IGE (23%, P < 0.001) or FE (34%, P = P < 0.001) who were unemployed. Index scores for the EuroQuol Scale with 5 dimensions and 3 levels were significantly lower for patients with TSC (time-trade-off [TTO]: 0.705, visual analog scale [VAS]: 0.577) than for patients with IGE (TTO: 0.897, VAS: 0.813; P < 0.001) or FE (TTO: 0.879, VAS: 0.769; P < 0.001). Revised Epilepsy Stigma Scale scores were also significantly higher for patients with TSC (3.97) than for patients with IGE (1.48, P < 0.001) or FE (2.45, P < 0.001). Overall Quality of Life in Epilepsy Inventory-31 items scores was significantly lower among patients with TSC (57.7) and FE (57.6) than among patients with IGE (66.6, P = 0.004 in both comparisons). Significant differences between patients with TSC and IGE were also determined for Neurological Disorder Depression Inventory for Epilepsy (TSC: 13.1; IGE: 11.2, P = 0.009) and Liverpool Adverse Events Profile scores (TSC: 42.7; IGE: 37.5, P = 0.017) with higher score and worse results for TSC patients in both questionnaires.

CONCLUSIONS

This study is the first to compare patients with TSC, IGE, and FE in Germany and underlines the excessive QoL burden and both direct and indirect cost burdens experienced by patients with TSC.

Evaluating the prevalence and risk factors for depression in patients with temporal lobe epilepsy with hippocampal sclerosis: A cross-sectional multicenter study

BACKGROUND

Epilepsy frequently accompanies Major Depressive Disorder (MDD). Notably, people with temporal lobe epilepsy and hippocampal sclerosis may face an increased susceptibility to MDD, as evidence indicates the involvement of the limbic system in the development of emotional symptoms.

OBJECTIVES

To determine the prevalence and predictors of depression in temporal lobe epilepsy with hippocampal sclerosis (TLE-HS) and compare them to those of other epilepsy types.

METHODS

A sample of 293 epilepsy patients, including 159 non-TLE-HS and 134 TLE-HS, were recruited from three hospitals. Of these, 215 completed a two-section electronic survey. The first section collected demographic and epilepsy data, while the second used the Arabic version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E).

RESULTS

Of 215 patients, 104 (48%) had TLE-HS-38 with right TLE-HS (37%), 56 with left TLE-HS (54%), and 10 with bilateral TLE-HS (10%). The prevalence and severity of depression was assessed with an NDDI-E score of 15 or higher identified 35 patients (16%) with MDD. Valproic acid and lamotrigine were associated with higher NDDI-E scores. No such associations were found for levetiracetam or carbamazepine. Polytherapy in TLE-HS showed a significant correlation with daily poor concentration.

CONCLUSION

We explored the differences in depression prevalence between TLE-HS and other epilepsy types and concluded they are minimal but slightly higher in TLE-HS. Predictors of depression such as seizure frequency and disease duration influenced MDD prevalence in TLE-HS. Lamotrigine and valproate were linked to higher NDDI-E scores.

Relationships among anxiety, depression, and health-related quality of life in adult epilepsy: A network analysis

OBJECTIVE

Comorbid depression and anxiety in patients with epilepsy (PWE) are common and frequently under-treated, thus, causing poor health-related quality of life (HRQoL). However, little is known regarding the interconnections between anxious/depressive symptoms and the dimensions of HRQoL. Therefore, we conducted a network analysis to explore these relationships in detail among Chinese adult PWE.

METHODS

A cohort of adult PWE was consecutively recruited from the First Affiliated Hospital of Chongqing Medical University. HRQoL, depression, and anxiety were measured with Quality of Life in Epilepsy Inventory-31, Neurological Disorders Depression Inventory for Epilepsy, and Generalized Anxiety Disorder 7-Item Scale, respectively. A regularized partial correlation network was constructed to investigate the interconnections between symptoms of anxiety/depression and the dimensions of HRQoL. We calculated expected influence (EI) and bridge expected influence (BEI) values to identify the most influential nodes.

RESULTS

A total of 396 PWE were enrolled in this study, 78.1% of whom had focal onset epilepsy. The prevalence of anxiety and depression was 30.3% and 28.8%, respectively. The symptoms "frustrated" and "uncontrollable worry" had the highest EI values, whereas "emotional well-being", "seizure worry", "difficulty finding pleasure", and "nervousness or anxiety" had the highest BEI values.

CONCLUSION

This study provides new insights into the relationships among anxiety, depression, and HRQoL. Critical central symptoms and bridge symptoms identified in the network might help to quickly identify PWE comorbid anxiety and depression in busy outpatient settings, thereby enabling early intervention and enhancing quality of life.

Comparative effectiveness of digital mental healthcare models for adults with epilepsy: A study protocol of a randomized controlled trial

OBJECTIVE

Mental health complaints are prevalent among people with epilepsy, yet there are major barriers that prevent access to psychological care, including high out-of-pocket costs and a lack of accessible specialized services. The purpose of the current study is to examine the comparative efficacy, acceptability, cost-effectiveness, and long-term outcomes of a digital psychological intervention when delivered under two models of care (i.e., guided vs. unguided) in supporting the mental health and functioning of adults with epilepsy.

METHOD

Approximately 375 participants across Australia will be enrolled. Eligible participants will have a confirmed diagnosis of epilepsy, experience difficulties with their emotional health, be at least 18 years of age, and live in Australia. Participants will be randomized (2:2:1) to receive the Wellbeing Neuro Course, a 10-week internet-delivered program, with (i.e., guided) or without guidance by a mental health clinician (i.e., unguided), or be allocated to a treatment-as-usual waiting-list control group. Participants will complete online questionnaires at pre-, post-treatment, and 3- and 12-month follow-up and consent to have their data linked to their medical records to capture healthcare system resource use and costs.

ANALYSIS

Primary outcome measures will be symptoms of depression and anxiety. A cost-utility analysis will be undertaken using the Australian healthcare system perspective and according to current economic evaluation guidelines. Resource use and costs to the healthcare system during the study period will be captured via data linkage to relevant administrative datasets in Australia.

SIGNIFICANCE

The results of this trial will provide important data concerning the relative outcomes of these different models of care and will inform the integration of digital psychological interventions translation into healthcare services.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of Macquarie University approved the proposed study (Reference No: 520231325151475). The results will be disseminated through peer-reviewed publication(s).

ANZCTR TRIAL REGISTRATION NUMBER

ACTRN12623001327673.

PLAIN LANGUAGE SUMMARY

This study seeks to find out if a 10-week online psychological treatment can improve the mental health and well-being of Australian adults with epilepsy. Around 375 participants will be randomly assigned to different groups: one will receive treatment with guidance from mental health clinician (guided group), one without guidance (unguided group), and one starting later (waiting control group). All participants will fill out the same outcome measures online. The main goal of this research is to compare these groups and assess how well the treatment works in improving mental health outcomes.

Attention-deficit hyperactivity disorder in adults with epilepsy: An indirect relationship with suicide risk

PURPOSE

Studies on attention-deficit hyperactivity disorder (ADHD) are scarce in adults with epilepsy. This study aimed to investigate the risk factors for ADHD and determine whether ADHD is directly associated with the risk of suicide in adults with epilepsy.

METHODS

ADHD was assessed using the Structured Clinical Interview for the DSM-5 Disorders Clinical Version. The Mini International Neuropsychiatric Interview (MINI) Plus 5.0.0, Neurological Disorders Depression Inventory for Epilepsy (NDDIE), and Generalized Anxiety Disorder-7 (GAD-7) were also used. Suicide risk was defined as a MINI suicidality score of ≥ 1. Stepwise logistic regression and mediation analyses were conducted.

RESULTS

Of the 157 adults with epilepsy, 19 (12.1 %) were diagnosed with ADHD, including inattentive (5.7 %), hyperactive (3.8 %), and combined (2.5 %) types. Thirty-two subjects (20.4 %) had a risk of suicide. ADHD was insignificantly associated with any epilepsy-related factors. The diagnosis of ADHD was not associated with suicide risk independent of NDDIE ≥ 14 and GAD-7 ≥ 7. Mediation effects of ADHD on suicidality using NDDIE ≥ 14 (odds ratio [OR] 2.850, 95 % confidence interval [CI] 1.398-5.811, p = 0.004) or GAD-7 ≥ 7 (OR 3.240, 95 % CI 1.537-6.828, p = 0.002) were statistically significant, with the proportion mediated being 84.5 % or 92.0 % of the total ADHD effect, respectively. These models were adjusted for age, sex, and composite epilepsy severity scores.

CONCLUSIONS

ADHD was diagnosed in 12.1% of adults with epilepsy and was not associated with any epilepsy-related factors. ADHD was indirectly associated with the risk of suicide resulting from depression and anxiety in adults with epilepsy.

Maladaptive personality traits in patients with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

We aimed to evaluate the sociodemographic, clinical, and psychological characteristics associated with psychogenic non-epileptic seizures (PNES) in patients with epilepsy, with particular emphasis on the personality profile assessed from a dimensional perspective.

METHODS

The cohort study included 77 consecutive inpatients with active epilepsy aged 36-55 years; 52 (67.5%) were female. The presence of PNES was confirmed by video-EEG monitoring. All patients underwent the Mini-International Neuropsychiatric Interview to diagnose psychiatric disorders. All participants completed the Neurological Disorders Depression Inventory in Epilepsy, the Epilepsy Anxiety Survey Instrument - brief version, and the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus Modified. Chi-square and Fisher's exact tests were used to compare categorical variables, and the Brunner-Munzel test was used for quantitative variables.

RESULTS

Twenty-four patients (31.2%) had both epilepsy and PNES. There were no significant differences in social, demographic or clinical characteristics, psychiatric diagnoses or depression severity. Compared to patients with epilepsy alone, patients with epilepsy and PNES had higher anxiety scores and more pronounced maladaptive personality traits such as disinhibition and psychoticism.

SIGNIFICANCE

The main novelty of our study is that using the recently proposed dimensional approach to personality disorders and an appropriate instrument we assessed all personality domains listed in two of the most widely used classifications of mental disorders (DSM-5 and ICD-11) in PWE with and without PNES. To our knowledge, this is the first study to demonstrate the association of the maladaptive traits of psychoticism and disinhibition with the development of PNES in PWE.

Experiences of using the MINDSET Self-Management mobile health app among Hispanic Patients:Results of a qualitative study

BACKGROUND

Interventions focusing on epilepsy self-management (ESM) are vital for promoting the health of people living with epilepsy. E-technology and mobile health (mHealth) tools are becoming increasingly integrated into practice to promote self-management strategies for chronic diseases, enhance care delivery, and reduce health disparities. Management Information and Decision Support Epilepsy Tool (MINDSET), a bilingual decision support tool (available in English and Spanish), was found to be both feasible and effective in facilitating goal-based ESM in the clinic.

PURPOSE

To assess the experience of using MINDSET as an ESM intervention among Hispanic patients with epilepsy to inform future interventional studies.

METHODS

This study used a Qualitative Descriptive (QD) framework to provide a rich and straightforward description of patients' subjective experiences using MINDSET. Participants were enrolled in the intervention group of a larger parent study (RCT) to assess the efficacy of MINDSET among Hispanic People with Epilepsy (PWE). The purposive, convenient, criterion-based sample for this qualitative analysis comprised of 42 patients who agreed to participate in a semi-structured interview at the end of the larger RCT. This RCT was conducted between August 2017 and January 2019. Spanish and English-speaking Hispanic adult patients (n = 94) with epilepsy in Arizona (n = 53) and Texas (n = 41) were randomly assigned within 6 neurology clinics to treatment (MINDSET plus Usual Care, hereafter referred to as MINDSET; n = 46) and comparison (Usual Care Only; n = 48) conditions.

RESULTS

Patient demographics, epilepsy conditions, and ESM behavioral characteristics were representative of the intervention group. Study participants were Hispanic, mainly of Mexican descent (94 %), with a mean age of 39 years, mostly female (53 %), and most of the participants reported having had one or more seizures per month (54 %). The MINDSET intervention revealed five ESM themes: (1) Awareness and Realization of Epilepsy Self-Management, (2) Communication and Partnership with Health Care Providers HCP, (3) Epilepsy Self-Management and Quality of Life, (4) Seizure Control, and (5) Optimism and Agency.

CONCLUSION

The participants who used MINDSET as a self-management intervention reported an overall positive experience. Qualitative data in this study show that MINDSET is a valuable ESM tool for Hispanic patients with epilepsy. Findings from this qualitative study were consistent with results from a larger parent study that recognized MINDSET as an effective platform for improving epilepsy self-management adherence.

Management of anhedonia after epilepsy surgery

Anhedonia is clinically defined as difficulty or inability to feel pleasure or to be motivated to perform activities that were previously pleasurable. Anhedonia is a core feature of depressive disorders but can be present in other conditions such as substance use and anxiety disorders. Herein we report the case of a 34-year-old female who developed marked anhedonia after left cortico-amygdalohippocampectomy. Despite optimal seizure control, the person struggled with anhedonia and other depressive symptoms. After ruling out medico-neurologic complications, she was prescribed with a selective serotonin reuptake inhibitor and cognitive-behavioral therapy. Anhedonia can be a challenging neuropsychiatric presentation that requires ruling out the effects of antiseizure medications, neurosurgery, and other drugs before prescribing antidepressants.

Mood disorders in adults with epilepsy: a review of unrecognized facts and common misconceptions

Epilepsy is one of the most common neurologic conditions. Its clinical manifestations are not restricted to seizures but often include cognitive disturbances and psychiatric disorders. Prospective population-based studies have shown that people with epilepsy have an increased risk of developing mood disorders, and people with a primary mood disorder have an increased risk of developing epilepsy. The existence of common pathogenic mechanisms in epilepsy and mood disorders may explain the bidirectional relation between these two conditions. Recognition of a personal and family psychiatric history at the time of evaluation of people for a seizure disorder is critical in the selection of antiseizure medications: those with mood-stabilizing properties (e.g., lamotrigine, oxcarbazepine) should be favoured as a first option in those with a positive history while those with negative psychotropic properties (e.g., levetiracetam, topiramate) avoided. While mood disorders may be clinically identical in people with epilepsy, they often present with atypical manifestations that do not meet ICD or DSM diagnostic criteria. Failure to treat mood disorders in epilepsy may have a negative impact, increasing suicide risk and iatrogenic effects of antiseizure medications and worsening quality of life. Treating mood disorders in epilepsy is identical to those with primary mood disorders. Yet, there is a common misconception that antidepressants have proconvulsant properties. Most antidepressants are safe when prescribed at therapeutic doses. The incidence of seizures is lower in people randomized to antidepressants than placebo in multicenter randomized placebo-controlled trials of people treated for a primary mood disorder. Thus, there is no excuse not to prescribe antidepressant medications to people with epilepsy.

Quality of life in people with epilepsy: The associations of anti-seizure medications and biopsychosocial variables

People with epilepsy, on average, experience lower quality of life (QOL) than healthy controls. This study examined the associations between specific anti-seizure medications, biopsychosocial factors, and QOL in people with epilepsy. Analysis of covariance revealed that individuals taking three or more anti-seizure medications had significantly lower QOL than those taking levetiracetam. Findings also demonstrated that when examining biopsychosocial factors as predictors of QOL in hierarchical regression, anxiety, depression, and daytime sleepiness were significant predictors of QOL. Once these factors were entered into the model, number of medications was no longer significant. The final model predicted 59.6% of the variance in QOL. In clinical settings, providers should take a patient-centered approach that includes regular assessment of QOL and an emphasis on good psychological care for those coping with anxiety, depression, and sleep difficulty. These findings underscore the importance of addressing psychological health and sleep factors within the epilepsy population.

What is the role of screening instruments in the management of psychiatric comorbidities in epilepsy? Tools and practical tips for the most common comorbidities: Depression and anxiety

Depression and anxiety are the most common psychiatric comorbidities in epilepsy and are known to increase healthcare utilization, the risk of refractory epilepsy, and anti-seizure medication intolerability. Despite this, depression and anxiety continue to be underrecognized and undertreated in people with epilepsy (PWE). Several barriers to the identification of depression and anxiety in PWE exist, including reliance on unstructured interviews rather than standardized, validated instruments. Moreover, there is a dearth of behavioral health providers to manage these comorbidities once identified. The use of validated screening instruments in epilepsy clinics can assist with both the identification of psychiatric symptoms and monitoring of treatment response by the epilepsy clinician for PWE with comorbid depression and/or anxiety. While screening instruments can identify psychiatric symptoms occurring within a specified time, they are not definitively diagnostic. Screeners can be time efficient tools to identify patients requiring further evaluation for diagnostic confirmation. This article reviews recent literature on the utility of depression and anxiety screening instruments in epilepsy care, including commonly used screening instruments, and provides solutions for potential barriers to clinical implementation. Validated depression and anxiety screening instruments can increase identification of depression and anxiety and guide epilepsy clinician management of these comorbidities which has the potential to positively impact patient care.

Expert opinion on diagnosis and management of epilepsy-associated comorbidities

Apart from seizure freedom, the presence of comorbidities related to neurological, cardiovascular, or psychiatric disorders is the largest determinant of a reduced health-related quality of life in people with epilepsy (PwE). However, comorbidities are often underrecognized and undertreated, and clinical management of comorbid conditions can be challenging. The focus of a comprehensive treatment regimen should maximize seizure control while optimizing clinical management of treatable comorbidities to improve a person's quality of life and overall health. A panel of four European epileptologists with expertise in their respective fields of epilepsy-related comorbidities combined the latest available scientific evidence with clinical expertise and collaborated to provide consensus practical advice to improve the identification and management of comorbidities in PwE. This review provides a critical evaluation for the diagnosis and management of sleep-wake disorders, cardiovascular diseases, cognitive dysfunction, and depression in PwE. Whenever possible, clinical data have been provided. The PubMed database was the main search source for the literature review. The deleterious pathophysiological processes underlying neurological, cardiovascular, or psychiatric comorbidities in PwE interact with the processes responsible for generating seizures to increase cerebral and physiological dysfunction. This can increase the likelihood of developing drug-resistant epilepsy; therefore, early identification of comorbidities and intervention is imperative. The practical evidence-based advice presented in this article may help clinical neurologists and other specialist physicians responsible for the care and management of PwE.

Validity and reliability study of the turkish version epilepsy self-stigma scale (ESSS-T)

AIM

We translated the Epilepsy Self-stigma Scale (ESSS) into Turkish and aimed to examine the Turkish version ESSS (ESSS-T) validity and reliability.

MATERIALS AND METHOD

From April to August 2023, patients with epilepsy (PWE) were recruited from the neurology outpatient clinic of Ataturk University Hospital in the eastern Turkish city of Erzurum (inclusion criteria: age 18 years or older and adequate reading and speaking ability in Turkish). We conducted our survey using a self-administered questionnaire. The questionnaire consisted of the ESSS-T after appropriate translation by back-translation, and self-esteem (the Rosenberg's Self-Esteem Scale, RSES), depression (the Neurological Disorders Depression Inventory for Epilepsy, NDDI-E), and general stigma (the Stigma Scale for Epilepsy, ESE) for construct validity. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to test factorial validity. Also, Cronbach's alpha coefficient was calculated to verify reliability.

RESULTS

Of the 126 patients, 106 agreed to give informed consent and responded to the questionnaire (84.1 % response rate). The results of EFA suggested the same three-factor structure as in the original version, but CFA showed some limitations in interpreting the three-factor structure and it may be safer to understand it as a unifactorial structure. The alpha coefficients were also validated by the ESSS-T. The alpha coefficients were α = 0.74 for the ESSS-T scale as a whole and α = 0.69-0.74 for each subscale, which were generally acceptable values.

CONCLUSION

The Turkish version of the ESSS proved valid and reliable. It is a measurement tool with a three-dimensional structure. It can be used to assess the self-stigmatization of patients with epilepsy in Turkey.

Effect of drug treatment changes and seizure outcomes on depression and suicidality in adults with drug-resistant focal epilepsy

OBJECTIVE

To investigate changes in depressive and suicidality status and their relationship with seizure outcomes after the addition or substitution of another antiseizure medication (ASM) in adults with drug-resistant focal epilepsy.

METHODS

Seven hundred seventy consecutively enrolled patients were assessed and followed prospectively for seizure outcome and depressive status over a 6-month period after starting treatment with a newly introduced ASM. The Neurological Disorders Depression Inventory for Epilepsy (NDDIE) was used to screen for depression and suicidality. Correlations of NDDIE results with clinical and treatment-related variables were assessed by using a stepwise logistic regression model.

RESULTS

At baseline, 50% of patients had a positive screening test result for depression and 13% had a positive screening test result for suicidal ideation. A psychiatric comorbidity at baseline was associated with a 2.3 times increased risk of an initially negative NDDIE screening result becoming positive at re-assessment after 6 months. In addition, the number of ASMs taken at baseline correlated with an increased risk of a change in depression screening test results from negative to positive during follow-up, whereas no association was identified with sociodemographic and epilepsy-related variables, including seizure outcomes. Approximately 6% of patients who were initially negative at screening for suicidal ideation became positive at the 6-month re-assessment. The risk of switch from a negative to a positive screening test result for suicidal ideation was increased more than two-fold in individuals who screened positive for depression at baseline, and was unrelated to the type of ASM introduced, sociodemographic variables, or seizure outcomes.

SIGNIFICANCE

Almost 1 in 5 adults with drug-resistant focal epilepsy who screen negative for depression become positive when re-assessed 6 months after a treatment change. At re-assessment 6 months later, 6.1% who screen initially negative for passive suicidal ideation become positive. These changes in screening status are independent of type of ASM introduced or seizure outcomes but correlate with psychiatric status at baseline.

Panic disorder in epilepsy

A 51-year-old woman showed structural epilepsy following an atypical, nontraumatic intracranial hemorrhage in the right frontal area. Despite successful seizure control with lamotrigine, she developed severe morning anxiety and panic attacks, leading to agoraphobia, social withdrawal, and psychogenic nonepileptic seizures. Neuropsychiatric and psychological assessments confirmed an anxiety disorder with no significant symptoms of depression. The patient received various psychopharmacological treatments with limited success. This case report illustrates that managing panic disorder in patients with structural epilepsy requires a comprehensive treatment approach that includes pharmacotherapy and psychotherapy. Differential diagnosis and accurate treatment are crucial because of the symptom overlap between panic attacks and peri-ictal fear. Screenings instruments such as the Panic and Agoraphobia Scale (PAS) can aid in assessing anxiety-related symptoms. First-line pharmacotherapy with selective serotonin reuptake inhibitors, especially sertraline, or venlafaxine can effectively reduce panic attacks and can be recommended in patients with epilepsy. Psychotherapy, particularly cognitive-behavioral therapy, is the treatment of choice. Referral to a psychiatrist is indicated when symptoms are severe or refractory to treatment.

A Prospective Post-Marketing Observational Study of Brivaracetam in People With Focal Epilepsy

We evaluated the effectiveness and tolerability of brivaracetam (BRV), an adjunctive antiseizure medication, as a treatment for focal epilepsy in adults. In this prospective study, we enrolled 51 participants from 3 sites across Canada. At 6 months, 68% (26/38) of participants were still taking BRV, among whom 35% (8/23) attained seizure freedom and 48% (11/23) saw their seizure frequency reduced by over 50%. We did not measure any significant change in irritability, quality of life, depression, and anxiety while treated with BRV. Our findings suggest BRV is effective in reducing seizure frequency among adults with focal epilepsy.

A protocol for a pooled analysis of cohort studies: The association between depression and anxiety in epileptic disorders

BACKGROUND/INTRODUCTION

Depressive and anxiety disorders constitute major mental health challenges affecting adults of all ages globally. It has been reported that individuals with depressive or anxiety disorders face an elevated risk of developing neurological conditions, including seizures and epilepsy. Additionally, people with these disorders tend to exhibit distinct clinical outcomes compared to the general population. However, the associations between depressive or anxiety disorders and epilepsy remain contentious. Thus, this study aims to elucidate the associations between these neuropsychiatric disorders, including depressive and anxiety disorders, and epilepsy or seizures.

METHODS

We will systematically search three electronic databases-PubMed, EMBASE, and the Cochrane Library-from inception through March 2023 to identify relevant cohort studies investigating the associations between depressive or anxiety disorders and epilepsy or seizures. Two independent reviewers will extract data from eligible studies using pre-designed standardized data extraction forms, and cross-check results. A third author will resolve any discrepancies. Quality assessment will be performed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Pooled risk estimates (Relative risks or hazard ratios with their 95% CI) will be calculated using the DerSimonian-Laird random-effects model. If between-study heterogeneity is identified, we will conduct subgroup analyses or meta-regressions to explore the possible sources of heterogeneity (participants, exposure, outcome, and study design) stratified by various study characteristics. Potential publication bias will be detected through the inspection of funnel plot asymmetry, complemented by the Egger linear regression approach (Egger's test) and the Begg rank correlation test (Begg's test).

DISCUSSION

This pooled analysis will evaluate the association between depressive or anxiety disorders and epilepsy or seizures, providing high-level evidence to inform early identification and prevention strategies for epilepsy or seizures.

ETHICS AND DISSEMINATION

Given that the data utilized for analysis in this pooled analysis does not involve human subjects or medical records, no ethical approval is required for this study. We intend to present the results of this study at national or international conferences or submit the findings to a peer-reviewed journal.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/WM2X8.

Can family members reliably assess mood and suicidal ideation in individuals with epilepsy?

BACKGROUND

Routine detection of depression, anxiety and suicidal ideation in people with epilepsy (PWE) remains suboptimal. We investigated the level of agreement between PWE and their proxies when evaluating these psychiatric symptoms.

METHODS

From October 2021 to March 2022, we conducted a cross-sectional anonymous survey at Vilnius University Hospital Santaros Klinikos (Vilnius, Lithuania). Persons accompanying PWE completed different scales measuring symptoms of depression and anxiety and evaluated suicidal ideation among PWE (defined as a non-zero score of the suicide item of the Beck depression inventory (BDI) or as a score > 1 of the item 4 of the Neurological Disorders Depression Inventory for Epilepsy, NDDI-E). Agreement between PWE and their proxies was measured using the Wilcoxon test for paired samples and Pearson's correlation analysis.

RESULTS

The study included 140 PWE (mean age 41.0 ± 18.1, 71 (50.7 %) female) and 140 proxies (mean age 49.0 ± 15.01, 105 (75.0 %) female, 57 (40.7 %) were parents, 51 (36.4 %) - spouses, 15 (10.7 %) - partners, 11 (7.9 %) - children and 6 (4.3 %) - siblings of PWE). There were no statistical differences in paired scores of the BDI, Hospital Anxiety and Depression scale, Generalized Anxiety Disorder scale-7, and the NDDI-E (p > 0.05). Proxies reported statistically higher scores on the Geriatric Depression Scale (Z =  - 2.026, p = 0.043) than PWE. The correlation between PWE and proxy evaluations for all instruments was moderate (varying from r = 0.500 to r = 0.688, p < 0.001). For most psychometric scales proxies became less accurate with higher scale scores for anxiety and depression and tended to underestimate the level of such symptoms (correlation between scale results and signed (PWE - proxy) mismatch varied from r = 0.368 to r = 0.641, p < 0.001). The measure of proxy-PWE agreement on suicidal ideation was low (Cohen's Κ = 0.192, p = 0.025); proxies missed 63 % (NDDI-E) to 70 % (BDI) of cases of suicidal ideation.

CONCLUSION

Companions of PWE provided comparable reports of participant anxiety and depression on a group level but tended to underestimate psychiatric symptoms as their scale scores became higher. Proxies significantly underreported suicidal ideation in those people who did express it. While proxy reporting should not be used interchangeably on an individual level, its use in group studies may be useful and ought to be investigated further.

Psychometric evaluation of the Serbian version of the Stigma Scale of Epilepsy (SSE)

OBJECTIVE

To evaluate the psychometric properties of the Serbian-language version of the Stigma Scale of Epilepsy (SSE).

METHODS

The sample consisted of 108 patients with epilepsy (PWE) (60.2 % were female, age range: 19-67 years) and 102 students (86.3 % were female, age range: 18-47 years). The study encompassed two phases: (1) translation of the SSE into Serbian using the back-translation technique, and (2) evaluation of reliability and construct validity of the Serbian-language version of SSE. In addition to the SSE, the PWE filled out a Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). The socio-demographic and clinical variables were noted for each patient by the semistructured interview. Besides completing the SSE, the students were asked if they knew anyone with epilepsy. The reliability of the questionnaire was tested by assessing the internal consistency of the scale (Cronbach's α), while construct validity was assessed by factor analysis, method of known-groups validation, and correlation analysis.

RESULTS

SSE demonstrates a satisfactory level of reliability in both samples, with Cronbach's α of 0.86 in the PWE sample and 0.90 in the student sample. Using exploratory factor analysis, four factors were identified in both samples, corresponding relatively well with the scale domains originally produced, with a few exceptions described. Adverse effects (AEs) of antiseizure medications (ASMs) and driving ability significantly influenced SSE scores, but there were no significant effects of other socio-demographic and clinical variables on epilepsy-related stigma in the PWE sample. In addition, depression severity significantly influenced SSE scores (based on NDDI-E cut-off score), with the SSE showing a positive association with PHQ-9 (r = 0.42, p < .001) and GAD-7 (r = 0.35, p < .001) as well. Regarding the student sample, the effects of personal knowledge of someone with epilepsy on SSE scores were found to be significant. Besides, students (M = 46.28, SD = 16.43) reported higher epilepsy-related stigma than patients (M = 40.66, SD = 17.01), t(208) = 2.43, p < .05, d = 0.34.

CONCLUSION

The Serbian version of the SSE has good psychometric properties and represents a useful tool for assessing epilepsy-related stigma in both patients and the general population.

Family support in adults with epilepsy

BACKGROUND

 The perception of family support in chronic disease can be relevant.

OBJECTIVE

 To assess the perception of family support in adult patients with epilepsy (PWEs) and relate it to quality of life (QoL) and clinical aspects.

METHODS

 Data from the Perceived Family Support Inventory (IPFS) of 130 PWEs were related to the clinical variables, QOLIE-31 scores, and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) with statistical tests, with p < 0.05.

RESULTS

 The mean age was 49.9 ± 17.2 years, and the duration of epilepsy was 20.8 ± 15.4 years. The presence of depression (scores ≥ 15) was associated with lower family support. Being married and non-occurrence of depression were the variables associated with a higher IPFS score (R = 0.2112), in the multiple linear regression.

CONCLUSION

 The perception of greater family support was associated with demographic aspects, the absence of depression, and better QoL. Family relationships may play an essential role in health adjustment behaviors and QoL in epilepsy.

Prevalence of suicidality in children and adolescents with depressive disorders with and without epilepsy

OBJECTIVE

Children with epilepsy (CWE) are at risk for a range of adverse emotional, behavioral, and social outcomes. Approximately one-third of CWE experience depressive disorders, and up to 20% of children and adolescents with epilepsy may experience suicidality, suggesting that epilepsy increases the risk for suicidality among children and adolescents with depressive disorders. Consequently, the goal of the present study is to compare rates of suicidality in children and adolescents diagnosed with depressive disorders with or without co-morbid epilepsy.

PARTICIPANTS AND METHODS

A retrospective chart review was conducted for 100 pediatric patients with a history of both seizures and depressive disorders and 100 patients with a history of depressive disorders only. Cases were coded for depression diagnosis, suicidality, suicidal ideation, suicide attempts, psychiatric hospitalizations, and self-injury. The distributions of these variables for the two groups were compared.

RESULTS

The age and sex distributions of the two groups were comparable. Patients with co-morbid depressive disorders and epilepsy found a high rate of suicidal ideation (69%) but did not differ from those with depressive disorders without epilepsy on any of the suicidality variables (all p > 0.20), with the exception of self-injury, which was higher in those without epilepsy.

CONCLUSIONS

CWE and co-morbid depression are at significant risk for suicidality, including ideation, attempts, and hospitalizations, but at rates that are comparable to those with depressive disorders without seizures. However, patients with co-morbid epilepsy are less likely to engage in other self-injurious behaviors. These findings support the need for careful monitoring of the psychiatric status of children and adolescents with epilepsy.

Rehabilitation of cognition and psychosocial well-being - a better life with epilepsy (ReCaP-ABLE): a protocol for a randomized waitlist-controlled trial

Despite advances in the understanding of cognitive dysfunction among people with epilepsy (PWE), evidence for cognitive rehabilitation in epilepsy (CoRE) remains scarce. We present the protocol of a randomized waitlist-controlled trial (ClinicalTrials.gov ID NCT05934786) of a psychological-behavioral intervention aiming to ameliorate quality of life as well as cognitive functioning in a mixed PWE sample. The study is set at Vilnius University Hospital Santaros Klinikos and will offer adult PWE six individual and two group sessions led by a certified psychologist and directed toward improving memory, attention, self-regulation, mood and quality of life. The trial is expected to address major gaps in the literature by providing novel evidence on the effectiveness of CoRE in patients with genetic generalized epilepsies, the importance of epilepsy-specific factors for the response to CoRE, the impact of CoRE on long-term memory as well as its maintenance effects.

Phase II randomised placebo-controlled trial of sodium selenate as a disease-modifying treatment in chronic drug-resistant temporal lobe epilepsy: the SeLECT study protocol

INTRODUCTION

Epilepsy is one of the most common neurological conditions worldwide. Despite many antiseizure medications (ASMs) being available, up to one-third of patients do not achieve seizure control. Preclinical studies have shown treatment with sodium selenate to have a disease-modifying effect in a rat model of chronic temporal lobe epilepsy (TLE).

AIM

This randomised placebo-controlled trial aims to evaluate the antiseizure and disease-modifying effects of sodium selenate in people with drug-resistant TLE.

METHODS

This will be a randomised placebo-controlled trial of sodium selenate. One hundred and twenty-four adults with drug-resistant TLE and ≥4 countable seizures/month will be recruited. Outcomes of interest will be measured at baseline, week 26 and week 52 and include an 8-week seizure diary, 24-hour electroencephalogram and cognitive, neuropsychiatric and quality of life measures. Participants will then be randomised to receive a sustained release formulation of sodium selenate (initially 10 mg three times a day, increasing to 15 mg three times a day at week 4 if tolerated) or a matching placebo for 26 weeks.

OUTCOMES

The primary outcome will be a consumer codesigned epilepsy-Desirability of Outcome Rank (DOOR), combining change in seizure frequency, adverse events, quality of life and ASM burden measures into a single outcome measure, compared between treatment arms over the whole 52-week period. Secondary outcomes will compare baseline measures to week 26 (antiseizure) and week 52 (disease modification). Exploratory measures will include biomarkers of treatment response.

ETHICS AND DISSEMINATION

The study has been approved by the lead site, Alfred Hospital Ethics Committee (594/20). Each participant will provide written informed consent prior to any trial procedures. The results of the study will be presented at national and international conferences, published in peer-reviewed journals and disseminated through consumer organisations.

CONCLUSION

This study will be the first disease-modification randomised controlled trial in patients with drug-resistant TLE.

TRIAL REGISTRATION NUMBER

ANZCTR; ACTRN12623000446662.

Content or context? A study protocol for a three-arm parallel randomised controlled trial of Re-PROGRAM, a brief internet-based intervention for patients with functional seizures

INTRODUCTION

Functional seizures (FS) mimic epilepsy but are not caused by epileptic electrical activity in the brain and are believed to have a psychological origin. There is a well-documented gap between the needs of patients with FS and available therapeutic resources. While there is potential for reducing seizure burden in patients via psychosocial intervention, there is no evidence-based care pathway or consistent availability of treatment and no effective pharmacological treatment. The objective of this study is to investigate the clinical efficacy and tolerability of a novel internet-based intervention in reducing seizure frequency.

METHODS AND ANALYSIS

A 3-arm parallel randomised controlled trial will compare the efficacy of brief guided internet-based therapy to unguided internet-based therapy and to standard care. Approximately 100 participants with FS will be recruited, with diagnostic criteria based on gold standard video-electroencephalogram (v-EEG) monitoring; patients will be randomly assigned to one of the three study arms. The primary study outcome will be FS frequency at 6 weeks and at follow-up (6 and 12 months) compared with baseline. Seizure frequency will be modelled using Poisson regression. Secondary outcomes include psychosocial functioning, healthcare resource usage, anxiety, depression, somatisation and life impact. Between-group differences will be evaluated using analysis of variance. Analysis of covariance will estimate within-group changes on secondary outcomes. Cognitive and psychological factors will be used as predictors of seizure reduction in exploratory analyses. A qualitative survey using a semi-structured interview will use thematic analyses to explore participants' treatment experiences, their impressions of FS management and perceived mechanisms for change.

ETHICS AND DISSEMINATION

The study was approved by the Human Research and Ethics Committee of the Alfred Hospital Human Research Ethics Committee as part of the Australian Multisite Ethics approval system. Results of the study will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000262707.

Factors related to the severity of obsessive-compulsive symptoms and their impact on suicide risk in epileptic patients

OBJECTIVE

To explore relevant factors for the severity of obsessive-compulsive symptoms (OCSs) in adult epileptic patients and investigate whether the severity of OCSs is a mediator in the relationship between depressive/anxiety symptoms and suicide risk in epileptic patients.

METHODS

This was a cross-sectional study from a hospital in Northeast China. Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Neurological Disorders Depression Inventory for Epilepsy (NDDIE), Generalized Anxiety Disorder (GAD-7), and Nurses' Global Assessment of Suicide Risk (NGASR) were used to assess the severity of OCSs, depressive symptoms, anxiety symptoms, and suicide risk in epileptic patients, respectively. The independent factors of the severity of OCSs and their mediating effects in the relationship between depressive/anxiety symptoms and suicide risk were evaluated by regression analyses and mediator models, respectively.

RESULTS

NDDIE scores (β = 0.404, p < 0.001), GAD-7 scores (β = 0.247, p = 0.009), and polytherapy (β = 0.119, p = 0.032) were the independent factors of Y-BOCS scores. The Y-BOCS scores partially mediated the relationship between GAD-7 scores and NGASR scores (standardized coefficients of indirect effect = 0.109, Bootstrap 95% CI = 0.024 to 0.214). Still, they did not mediate the relationship between NDDIE scores and NGASR scores (standardized coefficients of indirect effect = 0.062, Bootstrap 95% CI = -0.024 to 0.169).

CONCLUSIONS

Depressive symptoms, anxiety symptoms, and polytherapy are independently associated with the severity of OCSs in epileptic patients. Depressive and anxiety symptoms mediate the effect of the severity of OCSs on suicide risk in epileptic patients completely.

Prevalence and risk factors of anxiety and depression in adult patients with epilepsy: a multicenter survey-based study

Background

Depression and anxiety are the most common psychiatric comorbidities in patients with epilepsy (PWE). However, they are often unrecognized and consequently untreated.

Objective

The study was conducted to evaluate the prevalence and risk factors of anxiety and depression among Chinese adult PWE.

Design

Cross-sectional study.

Methods

Adult PWE were recruited from 13 tertiary epilepsy centers from February to September 2022. Generalized Anxiety Disorder-7 and Neurological Disorders Depression Inventory for Epilepsy were applied to evaluate anxiety and depression, respectively. Both univariate and multivariate logistic regression analyses models were performed to explore the risk factors of anxiety and depression.

Results

A total of 1326 PWE were enrolled in this study. The prevalence of anxiety and depression was 31.45% and 27.30%, respectively. Being female [odds ratio (OR) = 1.467, 95% CI: 1.134-1.899; p = 0.004], focal and focal to bilateral tonic-clonic seizures (TCSZ) (OR = 1.409, 95% CI: 1.021-1.939; p = 0.036), and seizure occurrence in the last 3 months (OR = 1.445, 95% CI: 1.026-2.044; p = 0.036) were the risk factors for anxiety. Focal and focal to bilateral TCSZ (OR = 1.531, 95% CI: 1.094-2.138; p = 0.013) and seizure occurrence in the last 3 months (OR = 1.644, 95% CI: 1.130-2.411; p = 0.010) were the risk factors for depression. In addition, for every 1-year increment of age, the odds of developing depression were decreased by 3.8% (p = 4.12e-5). Nevertheless, up to 70% of PWE did not receive any treatment for comorbidity.

Conclusion

There were approximately 30% of PWE screened positive for anxiety or depression. Both focal and focal to bilateral TCSZ and seizure occurrence in the last 3 months were estimated as risk factors for anxiety and depression. However, the current status of treatment was not optimal.

Factor Structure of the GHQ-12 and Their Applicability to Epilepsy Patients for Screening Mental Health Problems

Epilepsy, a severe neurological disorder impacting approximately 50 million individuals worldwide, is associated with a high prevalence of mental health issues. However, existing research has predominantly examined the relationship between epilepsy and depression or anxiety, neglecting other dimensions of mental health as assessed by factor scores from the general health survey (GHQ), such as the GHQ-12. This study aimed to explore how epilepsy affects both general mental health and specific dimensions of mental health. By employing a factor analysis and a predictive normative modeling approach, the study examined 426 epilepsy patients and 39,171 individuals without epilepsy. The findings revealed that epilepsy patients experienced poorer general mental health and specific aspects of mental health. Consequently, this study highlights the validity of GHQ-12 as a measure of mental health problems in epilepsy patients and emphasizes the importance of considering the impact of epilepsy on various dimensions of mental health, rather than focusing solely on depression or anxiety. Clinicians should incorporate these study results into the development of interventions aimed at enhancing mental well-being in epilepsy patients, ultimately leading to improved outcomes.

Adverse Event Profiles of Antiseizure Medications and the Impact of Coadministration on Drug Tolerability in Adults with Epilepsy

BACKGROUND

Antiseizure medication (ASM) as monotherapy or in combination is the treatment of choice for most patients with epilepsy. Therefore, knowledge about the typical adverse events (AEs) for ASMs and other coadministered drugs (CDs) is essential for practitioners and patients. Due to frequent polypharmacy, it is often difficult to clinically assess the AE profiles of ASMs and differentiate the influence of CDs.

OBJECTIVE

This retrospective analysis aimed to determine typical AE profiles for ASMs and assess the impact of CDs on AEs in clinical practice.

METHODS

The Liverpool AE Profile (LAEP) and its domains were used to identify the AE profiles of ASMs based on data from a large German multicenter study (Epi2020). Following established classifications, drugs were grouped according to their mode of action (ASMs) or clinical indication (CDs). Bivariate correlation, multivariate ordinal regression (MORA), and artificial neural network (ANNA) analyses were performed. Bivariate correlation with Fisher's z-transformation was used to compare the correlation strength of LAEP with the Hospital Anxiety and Depression Scale (HADS) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) to avoid LAEP bias in the context of antidepressant therapy.

RESULTS

Data from 486 patients were analyzed. The AE profiles of ASM categories and single ASMs matched those reported in the literature. Synaptic vesicle glycoprotein 2A (SV2A) and voltage-gated sodium channel (VGSC) modulators had favorable AE profiles, while brivaracetam was superior to levetiracetam regarding psychobehavioral AEs. MORA revealed that, in addition to seizure frequency, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) modulators and antidepressants were the only independent predictors of high LAEP values. After Fisher's z-transformation, correlations were significantly lower between LAEP and antidepressants than between LAEP and HADS or NDDI-E. Therefore, a bias in the results toward over interpreting the impact of antidepressants on LAEP was presumed. In the ANNA, perampanel, zonisamide, topiramate, and valproic acid were important nodes in the network, while VGSC and SV2A modulators had low relevance for predicting relevant AEs. Similarly, cardiovascular agents, analgesics, and antipsychotics were important CDs in the ANNA model.

CONCLUSION

ASMs have characteristic AE profiles that are highly reproducible and must be considered in therapeutic decision-making. Therapy using perampanel as an AMPA modulator should be considered cautiously due to its relatively high AE profile. Drugs acting via VGSCs and SV2A receptors are significantly better tolerated than other ASM categories or substances (e.g., topiramate, zonisamide, and valproate). Switching to brivaracetam is advisable in patients with psychobehavioral AEs who take levetiracetam. Because CDs frequently pharmacokinetically interact with ASMs, the cumulative AE profile must be considered.

TRIAL REGISTRATION

DRKS00022024, U1111-1252-5331.

Screening of Major Depression Disorder in Patients With Epilepsy in Indonesian National Referral Hospital

Background and Objectives

Major depressive disorder (MDD) is a common psychiatric disorder in patients with epilepsy (PWE). The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is one of the MDD screening tools used in PWE. This study aims to determine the accuracy of the valid and reliable NDDI-E Indonesian version as an MDD screening tool in PWE and investigate the prevalence and risk factors for the development of MDD in PWE.

Methods

A diagnostic cross-sectional study was conducted at Cipto Mangunkusumo National Referral Hospital, Indonesia. Patients were PWE aged 18 years or older who visited the epilepsy outpatient clinic. The valid and reliable NDDI-E Indonesian version and Mini International Neuropsychiatric Interview (MINI) International Classification of Disease, 10th Revision (ICD-10) were used to diagnose MDD. In phase II of the study, diagnostic accuracy was evaluated using the receiver operative characteristic (ROC) curve method to obtain the area under the curve (AUC) and diagnostic 2 x 2 table to determine the cutoff point, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). During phase III of the study, eligible individuals were screened for MDD using the NDDI-E Indonesian version. Demographic and clinical data were collected. Data analysis was performed using the χ2 test, Mann-Whitney test, and multivariate logistic regression analysis.

Results

A total of 105 individuals were involved, and only 23 of them were found to experience MDD based on MINI ICD-10. The best cutoff point for the NDDI-E Indonesian version was ≥11, with a sensitivity of 91.3%, specificity 89%, PPV 70%, and NPV 97.3%. The AUC obtained from ROC analysis was 97.5% (95% CI 95-99%, p < 0.001). Then, the survey was completed by 79 individuals, predominantly male, mostly within the age range of 26-45 years. The prevalence of MDD in PWE was 50.6%, and the significant risk factors were seizure frequency ≥8 times a year and the presence of chronic diseases (p < 0.001).

Discussion

The NDDI-E Indonesian version was a screening tool with a high diagnostic accuracy to detect MDD in PWE at a cutoff point of 11. Poor seizure control and the presence of other chronic diseases were the risk factors correlated with MDD development in PWE.

Proposed Recommendations for the Management of Depression in Adults with Epilepsy: An Expert Consensus

INTRODUCTION

Experts agree that there is a need for protocols to guide health professionals on how to best manage psychiatric comorbidities in patients with epilepsy (PWE). We aimed to develop practical recommendations for key issues in the management of depression in PWE.

METHODS

This was a qualitative study conducted in four steps: (1) development of a questionnaire on the management of depression in PWE to be answered; (2) literature review and, if evidence from guidelines/consensus or systematic reviews was available, drafting initial recommendations; (3) a nominal group methodology for reviewing initial recommendations and formulating new recommendations on those issues without available evidence; and (4) drafting and approving the final recommendations. A scientific committee (one neurologist and one psychiatrist) was responsible for the development of the project and its scientific integrity. The scientific committee selected a panel of experts (nine neurologists and nine psychiatrists with experience in this field) to be involved in the nominal group meetings and to formulate final recommendations.

RESULTS

Fifteen recommendations were formulated. Four on the screening and diagnosis: screening and diagnosis of depression, evaluation of the risk of suicide, and diagnosis of depression secondary to epilepsy; nine on the management of depression: referral to a psychiatrist, selection of the antiseizure medication, change of antiseizure medication, antidepressant treatment initiation, selection of antidepressant, use of antidepressants during pregnancy, use of psychotherapy, antidepressant treatment duration, and discontinuation of antidepressant treatment; two on the follow-up: duration of the follow-up under usual conditions, and follow-up of patients at risk of suicide.

CONCLUSION

We provide recommendations based on expert opinion consensus to help healthcare professionals assess depression in PWE. The detection and treatment of major depressive disorders are key factors in improving epilepsy outcomes and avoiding suicide risk.

Screening for anxiety, depression and suicidality by epilepsy specialists in adult services in Scotland

OBJECTIVE

Clinical guidelines recommend screening people with epilepsy (PWE) regularly for mental distress, but it is unclear how guidelines are implemented. We surveyed epilepsy specialists in adult Scottish services to determine approaches used to screen for anxiety, depression, and suicidality; the perceived difficulty of screening; factors associated with intention to screen; and treatment decisions made following positive screens.

METHODS

An anonymous email-based questionnaire survey of epilepsy nurses and epilepsy neurology specialists (n = 38) was conducted.

RESULTS

Two in every three specialists used a systematic screening approach; a third did not. Clinical interview was employed more often than standardized questionnaire. Clinicians reported positive attitudes towards screening but found screening difficult to implement. Intention to screen was associated with favorable attitude, perceived control, and social norm. Pharmacological and non-pharmacological interventions were proposed equally often for those screening positive for anxiety or depression.

CONCLUSION

Routine screening for mental distress is carried out in Scottish epilepsy treatment settings but is not universal. Attention should be paid to clinician factors associated with screening, such as intention to screen and resulting treatment decisions. These factors are potentially modifiable, offering a means of closing the gap between guideline recommendations and clinical practice.

Fear of sleep in people with epilepsy

More than one third of people with epilepsy (PWE) report experiencing insomnia. This is highly concerning given that sleep loss both triggers and exacerbates seizures. It is therefore paramount that we understand the underlying mechanisms of insomnia in PWE. Nevertheless, research in this area remains limited, with little understanding of the emerging or maintaining factors of insomnia in PWE. Therefore, the current study sought to explore fear of sleep as a novel explanation for the increased rate of insomnia in PWE, and whether fear of sleep was related to post-seizure trauma. We recruited 184 PWE and 197 healthy controls via social media and collected data using a series of online questionnaires. We found that fear of sleep did not significantly differ between the epilepsy and control group. In the epilepsy group, fear of sleep seemed to be largely driven by trauma, especially post-seizure trauma but also non-seizure related trauma, along with anxiety and higher seizure frequency. Fear of sleep in the control group was also largely driven by trauma, but also anxiety and depression. Finally, we found more severe and prevalent insomnia in PWE relative to controls, and in both groups, fear of sleep was the most significant contributor to insomnia. Our novel findings carry important clinical implications. First, they point to the central role of trauma in fear of sleep not only in PWE but also in the general population. Our findings also indicate that fear of sleep is an important maintaining factor of insomnia. Ultimately, these results suggest that all individuals with insomnia may benefit from insomnia interventions targeted at trauma, depression, anxiety, and fear of sleep. PWE are likely to benefit from additional treatment components for seizure-related trauma and seizure management. To better understand the reliability and generalisability of our novel findings, future research should further assess fear of sleep and its role in maintaining insomnia in the epilepsy population.

Association Between Frailty and Antiseizure Medication Tolerability in Older Adults With Epilepsy

BACKGROUND AND OBJECTIVE

Frailty is an important aspect of biological aging, referring to the increased vulnerability of individuals with frailty to physical and psychological stressors. While older adults with epilepsy are an important and distinct clinical group, there are no data on frailty in this population. We hypothesize that frailty will correlate with the seizure frequency and especially the tolerability of antiseizure medications (ASMs) in older adults with epilepsy.

METHODS

We recruited individuals aged 60 years or older with active epilepsy from 4 Canadian hospital centers. We reported the seizure frequency in the 3 months preceding the interview, while ASM tolerability was quantified using the Liverpool Adverse Events Profile (LAEP). We applied 3 measures of frailty: grip strength as a measure of physical frailty, 1 self-reported score (Edmonton frail score [EFS]), and 1 scale completed by a healthcare professional (clinical frailty scale [CFS]). We also administered standardized questionnaires measuring levels of anxiety, depression, functional disability, and quality of life and obtained relevant clinical and demographic data.

RESULTS

Forty-three women and 43 men aged 60-93 years were recruited, 87% of whom had focal epilepsy, with an average frequency of 3.4 seizures per month. Multiple linear regression and zero-inflated negative binomial regression models showed that EFS and CFS scores were associated with decreased ASM tolerability, each point increase leading to 1.83 (95% CI: 0.67-4.30) and 2.49 (95% CI: 1.27-2.39) point increases on the LAEP scale, respectively. Neither the EFS and CFS scores nor grip strength were significantly associated with seizure frequency. The EFS was moderately correlated with depression, anxiety, quality of life, and functional disability, demonstrating the best construct validity among the 3 tested measures of frailty.

DISCUSSION

The EFS was significantly, both statistically and clinically, associated with ASM tolerability. It also showed multiple advantages in performance while assessing for frailty in older adults with epilepsy, when compared with the 2 other measures of frailty that we tested. Future studies must focus on what role the EFS during epilepsy diagnosis may play in ASM selection among older adults with epilepsy.

Body image dissatisfaction: A novel predictor of poor quality of life in epilepsy

OBJECTIVE

People with epilepsy have long reported reduced quality of life (QoL) compared to healthy peers. This initial study seeks to broaden our understanding of QoL in adults with epilepsy, by examining the adverse impact of body image dissatisfaction for the first time. This aim stems from the observation that both seizures and their medical treatment can cause unwanted changes to physical appearances, such as weight change, hirsutism, and acne.

METHOD

Sixty-three adults with epilepsy and 48 age- and gender-matched healthy controls were recruited from a tertiary epilepsy program and targeted social media. Participants completed an online suite of well-validated questionnaires canvassing state (current) and trait (long-term) aspects of body image dissatisfaction, mood, QoL, and medical history.

RESULTS

People with epilepsy reported significantly elevated levels of trait body image dissatisfaction compared to controls across the dimensions of appearance evaluation, body areas satisfaction, and self-classified weight (p = 0.02); but did not differ from controls on state body image dissatisfaction (p > 0.05). All facets of body image dissatisfaction in participants with epilepsy were strongly associated with reduced QoL, together with heavier body weight, depressive symptoms, medical comorbidities, and a belief that epilepsy hindered their ability to attain a healthier physique. Multiple regression revealed that body image dissatisfaction was the strongest unique contributor to poor QoL in the epilepsy group (β = 0.46, p ≤ 0.001), above and beyond the contribution of current depressive symptoms (β = 0.34, p ≤ 0.01).

SIGNIFICANCE

This is the first study to highlight the high rates of body image dissatisfaction among adults with epilepsy, and the significantly detrimental impact it has on patient well-being. It also opens novel avenues for psychological interventions in epilepsy, that focus on enhancing positive body image as a means of holistically improving the often-poor psychological outcomes for people with this condition.

Impact of acute symptomatic seizures and their management on patient-reported outcomes after stroke

OBJECTIVE

Acute symptomatic seizures (ASyS) after stroke are not uncommon. However, the impact of ASyS and its management with anti-seizure medications (ASMs) on patient-reported outcome measures (PROMs) remains poorly investigated. The objective of our study is to evaluate the association between PROMs and ASyS and ASMs following stroke.

METHODS

We performed a retrospective cohort study of all stroke patients who underwent inpatient continuous EEG (cEEG) monitoring performed due to suspected ASyS, including the ones with observed convulsive ASyS, from 04/01/2012 to 03/31/2018, who completed PROMs within 6 months of hospital discharge. Patient-reported outcome measures, including one Neuro-QoL and six PROMIS v1.0 domain scales, were completed by patients as the standard of care in ambulatory stroke clinics. Since ASMs are sometimes used without clearly diagnosed ASyS, we performed group comparisons based on ASM status at discharge, irrespective of their ASyS status. T-tests or Wilcoxon rank sum tests compared continuous variables across groups and chi-square tests or Fisher's exact tests were used for categorical variables.

RESULTS

A total of 508 patients were included in the study [mean age 62.0 ± 14.1 years, 51.6% female; 244 (48.0%) ischemic stroke, 165 (32.5%) intracerebral hemorrhage, and 99 (19.5%) subarachnoid hemorrhage]. A total of 190 (37.4%) patients were discharged on ASMs. At the time of the first PROM, conducted a median of 47 (IQR = 33-78) days after the suspected ASyS, and 162 (31.9%) were on ASMs. ASM use was significantly higher in patients diagnosed with ASyS. Physical Function and Satisfaction with Social Roles and Activities were the most affected health domains. Patient-reported outcome measures were not significantly different between groups based on ASyS (electrographic and/or convulsive), ASM use at hospital discharge, or ASM status on the day of PROM completion.

SIGNIFICANCE

There were no differences in multiple domain-specific PROMs in patients with recent stroke according to ASyS status or ASM use suggesting the possible lack of the former's sensitivity to detect their impact. Additional research is necessary to determine if there is a need for developing ASyS-specific PROMs.