The effect of depression and side effects of antiepileptic drugs on injuries in patients with epilepsy

Ganoderic Acid A: A Potential Natural Neuroprotective Agent for Neurological Disorders: A Review

Ganoderic acid A (GAA) is one of the major triterpenoids in Ganoderma lucidum (GL). Accumulating evidence has indicated that GAA demonstrates multiple pharmacological effects and exhibits treatment potential for various neurological disorders. Here, the effects and mechanisms of GAA in the treatment of neurological disorders were evaluated and discussed through previous research results. By summarizing previous research results, we found that GAA may play a neuroprotective role through various mechanisms: anti-inflammatory, anti-oxidative stress, anti-apoptosis, protection of nerve cells, and regulation of nerve growth factor. Therefore, GAA is a promising natural neuroprotective agent and this review would contribute to the future development of GAA as a novel clinical candidate drug for treating neurological diseases.

Association of first anti-seizure medication choice with injuries in older adults with newly diagnosed epilepsy

BACKGROUND

Epilepsy incidence increases exponentially in older adults, who are also at higher risk of adverse drug effects. Anti-seizure medications (ASM) may be associated with sedation and injuries, but discontinuation can result in seizures. We sought to determine whether there was an association between prescribing non-guideline concordant ASM and subsequent injury as this could inform care models.

METHODS

Retrospective cohort study of adults 50 years or older with newly-diagnosed epilepsy in 2015-16, sampled from the MarketScan Databases. The outcome of interest was injury within 1-year of ASM prescription (e.g., burns, falls) and the exposure of interest was ASM category (recommended vs. not recommended by clinical guidelines). Descriptive statistics characterized covariates and a multivariable Cox-regression model was built to examine the association between ASM category and subsequent injury.

RESULTS

5,931 people with newly diagnosed epilepsy were prescribed an ASM within 1-year. The three most common ASMs were: levetiracetam (62.86%), gabapentin (11.73%), and phenytoin (4.45%). Multivariable Cox-regression found that medication category was not associated with injury; however, older age (adjusted hazard ratio (AHR) 1.01/year), history of prior injury (AHR 1.77), traumatic brain injury (AHR 1.55) and ASM polypharmacy (AHR 1.32) were associated with increased hazard of injury.

CONCLUSIONS

Most older adults appear to be getting appropriate first prescriptions for epilepsy. However, a substantial proportion still receives medication that guidelines suggest avoiding. In addition, we show that ASM polypharmacy is associated with an increased hazard of injury within 1- year. Efforts to improve prescribing in older adults with epilepsy should consider how to reduce. both polypharmacy and exposure to medications that guidelines recommend avoiding.

Impact of psychiatric comorbidities on the treatment of epilepsies in adults

INTRODUCTION

Epilepsy is often accompanied by psychiatric comorbidities and the management of epilepsy in these patients presents unique challenges due to the interplay between the underlying neurological condition and the psychiatric symptoms and the combined use of multiple medications.

AREAS COVERED

This paper aims to explore the complexities associated with managing epilepsy in the presence of psychiatric comorbidities, focusing on the impact of psychiatric disorders on epilepsy treatment strategies and the challenges posed by the simultaneous administration of multiple medications.

EXPERT OPINION

Patients with epilepsy and psychiatric comorbidities seem to present with a more severe form of epilepsy that is resistant to drug treatments and burdened by an increased morbidity and mortality. Whether prompt treatment of psychiatric disorders can influence the long-term prognosis of the epilepsy is still unclear as well as the role of specific treatment strategies, such as neuromodulation, in this group of patients. Clinical practice recommendations and guidelines will prompt the development of new models of integrated care to be implemented.

Neuropsychiatric and Cognitive Comorbidities in Epilepsy

PURPOSE OF REVIEW

This article discusses psychiatric and cognitive comorbidities of epilepsy over the lifespan and illustrates opportunities to improve the quality of care of children and adults with epilepsy.

RECENT FINDINGS

One in 3 people with epilepsy have a lifetime history of psychiatric disorders, and they represent an important prognostic marker of epilepsy. Contributors are diverse and display a complex relationship. Cognitive comorbidities are also common among those living with epilepsy and are increasingly recognized as a reflection of changes to underlying brain networks. Among the cognitive comorbidities, intellectual disability and dementia are common and can complicate the diagnostic process when cognitive and/or behavioral features resemble seizures.

SUMMARY

Comorbidities require consideration from the first point of contact with a patient because they can determine the presentation of symptoms, responsiveness to treatment, and the patient's day-to-day functioning and quality of life. In epilepsy, psychiatric and cognitive comorbidities may prove a greater source of disability for the patient and family than the seizures themselves, and in the case of essential comorbidities, they are regarded as core to the disorder in terms of etiology, diagnosis, and treatment.

Depression and Anxiety in Adult Persons With Epilepsy and Their Caregivers: A Survey-Based Study at a Tertiary Care Center

ABSTRACT

This study evaluated the rates of depression and anxiety and their determinants in adult persons with epilepsy and their caregivers. Both completed surveys about demographic, disease-related, and psychosocial characteristics. One hundred patients and caregivers participated. A mood disorder was present in 89% of patients and 56% of caregivers. In the univariate analysis, the presence of mood disorder in the patient was associated with being unmarried, unemployed, frequent hospitalizations, side effects from polypharmacy, patient stigma, patient quality of life, caregiver anxiety, and caregiver burden. In the multivariate analysis, medication side effects sustained as an important determinant. In the univariate analysis, the presence of mood disorder in the caregiver was associated with seizure frequency, patient anxiety, patient quality of life, caregiver stigma, and caregiver burden. In the multivariate analysis, patient anxiety level and caregiver burden sustained as important determinants. Adult persons with epilepsy and their caregivers experience high rates of mood disorders, explained by certain clinical factors.

Managing depression and anxiety in people with epilepsy: A survey of epilepsy health professionals by the ILAE Psychology Task Force

Objectives

The Psychology Task Force of the Medical Therapies Commission of the International League Against Epilepsy (ILAE) has been charged with taking steps to improve global mental health care for people with epilepsy. This study aimed to inform the direction and priorities of the Task Force by examining epilepsy healthcare providers' current practical experiences, barriers, and unmet needs around addressing depression and anxiety in their patients.

Methods

A voluntary 27-item online survey was distributed via ILAE chapters and networks. It assessed practices in the areas of screening, referral, management, and psychological care for depression and anxiety. A total of 445 participants, from 67 countries (68% high income), commenced the survey, with 87% completing all components. Most respondents (80%) were either neurologists or epileptologists.

Results

Less than half of respondents felt adequately resourced to manage depression and anxiety. There was a lack of consensus about which health professionals were responsible for screening and management of these comorbidities. About a third only assessed for depression and anxiety following spontaneous report and lack of time was a common barrier (>50%). Routine referrals to psychiatrists (>55%) and psychologists (>41%) were common, but approximately one third relied on watchful waiting. A lack of both trained mental health specialists (>55%) and standardized procedures (>38%) was common barriers to referral practices. The majority (>75%) of respondents' patients identified with depression or anxiety had previously accessed psychotropic medications or psychological treatments. However, multiple barriers to psychological treatments were endorsed, including accessibility difficulties (52%).

Significance

The findings suggest that while the importance of managing depression and anxiety in patients with epilepsy is being recognized, there are ongoing barriers to effective mental health care. Key future directions include the need for updated protocols in this area and the integration of mental health professionals within epilepsy settings.

A systematic review of neuroimaging studies of depression in adults with epilepsy

OBJECTIVE

Depression is a relatively common comorbidity in people with epilepsy with a lifetime history identified in 1 in 4 individuals. In this paper, we aimed to provide a systematic review of structural and functional brain region-specific group differences of adults with epilepsy and depression and to discuss existing evidence as compared to that in people with depression.

METHODS

We undertook a systematic review of neuroimaging studies of depression in adults with epilepsy through MEDLINE/PubMed, Embase and PsycInfo searches until June 2020.

RESULTS

A total of 44 studies were included in the qualitative synthesis: 21 on structural neuroimaging, 9 on functional, and 14 on pharmaco/metabolic neuroimaging. Almost all studies focused on temporal lobe epilepsy (TLE). Patterns of changes in the hippocampi and subcortical structures seem to be different from those reported in depression outside epilepsy. Cortical changes are grossly similar as well as the lack of any laterality effect. Serotonin dysfunction seems to be due to different mechanisms with reduced synaptic availability for depression in epilepsy as compared to reduced 5HT1 receptor density outside epilepsy. Depressive symptoms seem to correlate with a dysfunction in temporolimbic structures contralateral to the epileptogenic zone especially in patients with de novo postsurgical depression.

CONCLUSIONS

Depression, at least in TLE, seems to be associated with a different pattern of brain changes as compared to major depression, potentially supporting the notion of phenomenological peculiarities of depression in epilepsy.

Prediction of the recurrence risk in patients with epilepsy after the withdrawal of antiepileptic drugs

Many seizure-free patients who consider withdrawing from antiepileptic drugs (AEDs) hope to discontinue treatment to avoid adverse effects. However, withdrawal has certain risks that are difficult to predict. In this study, we performed a literature review, summarized the causes of significant variability in the risk of postwithdrawal recurrent seizures, and reviewed study data on the age at onset, cause, types of seizures, epilepsy syndrome, magnetic resonance imaging (MRI) abnormalities, epilepsy surgery, and withdrawal outcomes of patients with epilepsy. Many factors are associated with recurrent seizures after AED withdrawal. For patients who are seizure-free after treatment, the role of an electroencephalogram (EEG) alone in ensuring safe withdrawal is limited. A series of prediction models for the postwithdrawal recurrence risk have incorporated various potentially important factors in a comprehensive analysis. We focused on the populations of studies investigating five risk prediction models and analyzed the predictive variables and recommended applications of each model, aiming to provide a reference for personalized withdrawal for patients with epilepsy in clinical practice.

Depressive symptoms and difficulties in emotion regulation in adult patients with epilepsy: Association with quality of life and stigma

OBJECTIVE

The objective of the study was to assess depressive symptoms (DS) and difficulties in emotion regulation (ER) in adult people with epilepsy (PWE) and their correlation with quality of life and stigmatization feelings of patients.

MATERIALS AND METHODS

We enrolled consecutively 110 PWE who completed the Beck Depression Inventory-II (BDI-II) questionnaire and, for the first time, the Italian translation of Difficulties in Emotion Regulation Scale (DERS) to evaluate DS and ER. They also fulfilled the Italian version of the Stigma Scale of Epilepsy (SSE), which allowed the quantification of the stigma perception by our cohort of patients and a 3-item Jacoby's Stigma Scale (JSS) and QOLIE-31 (Q31) for the evaluation of stigma and the quality of life. The results of BDI-II and DERS were correlated with clinical details of PWE, as well as the Q31 and SSE scores. Finally, a multiple stepwise regression analysis was applied to identify the main factors affecting DS and ER difficulties in these patients.

RESULTS

About 30% of PWE evidenced DS, of which 17.3% showed a BDI-II score higher than 19, suggestive of moderate to severe DS. Several factors related to epilepsy (seizure frequency, number of antiepileptic drugs (AEDs)) as well as ER and quality of life/stigmatization perception resulted significantly correlated with DS. As a new finding, the main factors affecting DS in PWE turned out to be the difficulties in ER and quality of life and stigma perception (as evaluated through Q31 and JSS scores).

CONCLUSIONS

Our findings evidenced that DS in PWE are highly prevalent and strongly correlated with ER difficulties that mostly influence DS together with quality of life and stigma perception. Depressive symptoms and emotion dysregulation are linked by a bidirectional relationship and are significantly associated with worse quality of life and higher stigmatization feelings.

Antiepileptic Drug Treatment Outcomes and Seizure-Related Injuries Among Adult Patients with Epilepsy in a Tertiary Care Hospital in Ethiopia

Objective

Anti-epileptic drugs (AEDs) are the primary therapeutic modalities for epilepsy management. However, one-third of epileptic patients continue to experience seizure even with appropriate AED use. Patients with epilepsy are at increased risk for seizure-related injury and they have higher incidences of home, street and work accidents. There is a paucity of data on AED use pattern and treatment outcomes among patients with epilepsy in the tertiary hospitals of Ethiopia. Therefore, the aim of this study was to assess AED use pattern, treatment outcome, and prevalence of seizure-related injury among patients with epilepsy in Tikur Anbessa specialized Hospital (TASH), Ethiopia.

Patients and Methods

An institution-based cross-sectional study was carried out on 291 patients with epilepsy attending the neurology clinic of TASH. A semi-structured questionnaire and data abstraction format were used to collect data through patient interview and medical chart review. Binary logistic regression was utilized to identify the associated factors of treatment outcome.

Results

About 172 (59%) of the patients were taking a single AED, in which phenobarbital, 195 (67%), and phenytoin, 97 (33.3%), were the most frequently prescribed AEDs as monotherapy and combination therapy. Headache, depressed mood and epigastric pain were frequently reported as adverse drug reactions. Seizure-related injury was reported among 78 (26.8%) patients and head injury 15 (5.2%), desntal injury 15 (5.2%), soft tissue injury 14 (4.8%) and burns 10 (3.4%) were the commonest. About two-thirds (191, 65.6%) of the study participants had uncontrolled seizure. Medication adherence and multiple AEDs were significantly associated with treatment outcome.

Conclusion

All the study participants were put on old generation AEDs with phenobarbital being the most frequently used. About two-thirds of the patients had uncontrolled seizure and seizure-related injury is still a serious concern among patients with epilepsy.

Common psychiatric comorbidities in epilepsy: How big of a problem is it?

Psychiatric illness and epilepsy commonly co-occur in adults and in children and adolescents. Theories of comorbidity are complex, but recurring associations between the conditions suggest overlap that is more than simple co-occurrence. Common underlying pathophysiology may imply that epilepsy itself may constituently include psychiatric symptoms. Conditions such as depression or cognitive difficulties commonly occur and in some cases, are considered to be associated with specific epilepsy characteristics such as localization or seizure type. Regardless of etiologic attributions to psychiatric comorbidity, it is clear today that treatment for epilepsy needs to target psychiatric illness. In many cases, quality-of-life improvements depend more upon addressing psychiatric symptoms than seizures themselves. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Developments in depression in epilepsy: screening, diagnosis, and treatment

INTRODUCTION

Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated. Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur. Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.

Validation of the Chinese version of the Hamilton Rating Scale for Depression in adults with epilepsy

OBJECTIVE

This study aimed to validate the Chinese version of the 17-item Hamilton Rating Scale for Depression (C-HRSD-17) for use in adult patients with epilepsy (PWE).

METHODS

A consecutive sample of Chinese adult PWE from a tertiary hospital was examined using the C-HRSD-17 and the Mini International Neuropsychiatric Interview (MINI) Plus Chinese Version 5.0.0.

RESULTS

A total of 191 PWE completed the assessment of depression. According to the MINI, thirty patients (15.7%) had current major depressive disorder (MDD). The Cronbach's α coefficient for the C-HRSD-17 was 0.832. Receiver operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.983 (95% CI = 0.968-0.998). With a cutoff score of 9, the C-HRSD-17 demonstrated the best psychometric properties, with a sensitivity of 96.7%, a specificity of 93.8%, a positive predictive value (PPV) of 74.4%, and a negative predictive value (NPV) of 99.3%.

CONCLUSION

The C-HRSD-17 proved to be a valid and reliable assessment tool, with a cutoff score of 9 for screening of current MDD in Chinese adult PWE.

Current and emerging drug therapies for the treatment of depression in adults with epilepsy

INTRODUCTION

Depression is the most frequent psychiatric comorbidity among people with epilepsy. It can impact on quality of life and increases the risk of morbidity and premature mortality.

AREAS COVERED

The authors review the available data on current and emerging drug treatments for depression in epilepsy. Sources have been identified through Medline/PubMed searches while ongoing clinical trials have been identified through a ClinicalTrials.gov search

EXPERT OPINION

SSRIs are the drug class with the largest amount of data. Though promising, the level of evidence provided by these studies is still low as the majority have relevant methodological limitations. Antiepileptic drugs under development have the unique opportunity to be of multi-use in the treatment of epilepsy and depression. The serotoninergic system has already been identified as a potential area of interest, but new targets are still needed in epilepsy and depression. For this reason, it is important that basic scientists working on these two conditions develop collaborative projects and integrate findings.