Treatment of anxiety disorders in epilepsy: An evidence-based approach

Separation anxiety disorder, perceived overprotection and quality of life in epilepsy patients

OBJECTIVE

People with epilepsy suffer from the stress of living with a chronic, unpredictable disease that can lead to discrimination, misunderstanding, social stigma, and loss of autonomy in activities of daily life, elevating anxiety. Within the scope of this research, we aimed to elucidate the frequency of separation anxiety disorder in adult people with epilepsy and to examine the relationship between separation anxiety symptoms, perceived overprotection, and quality of life in comparison to the control group.

MATERIAL AND METHODS

This prospective study was conducted with 105 people with epilepsy and 115 healthy volunteers. All participants were evaluated by a psychiatrist in this study using a DSM-5-based clinical interview. Sociodemographic Data Questionnaire, Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), Separation Anxiety Symptom Inventory (SASI), Adult Separation Anxiety Questionnaire (ASA-27), Beck Depression Inventory (BDI) were administered to both groups, and Overprotection Scale, Quality of Life in Epilepsy Inventory (QOLIE-31) to only epilepsy group. Hierarchical regression analysis was used to explain the quality of life in epilepsy. Multivariate linear regression analysis was used to explain separation anxiety symptom scores.

RESULTS

The rates of education, employment, and living alone were lower in the epilepsy group (p < 0.001, p < 0.001 and p < 0.001). Separation anxiety disorder of adulthood and other psychiatric comorbidities were significantly higher in the epilepsy group (p = 0.029 and p = 0.003). There was a significant negative correlation between the quality of life in epilepsy and separation anxiety symptom level, overprotection, and depression scores (p < 0.001, p = 0.01 and p < 0.01). In the logistic regression analysis, adult separation anxiety symptom level and depression scores were found to be independent factors for quality of life in epilepsy (p = 0.029 and p < 0.01). In patients with epilepsy, depression and quality of life scores were predictors for adult separation anxiety symptoms severity (p = 0.02 and p = 0.01).

CONCLUSION

The frequency of diagnosis of separation anxiety disorder in adulthood was significantly higher in people with epilepsy. Overprotective attitudes of families and low quality of life were associated with high levels of separation anxiety.

Epilepsy is more than a simple seizure disorder: Parallels between human and canine cognitive and behavioural comorbidities

Psychiatric and cognitive comorbidities have been known to play a major role in human epilepsy for a long time. People with epilepsy (PWE) frequently express signs of varying psychiatric and cognitive disorders affecting their quality and quantity of life (QoL/QaoL). Over the last few years, research on behavioural comorbidities and their effect on the underlying disease have been performed in canine epilepsy. The following article reviews manifestations of comorbidities in canine epilepsy with an emphasis on patterns of clinical signs and their effects on QoL and QaoL. Cognitive and behavioural alterations in epileptic dogs are mainly represented by fear-/anxiety related behaviour and cognitive impairment (CI). Reduced trainability and altered reactions to daily situations are common results of comorbid changes posing obstacles in everyday life of owners and their dog. In addition, clinical signs similar to attention deficit hyperactivity disorder (ADHD) in humans have been reported. Canine attention-deficit-hyperactivity-disorder-like (c-ADHD-like) behaviour should, however, be evaluated critically, as there are no official criteria for diagnosis of ADHD or ADHD-like behaviour in dogs, and some of the reported signs of c-ADHD-like behaviour could be confused with anxiety-associated behaviour. Many intrinsic and extrinsic factors could potentially influence the development of behavioural and cognitive comorbidities in canine epilepsy. In particular, seizure frequency/severity, signalment and factors concerning disease management, such as pharmacotherapy and nutrition, are closely linked with the presence of the aforementioned comorbid disorders. Further studies of behavioural alterations in epileptic dogs are needed to comprehend the complexity of clinical signs and their multifactorial origin.

Epilepsy is more than a simple seizure disorder: Causal relationships between epilepsy and its comorbidities

This review draws connections between the pathogenesis of canine epilepsy and its most commonly recognised comorbidities: cognitive impairment (CI), attention deficit hyperactivity disorder (ADHD)-like behaviour, fear and anxiety. Uni/bidirectional causalities and the possibility of a common aetiology triggering both epilepsy and the associated diseases are considered. Research on this topic is sparse in dogs, so information has been gathered and assessed from human and laboratory animal studies. Anatomical structures, functional connections, disrupted neurotransmission and neuroinflammatory processes collectively serve as a common foundation for epilepsy and its comorbidities. Specific anatomical structures, especially parts of the limbic system, such as the amygdala and the hippocampus, are involved in generating seizures, as well as cognitive- and behavioural disorders. Furthermore, disturbances in inhibitory and excitatory neurotransmission influence neuronal excitability and networks, leading to underlying brain dysfunction. Functional magnetic resonance imaging (fMRI), interictal epileptiform discharges (IEDs), and electroencephalography (EEG) have demonstrated functional brain connections that are related to the emergence of both epilepsy and its various comorbidities. Neuroinflammatory processes can either cause or be a consequence of seizures, and inflammatory mediators, oxidative stress and mitochondrial dysfunction, can equally evoke mood disorders. The extensive relationships contributing to the development and progression of seizures and comorbid cognitive and behavioural conditions illustrate the complexity of the disease that is epilepsy.

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.

Virtual Reality Therapy for People With Epilepsy and Related Anxiety: Protocol for a 3-Phase Pilot Clinical Trial

BACKGROUND

Anxiety is one of the most common psychiatric comorbidities in people with epilepsy and often involves fears specifically related to the condition, such as anxiety related to the fear of having another seizure. These epilepsy- or seizure-related fears have been reported as being more disabling than the seizures themselves and significantly impact quality of life. Although research has suggested that exposure therapy (ET) is helpful in decreasing anxiety in people with epilepsy, no research to our knowledge has been conducted on ET in people with epilepsy using virtual reality (VR). The use of novel technologies such as an immersive VR head-mounted display for ET in this population offers several benefits. Indeed, using VR can increase accessibility for people with epilepsy with transportation barriers (eg, those who live outside urban centers or who have a suspended driver's license owing to their condition), among other advantages. In the present research protocol, we describe the design of an innovative VR-ET program administered in the home that focuses on decreasing anxiety in people with epilepsy, specifically anxiety related to their epilepsy or seizures.

OBJECTIVE

Our primary objective is to examine the feasibility of the study protocol and proposed treatment as well as identify suggestions for improvement when designing subsequent larger clinical trials. Our secondary objective is to evaluate whether VR-ET is effective in decreasing anxiety in a pilot study. We hypothesize that levels of anxiety in people with epilepsy will decrease from using VR-ET.

METHODS

This mixed methods study comprises 3 phases. Phase 1 involves engaging with those with lived experience through a web-based questionnaire to validate assumptions about anxiety in people with epilepsy. Phase 2 involves filming videos using a 360° camera for the VR-ET intervention (likely consisting of 3 sets of scenes, each with 3 intensity levels) based on the epilepsy- and seizure-related fears most commonly reported in the phase 1 questionnaire. Finally, phase 3 involves evaluating the at-home VR-ET intervention and study methods using a series of validated scales, as well as semistructured interviews.

RESULTS

This pilot study was funded in November 2021. Data collection for phase 1 was completed as of August 7, 2022, and had a final sample of 18 participants.

CONCLUSIONS

Our findings will add to the limited body of knowledge on anxiety in people with epilepsy and the use of VR in this population. We anticipate that the insights gained from this study will lay the foundation for a novel and accessible VR intervention for this underrecognized and undertreated comorbidity in people with epilepsy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05296057; https://clinicaltrials.gov/ct2/show/NCT05296057.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41523.

Describing epilepsy-related anxiety to inform the design of a virtual reality exposure therapy: Results from Phase 1 of the AnxEpiVR clinical trial

People with epilepsy (PwE) are at a greater risk of comorbid anxiety, which is often related to the fear of having another seizure for safety or social reasons. While virtual reality (VR) exposure therapy (ET) has been successfully used to treat several anxiety disorders, no studies to date have investigated its use in this population. This paper discusses Phase 1 of the three-phase AnxEpiVR pilot study. In Phase 1, we aimed to explore and validate scenarios that provoke epilepsy/seizure-specific (ES) interictal anxiety and provide recommendations that lay the foundation for designing VR-ET scenarios to treat this condition in PwE. An anonymous online questionnaire (including open- and closed-ended questions) that targeted PwE and those affected by it (e.g., through a family member, friend, or as a healthcare professional) was promoted by a major epilepsy foundation in Toronto, Canada. Responses from n = 18 participants were analyzed using grounded theory and the constant comparison method. Participants described anxiety-provoking scenes, which were categorized under the following themes: location, social setting, situational, activity, physiological, and previous seizure. While scenes tied to previous seizures were typically highly personalized and idiosyncratic, public settings and social situations were commonly reported fears. Factors consistently found to increase ES-interictal anxiety included the potential for danger (physical injury or inability to get help), social factors (increased number of unfamiliar people, social pressures), and specific triggers (stress, sensory, physiological, and medication-related). We make recommendations for incorporating different combinations of anxiety-related factors to achieve a customizable selection of graded exposure scenarios suitable for VR-ET. Subsequent phases of this study will include creating a set of VR-ET hierarchies (Phase 2) and rigorously evaluating their feasibility and effectiveness (Phase 3).

German translation and validation of the brief Epilepsy Anxiety Survey Instrument (brEASI)

BACKGROUND

Anxiety disorders remain undiagnosed in routine clinical practice in up to two thirds of affected patients with epilepsy despite their significant impact on medical and psychosocial outcomes. The study objective was to translate and validate the German 8-item "brief Epilepsy Anxiety Survey Instrument" (brEASI) to facilitate effective screening for the presence of anxiety disorders in German-speaking patients.

METHODS

After expert translation into German, the brEASI was completed by consecutive adult inpatients with epilepsy hospitalized for seizures at an academic reference epilepsy center. Patients also completed the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), the Generalized Anxiety Disorder scale (GAD-7) for external validity, and underwent a standardized interview (Mini-DIPS-OA) as a gold standard to determine the presence of an ICD-10 anxiety disorder (generalized anxiety disorder (GAD), panic disorder, agoraphobia, and social phobia). Receiver operating characteristics (ROC) were calculated to determine the diagnostic accuracy of the brEASI, including the associated area under the curve (AUC) statistics to determine the potential of the brEASI to identify ICD-10 anxiety disorders diagnosed by interview. For comparative purposes, these analyses were also conducted for the GAD-7.

RESULTS

Of 80 recruited adult inpatients with epilepsy, 18 (23 %) were found to have a current anxiety disorder through standardized interview. In this study, both brEASI and GAD-7 showed a better diagnostic performance at a cutoff of >5 than at the previously reported cutoff values of >6 and >9, respectively. The AUC of the German brEASI was outstanding (AUC = 0.90, 95 % confidence interval (CI) = 0.82-0.96) for detecting all anxiety disorders and excellent for detecting non-GAD disorders (AUC = 0.85, CI = 0.76-0.92) at a cutoff of >5. At this optimal cutoff of >5 the brEASI demonstrated better sensitivity and specificity (89 % and 84 %) for identifying anxiety disorders than the GAD-7 (83 % and 74 %). The final German version of the brEASI is free to download at https://www.v-neuro.de/veroeffentlichungen/.

CONCLUSION

The German version of the brEASI represents a valid and reliable epilepsy-specific anxiety screening instrument. A positive screening result should be followed by further diagnostic procedures. Appropriate therapeutic steps should be initiated if the presence of an anxiety disorder or other psychiatric disorders is confirmed.

Epilepsy-associated comorbidities among adults: A plausible therapeutic role of gut microbiota

Epilepsy is a debilitating disorder that affects about 70 million people in the world currently. Most patients with epilepsy (PWE) often reported at least one type of comorbid disorder. These may include neuropsychiatric disorders, cognitive deficits, migraine, cardiovascular dysfunction, systemic autoimmune disorders and others. Current treatment strategies against epilepsy-associated comorbidities have been based on targeting each disorder separately with either anti-seizure medications (ASMs), anti-inflammatories or anti-depressant drugs, which have often given inconsistent and ineffective results. Gut dysbiosis may be a common pathological pathway between epilepsy and its comorbid disorders, and thus may serve as a possible intervention target. Therefore, this narrative review aimed to elucidate the potential pathological and therapeutic role of the gut microbiota in adult epilepsy-associated comorbidities. This review noticed a scarcity in the current literature on studies investigating the direct role of the gut microbiota in relation to epilepsy-associated comorbidities. Nevertheless, gut dysbiosis have been implicated in both epilepsy and its associated comorbidities, with similarities seen in the imbalance of certain gut microbiota phyla (Firmicutes), but differences seen in the mechanism of action. Current gut-related interventions such as probiotics have been consistently reported across studies to provide beneficial effects in correcting gut dysbiosis and improving various disorders, independent of epilepsy. However, whether these beneficial effects may translate towards epilepsy-associated comorbidities have yet to be determined. Thus, future studies determining the therapeutic potential of gut microbiota interventions in PWE with epilepsy-associated comorbidities may effectively improve their quality of life.

Owner reported management of interictal anxiety behaviours in canine epilepsy

BACKGROUND

Idiopathic epilepsy (IE) is the most common chronic neurological condition in dogs, and can be associated with interictal (between seizure) anxiety (IIA). It is unclear how owners manage their pet's IIA, including how much veterinary support they receive for it.

METHODS

An international online questionnaire collected data on IIA prevalence, management of IIA and perceived levels of veterinary support for IIA from owners of dogs diagnosed with IE.

RESULTS

Valid responses were available from n = 220 owners. IIA was reported by 83.6% of owners. Common management strategies were behavioural or training techniques, reported by 90.4% of owners, whilst 34.4% reported use of behavioural products. Only 28.5% of owners felt fully supported by their vet in managing IIA. Owners who felt unsupported were less likely to have received advice on behavioural management or training from their vet (p = 0.003).

CONCLUSION

Access to veterinary support for the management of IIA is needed for owners of dogs with IE.

Sex differences in seizure effects on social anxiety in persons with epilepsy

PURPOSE

We investigated sex differences in the effect of seizures on social anxiety in persons with epilepsy.

METHOD

In this cross-sectional multicenter study, social anxiety was measured using the short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). SPS-6 scores ≥ 9 and SIAS-6 scores ≥ 12 were considered to indicate social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9, Stigma Scale-Revised, and Family Adaptation-Partnership-Growth-Affection-Resolve scale were also completed. A logistic regression analysis with an interaction term was used to analyze the data.

RESULTS

Out of 285 participants, a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12 were noted in 62 (21.8%) and 36 (12.6%) of participants, respectively. There was no difference in the prevalence of social anxiety between men and women. Intractable seizures and lack of seizure freedom were associated with a SPS-6 score ≥ 9 and a SIAS-6 score ≥ 12, but statistical significance was lost in the adjusted models. However, intractable seizures and lack of seizure freedom significantly interacted with sex for a SPS-6 score ≥ 9 (p = 0.018) and a SIAS-6 score ≥ 12 (p = 0.048) in both the separate and adjusted models. Specifically, intractable seizures tended to be positively associated with SPS-6 scores ≥ 9 than non-intractable seizures in men only (odds ratio = 2.602, p = 0.068), whereas lack of seizure freedom tended to be negatively associated with SIAS-6 scores ≥ 12 than seizure freedom in women only (odds ratio = 4.804, p = 0.053).

CONCLUSION

We found significant sex differences in seizure effects on social anxiety. Intractable seizures were associated with social phobia in men, whereas lack of seizure freedom in the last year was associated with social interaction anxiety in women.

Therapeutic Targets for the Treatment of Comorbidities Associated with Epilepsy

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

Neurologist prescribing versus psychiatry referral: Examining patient preferences for anxiety and depression management in a symptomatic epilepsy clinic sample

OBJECTIVE

Anxiety and depression symptoms in epilepsy are common, impactful and under-recognized and undertreated. While prior survey data suggests equipoise among epileptologists for managing anxiety and/or depression via prescribing in the epilepsy clinic versus psychiatry referral, patient preferences are unknown and should potentially influence practice habits among epileptologists. Thus, the primary objective of this study was to determine patient preference for anxiety and/or depression prescribing by neurologists versus psychiatry referral among an adult epilepsy clinic sample of symptomatic patients.

METHODS

Management preferences for anxiety and/or depression were surveyed in an adult tertiary care epilepsy clinic. Individuals who screened positive for anxiety and/or depression symptoms on validated instruments during a routine care-embedded learning health system study were recruited. Demographics, social variables, psychiatric treatment history, and treatment priorities and preferences were surveyed. Preference was defined as a slightly greater than 2:1 ratio in favor neurology prescribing or psychiatry referral. The study was powered to assess this primary objective using a two-sample binomial test. Multinomial logistic regression examined an a priori multivariable model of treatment preference (secondary objective).

RESULTS

The study sample included N = 63 symptomatic adults, with 64% women and mean age 42.2 years. Most reported past or current treatment for anxiety and/or depression, and treatment for these symptoms was a high or moderate priority among 65.1% of the sample. Neurologist prescribing was preferred in 83.0% (nearly 5:1) over psychiatry referral among those who chose neurology or psychiatry (as opposed to neither of the two; p < 0.001, 95% CI 0.702-0.919). Overall, 69.8% of the total study sample preferred neurology prescribing. Multivariable modeling indicated preference for neither management option (compared with neurologist prescribing) was associated with low overall treatment prioritization and having never received neurologist medication management. None of the factors examined in the a priori multivariable model were associated with selecting psychiatry referral (compared to neurologist prescribing).

CONCLUSION

In this sample, most patients indicated a preference for neurologists to prescribe for anxiety or depression symptoms in the epilepsy clinic. Care models involving neurologist prescribing for anxiety and depression symptoms merit further investigation and potential adoption in clinical practice.

Investigation of Sexual Satisfaction in Women with Epilepsy and Its Clinical Correlates

Women with epilepsy are at increased risk of sexual dysfunction. The aim of this cross-sectional study was to investigate the effect of antiepileptic drugs on sexual function and satisfaction in women with epilepsy. In this cross-sectional study, 80 married women with epilepsy who were under treatment with antiepileptic drugs for at least 1 year were evaluated. Sexual function in patients was assessed using the Female Sexual Function Index. The mean age (± standard deviation [SD]) of women was 28.8 (± 5.9) years. The mean (± SD) duration of epilepsy was 8.6 (± 4.1) years. Thirteen women (16.2%) had focal epilepsy and 67 (83.7%) had generalized epilepsy. The mean (± SD) overall sexual performance of patients was 20.5 (± 4.7). Fifteen patients (21.3%) had decreased sexual function and 78.2% had unfavorable sexual performance. Generalized epilepsy, multi-drug regimen, disease duration of more than 10 years, and age > 30 years were associated with sexual dysfunction. Due to the high prevalence of sexual dysfunction in women with epilepsy, special attention should be given to appropriate management of these patients.

The intersections of stress, anxiety and epilepsy

Stress is ubiquitous in chronic medical conditions; however, the connections to psychiatric and neurologic conditions are not always clearly established. Epilepsy is a unique illness that is intimately intertwined with stress and anxiety not only as a result of the disease process but also as a cause of disease exacerbation. Anxiety and depression also involve stress management and often overlap with epilepsy. Anxiety symptoms themselves may be present as intrinsic aspects of seizure phenomena, either during the events or closely related to them. The pathways of stress and anxiety involve the hypothalamic pituitary adrenal (HPA) axis and explain at least in part how stress may lead to worsening seizure control. Ultimately, the study of stress, anxiety, and epilepsy offers insight into mind and body connections, and furthers understanding of neuropsychiatric illness.

Who is willing to participate in research? A screening model for an anxiety and depression trial in the epilepsy clinic

OBJECTIVE

Anxiety and depression in epilepsy are prevalent, associated with poor outcomes, underrecognized, undertreated, and thus a key area of need for treatment research. The objective of this study was to assess factors associated with research participation among epilepsy clinic patients who screened positive for anxiety or depression. This was accomplished by characterizing clinical and psychiatric factors among patients seen in an epilepsy clinic and evaluating which factors were associated with consent for potential research participation, via a combined clinical and research screening model.

METHODS

In a pragmatic trial of anxiety and depression treatment in epilepsy, individuals with a positive screen for anxiety and/or depression at a routine epilepsy clinic visit were invited to opt-in (via brief electronic consent) to further eligibility assessment for a randomized treatment study. Information on psychiatric symptoms and treatment characteristics were collected for dual clinical care and research screening purposes. Cross-sectional association of demographic, clinical, and psychiatric factors with opting-in to research was analyzed by multiple logistic regression.

RESULTS

Among N = 199 unique adults with a first positive screen for anxiety and/or depression among 786 total screening events, 154 (77.4%) opted-in to further potential research assessment. Higher depression scores and current treatment with an antidepressant were independently associated with opting-in to research (depression odds ratio (OR) = 1.13 per 1-point increase in Neurological Disorders Depression Inventory-Epilepsy (NDDI-E) score, p = 0.028, 95% confidence interval (CI): 1.01-1.26; antidepressant OR = 2.37, p = 0.041, CI: 1.04-5.41). Nearly half of the 199 individuals (43.7%) with anxiety and/or depression symptoms were already being treated with an antidepressant, and 46.7% were receiving neither antidepressant therapy nor mental health specialty care. One-quarter (24.1%) reported a past psychiatric hospitalization, yet only half of these individuals were receiving mental health specialty care.

SIGNIFICANCE

Our results demonstrate a high willingness to participate in research using a brief electronic consent approach at a routine clinic visit. Adults with persistent anxiety or depression symptoms despite antidepressant therapy and those with higher depression scores were more willing to consider a randomized treatment study. This has implications for future study design, as individuals already on treatment or those with more severe symptoms are often excluded from traditional research designs. We also found a high burden of psychiatric disease and high prevalence of persistent symptoms despite ongoing antidepressant treatment.

Group-based cognitive behavioral therapy program for improving poor sleep quality and quality of life in people with epilepsy: A pilot study

Sleep difficulties are commonly reported by patients with epilepsy and can have a detrimental impact on overall quality of life. The purpose of this pilot study was to assess the efficacy of a psychotherapeutic approach, namely Cognitive Behavioral Therapy for Insomnia (CBT-I), in improving sleep quality in patients with epilepsy. Twenty outpatients with epilepsy who reported poor sleep quality were randomized to either a control or CBT-I treatment group, which involved four group-based CBT-I sessions, delivered on a weekly basis. In addition to completing a range of standardized measures related to sleep quality and quality of life, participants also monitored their sleep with a self-completed sleep diary over a two-week period, on two separate occasions. Following CBT-I treatment, no between-group difference was found on any sleep or quality of life measure. However, both the treatment and control groups improved on measures of sleep quality, quality of life, sleep hygiene behaviors, and dysfunctional beliefs about sleep. These findings suggest that sleep monitoring alone may have the potential for prompting healthy behavior change in this clinical population.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Anxiety disorders in outpatient clinics of epilepsy in tertiary care hospitals: A meta-analysis

BACKGROUND AND PURPOSE

Although anxiety disorders (ADs) occur frequently in people with epilepsy (PWE) and impair quality of life and treatment outcomes, current efforts to categorize and investigate AD subtypes in PWE remain insufficient. Thus, the present meta-analysis aimed to determine the current prevalence rates of any AD type and various AD subtypes in PWE managed by outpatient clinics.

METHODS

MEDLINE, EMBASE, Cochrane Library, Web of Science, and SCOPUS were searched to identify and select studies that assessed the prevalence of ADs or individual AD subtypes in adult PWE under the routine care of outpatient epilepsy clinics in tertiary hospitals. Only studies that used gold-standard diagnostic tools for assessing ADs were included in this meta-analysis.

RESULTS

The database search ultimately identified 15 studies, of which 9 provided current prevalence rates of any type of AD. The pooled estimated prevalence of any AD was 26.1 %. Of the 15 total studies, 13 provided current prevalence rates of generalized anxiety disorder (GAD), revealing an overall estimated prevalence of 18.2 %. In terms of current prevalence rates, GAD was highest, followed by agoraphobia, social phobia, panic disorder, and obsessive-compulsive disorder.

CONCLUSIONS

Among PWE managed in the outpatient epilepsy clinics of tertiary care hospitals, the current prevalence of any AD was 26.1 %, and GAD was the most prevalent subtype of AD.

Correlates of Stigma in People with Epilepsy

Background and Purpose

Epilepsy is often associated with substantial stigma. This study evaluated clinical correlates of stigma in a sample of people living with epilepsy (PLWE) considered high risk due to frequent seizures or other negative health events.

Methods

Data were derived from an epilepsy self-management clinical trial. Standardized measures assessed socio-demographics, epilepsy stigma, epilepsy severity, self-efficacy, self-management competency, health literacy, depressive symptoms severity, functional status, social support and quality of life.

Results

There were 120 individuals, mean age of 41.73 (SD=17.08), 81 men (66.9%), and 79 (65.3%) African-American. Individual factors correlated with worse stigma w ere indicative of more severe or poorly controlled seizures (frequent seizures, worse seizure severity scores, more antiepileptic drugs), mental health comorbidity (worse depression severity, other comorbidities) and factors related to individual functioning and perceived competency in managing their health (health literacy, health functioning, self-efficacy, quality of life). Multivariable linear regression found that worse quality of life, and having a mental condition were associated with more stigma (β=6.4 and 6.8, respectively), while higher self-efficacy, health literacy and social support were associated with less stigma (β=−0.06, −2.1, and −0.3, respectively). These five variables explained 50% of stigma variation.

Conclusions

Stigma burden can be substantial among PLWE and may vary depending on contextual factors such as mental health comorbidity. Care approaches that screen for psychiatric comorbidities, address low health literacy, institute promising self-management programs, and employ effective health communication strategies about epilepsy misconceptions, may reduce epilepsy related burden.

Effect of rutin on anxiety-like behavior and activity of acetylcholinesterase isoforms in specific brain regions of pentylenetetrazol-treated mice

The aim of the present study was to investigate the effect of rutin administration (100 mg/kg/day) to pentylenetetrazol (PTZ)-treated Balb-c mice (60 mg/kg/day), with respect to anxiety-like behavior using both open-field and elevated plus-maze (EPM) tests, and acetylcholinesterase (AChE) activity in salt-soluble (SS) fraction and detergent-soluble (DS) fraction of the cerebral cortex, hippocampus, striatum, midbrain, and diencephalon. Our results demonstrated that the administration of PTZ in 3 doses and the induction of seizures increased significantly anxiety behavior of mice and reduced significantly DS-AChE activity in all brain regions examined, while the reduction in the SS fraction was brain region-specific. Rutin administration to normal mice did not affect their behavior, while it induced a brain region-specific reduction in SS-AChE and a significant decrease in DS-AChE in all brain regions. We demonstrated for the first time that pretreatment of PTZ-mice with rutin (PTZ + Rutin group) prevented the manifestation of anxiety and induced interestingly a further significant reduction on the SS- and DS-AChE activities only in the cerebral cortex and striatum, in comparison with PTZ group. Our results show that rutin exhibits an important anxiolytic effect and an anticholinesterase activity in specific brain areas in the seizure model of PTZ.

Behavioural changes in dogs with idiopathic epilepsy

BACKGROUND

Breed-specific and broader cohort studies have shown behavioural changes in dogs following the onset of idiopathic epilepsy (IE).

METHODS

A cross-sectional, case-control questionnaire study was carried out to strengthen this body of evidence. Owners of eight breeds of dog completed an online questionnaire about their dogs' behaviour; once for control dogs and twice for dogs with IE, for both pre-IE and post-IE onset behaviour.

RESULTS

Ninety-six (24.74 per cent) dogs with IE and 292 (75.26 per cent) age and breed-matched control dogs met the inclusion criteria. Control dogs had significantly higher 'Trainability' scores than dogs with IE (P=0.04). After IE, dogs had significantly higher 'Dog-Directed Fear or Aggression' (P=0.02), 'Non-Social Fear' (P=0.01), 'Attachment/Attention-Seeking Behaviour' (P=0.04), 'Attention-Deficit' (P=0.02) and significantly lower 'Trainability' (P=0.02) than prior to the onset of IE. Medication status did not significantly affect any behavioural factor, but drug-resistant dogs had significantly less 'Trainability' than drug-responsive (P=0.04) and partially drug-responsive dogs (P=0.03).

CONCLUSION

Behavioural differences related to cognitive function are seen between dogs with IE and controls. Behavioural changes related to anxiety, attention and cognition are seen in dogs following the onset of IE. The ability to clinically define and diagnose behavioural comorbidities in dogs is much needed from both a clinical and research perspective.

Should adult neurologists play a role in the management of the most common psychiatric comorbidities? Practical considerations

Despite the high prevalence and negative impact of psychiatric comorbidities on the life of adults with epilepsy, significant unmet mental health care need exists because of a variety of factors, including poor access to mental health care providers. A potential solution to address access barriers is neurologist-driven diagnosis and management of common psychiatric conditions in epilepsy, of which mood and anxiety disorders are the most common. In this manuscript, patient selection criteria and practical treatment strategies are outlined for common mood and anxiety disorders that can be safely managed by neurologists. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Cognition, mood and quality-of-life outcomes among low literacy adults living with epilepsy in rural Kenya: A preliminary study

Epilepsy is frequently associated with neurocognitive impairments, mental health, and psychosocial problems but these are rarely documented in low- and middle-income countries. The aim of this study was to examine the neurocognitive outcomes, depressive symptoms, and psychosocial adjustments of people with epilepsy (PWE) in Kilifi, Kenya. We evaluated the impact of these outcomes on health-related quality of life. Self-report, interviewer-administered measures of depression (Major Depression Inventory) and quality of life (RAND SF-36) were administered to 63 PWE and 83 community controls. Neurocognitive functioning was assessed using Raven's Standard Progressive Matrices, Digit Span, and Contingency Naming Test. The results show that PWE have poorer scores for executive function, working memory, intelligence quotient (IQ), depression, and quality of life than controls. Twenty-seven (27%) of PWE had depressive symptoms, which was significantly greater than in controls (6%); P < 0.001. Quality-of-life scores were significantly lower in PWE with depressive symptoms than in those without depressive symptoms (Mean QoL scores (standard deviation (SD)): 46.43 (13.27) versus 64.18 (17.69); P = 0.01. On adjusted linear regression models, depression affected total quality-of-life scores (P = 0.07) as well as individual health indicator domains touching on pain (P = 0.04), lethargy/fatigue (P = 0.01), and emotional well-being (P = 0.02). Our results show that epilepsy is associated with a significant burden of mental health and neurocognitive impairments in the community; however, community-based studies are needed to provide precise estimates of these disorders.

A review of treatment options for behavioural manifestations of clinical anxiety as a comorbidity in dogs with idiopathic epilepsy

Psychiatric comorbidities affect a large percentage of people with epilepsy and have a detrimental impact on their quality of life. Recently, behavioural comorbidities, with similar characteristics to human psychiatric diseases, have been identified in dogs with idiopathic epilepsy. In particular, behaviours motivated by the fear-anxiety emotional system have been found to be associated with the occurrence of idiopathic epilepsy in both dogs receiving anti-epileptic drugs, and drug-naïve dogs. There has been little research into the relationship between epilepsy and behavioural signs, and even less into potential treatment protocols. The following article will review available literature from human medicine to describe the current state of knowledge about the bi-directional relationship between anxiety and epilepsy, draw parallels from reported anxiogenic and anxiolytic properties of anti-epileptic drugs and attempt to provide pharmaceutical and behavioural guidance for veterinary patients with epilepsy and comorbid anxiety.

A novel metabolism-based phenotypic drug discovery platform in zebrafish uncovers HDACs 1 and 3 as a potential combined anti-seizure drug target

Despite the development of newer anti-seizure medications over the past 50 years, 30-40% of patients with epilepsy remain refractory to treatment. One explanation for this lack of progress is that the current screening process is largely biased towards transmembrane channels and receptors, and ignores intracellular proteins and enzymes that might serve as efficacious molecular targets. Here, we report the development of a novel drug screening platform that harnesses the power of zebrafish genetics and combines it with in vivo bioenergetics screening assays to uncover therapeutic agents that improve mitochondrial health in diseased animals. By screening commercially available chemical libraries of approved drugs, for which the molecular targets and pathways are well characterized, we were able to reverse-identify the proteins targeted by efficacious compounds and confirm the physiological roles that they play by utilizing other pharmacological ligands. Indeed, using an 870-compound screen in kcna1-morpholino epileptic zebrafish larvae, we uncovered vorinostat (Zolinza™; suberanilohydroxamic acid, SAHA) as a potent anti-seizure agent. We further demonstrated that vorinostat decreased average daily seizures by ∼60% in epileptic Kcna1-null mice using video-EEG recordings. Given that vorinostat is a broad histone deacetylase (HDAC) inhibitor, we then delineated a specific subset of HDACs, namely HDACs 1 and 3, as potential drug targets for future screening. In summary, we have developed a novel phenotypic, metabolism-based experimental therapeutics platform that can be used to identify new molecular targets for future drug discovery in epilepsy.

Anxiolytic Effect of Exogenous Ketone Supplementation Is Abolished by Adenosine A1 Receptor Inhibition in Wistar Albino Glaxo/Rijswijk Rats

Anxiety disorders are one of the most common mental health problems worldwide, but the exact pathophysiology remains largely unknown. It has been demonstrated previously that administration of exogenous ketone supplement KSMCT (ketone salt/KS + medium chain triglyceride/MCT oil) by intragastric gavage for 7 days decreased the anxiety level in genetically absence epileptic Wistar Albino Glaxo/Rijswijk (WAG/Rij) rats. To investigate the potential role of the adenosinergic system in the pathomechanism of anxiety we tested whether the inhibition of adenosine A₁ receptors (A₁Rs) influence the anxiolytic effect of the exogenous ketone supplement. As A₁Rs may mediate such an effect, in the present study we used a specific A₁R antagonist, DPCPX (1,3-dipropyl-8-cyclopentylxanthine) to test whether it modulates the anxiolytic effect of sub-chronically (7 days) applied KSMCT in the previously tested animal model by using elevated plus maze (EPM) test. We administered KSMCT (2.5 g/kg/day) alone by intragastric gavage and in combination with intraperitoneally (i.p.) injected of DPCPX in two doses (lower: 0.15 mg/kg, higher: 0.25 mg/kg). Control groups represented i.p saline and water gavage with or without i.p. DPCPX administration (2.5 g/kg/day). After treatments, the level of blood glucose and beta-hydroxybutyrate (βHB), as well as body weight were recorded. KSMCT alone significantly increased the time spent in the open arms and decreased the time spent in the closed arms, supporting our previous results. Injection of lower dose of DPCPX decreased, while higher dose of DPCPX abolished the effect of KSMCT administration on EPM. Blood βHB levels were significantly increased after administration of KSMCT, while DPCPX did not change the KSMCT induced increase in blood βHB levels. These results demonstrate that A₁R inhibition modified (decreased) the anti-anxiety effect of KSMCT administration implying that the adenosinergic system, likely via A₁Rs, may modulate the exogenous ketone supplement induced anxiolytic influence.

[Psychiatric comorbidities in epilepsy]

Psychiatric comorbidities are overrepresented in people suffering from epilepsy in comparison to the general population. There is a two-way link between epilepsy and psychiatric disorders. Psychiatric symptomatology is specific in epilepsy, according to the chronology of symptoms in relation to the seizure (inter, pre- or postictal). Easy to use, fast and efficient self-administered questionnaires are available to evaluate depressive (NDDI-E) and generalized anxiety disorder (GAD-7) symptoms. Selective serotonin reuptake inhibitors (SSRIs) are not proconvulsant and can be safely used to treat depressive or anxious disorders.

Implementation of psychological clinical trials in epilepsy: Review and guide

The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.

Overexpression of the 18 kDa translocator protein (TSPO) in the hippocampal dentate gyrus produced anxiolytic and antidepressant-like behavioural effects

The 18 kDa translocator protein (TSPO) is a five transmembrane domain protein that plays a crucial role in neurosteroid (e.g., allopregnanolone) synthesis by promoting the transport of cholesterol to the inner mitochondrial membrane. This protein is predominantly expressed in steroid-synthesizing tissues, including the central and peripheral nervous system, affecting stress-related disorders such as anxiety and depression. Recent studies have focused on the hippocampal dentate gyrus, which is very important for involvement of anxiety and depression. However, the exact role that TSPO plays in the pathophysiology of anxiety and depression and the involvement of the hippocampal dentate gyrus in regulating these behavioural effects remain elusive. This study used the lentiviral vectors mediating TPSO overexpression to assess the effects of TPSO overexpression in the hippocampal dentate gyrus on anxiolytic and antidepressant-like behavioural effects in mice. The expression of TSPO and the concentration of allopregnanolone in hippocampus tissues (3 mm in diameter around the injection site on both sides) were measured by Western blot and ELISA, respectively. The results indicated that microinjection of the LV-TSPO resulted in a significant increase in TSPO expression and allopregnanolone concentration in the hippocampus. Moreover, TSPO overexpression of the mouse hippocampal dentate gyrus generated significant anxiolytic and antidepressant-like behavioural effects in a series of behavioural models. These effects were completely blocked by the TSPO antagonist PK11195 (3 mg/kg, intraperitoneally) and the 5α-reductase inhibitor finasteride (5 mg/kg,intraperitoneally). Meanwhile, the increased allopregnanolone was also reversed by PK11195 and finasteride. In addition, neither PK11195 nor finasteride had an effect on the expression of TSPO. Overall, our results are the first to suggest that the overexpression of TSPO in the hippocampal dentate gyrus produced anxiolytic and antidepressant-like behavioural effects that are partially mediated by downstream allopregnanolone biosynthesis. Our results suggest that TSPO would be a potential anxiolytic and antidepressant therapeutic target.

Exogenous Ketone Supplements Reduce Anxiety-Related Behavior in Sprague-Dawley and Wistar Albino Glaxo/Rijswijk Rats

Nutritional ketosis has been proven effective for seizure disorders and other neurological disorders. The focus of this study was to determine the effects of ketone supplementation on anxiety-related behavior in Sprague-Dawley (SPD) and Wistar Albino Glaxo/Rijswijk (WAG/Rij) rats. We tested exogenous ketone supplements added to food and fed chronically for 83 days in SPD rats and administered sub-chronically for 7 days in both rat models by daily intragastric gavage bolus followed by assessment of anxiety measures on elevated plus maze (EPM). The groups included standard diet (SD) or SD + ketone supplementation. Low-dose ketone ester (LKE; 1,3-butanediol-acetoacetate diester, ~10 g/kg/day, LKE), high dose ketone ester (HKE; ~25 g/kg/day, HKE), beta-hydroxybutyrate-mineral salt (βHB-S; ~25 g/kg/day, KS) and βHB-S + medium chain triglyceride (MCT; ~25 g/kg/day, KSMCT) were used as ketone supplementation for chronic administration. To extend our results, exogenous ketone supplements were also tested sub-chronically on SPD rats (KE, KS and KSMCT; 5 g/kg/day) and on WAG/Rij rats (KE, KS and KSMCT; 2.5 g/kg/day). At the end of treatments behavioral data collection was conducted manually by a blinded observer and with a video-tracking system, after which blood βHB and glucose levels were measured. Ketone supplementation reduced anxiety on EPM as measured by less entries to closed arms (sub-chronic KE and KS: SPD rats and KSMCT: WAG/Rij rats), more time spent in open arms (sub-chronic KE: SPD and KSMCT: WAG/Rij rats; chronic KSMCT: SPD rats), more distance traveled in open arms (chronic KS and KSMCT: SPD rats) and by delayed latency to entrance to closed arms (chronic KSMCT: SPD rats), when compared to control. Our data indicates that chronic and sub-chronic ketone supplementation not only elevated blood βHB levels in both animal models, but reduced anxiety-related behavior. We conclude that ketone supplementation may represent a promising anxiolytic strategy through a novel means of inducing nutritional ketosis.

Affective disorders and functional (non-epileptic) seizures in persons with epilepsy

OBJECTIVE

This paper aims to describe the prevalence, assessment and management of affective disorders as well as functional (non-epileptic) seizures in people with epilepsy.

METHOD

This paper comprises a selective review of the literature of the common affective manifestations of epilepsy.

RESULTS

Affective disorders are the most common psychiatric comorbidity seen in people with epilepsy and assessment and management parallels that of the general population. Additionally, people with epilepsy may experience higher rates of mood instability, irritability and euphoria, classified together as a group, interictal dysphoric disorder and resembling an unstable bipolar Type II disorder. Functional seizures present unique challenges in terms of identification of the disorder and a lack of specific management.

CONCLUSIONS

Given their high prevalence, it is important to be able to recognise affective disorders in people with epilepsy. Management principles parallel those in the general population with specific caution exercised regarding the potential interactions between antidepressant medications and antiepileptic drugs. Functional seizures are more complex and require a coordinated approach involving neurologists, psychiatrists, general practitioners, nursing and allied health. There is very limited evidence to guide psychological and behavioural interventions for neurotic disorders in epilepsy and much more research is needed.

Behavioral health in young adults with epilepsy: Implications for transition of care

AIM

Neurodevelopmental and behavioral health disorders commonly occur with epilepsy, yet risk for young adults is unknown. The aim of this study was to determine the distribution and risk characteristics of neurodevelopmental and behavior health comorbidities among young adults with epilepsy compared with those among young adults with migraine and healthy controls.

METHOD

A case-control study examining hospital admission, outpatient, and emergency department (ED) visits for young adults with an ICD-9-CM diagnosis of epilepsy, migraine, or lower extremity fracture (LEF) was conducted. The association of epilepsy, migraine, or LEF with comorbidities was evaluated with univariate and multivariate polytomous logistic regression.

RESULTS

From 2000 to 2013, 29,139 young adults ages 19 to 25years were seen in hospitals and EDs for epilepsy (5666), migraine (17,507), or LEF (5966). Young adults with epilepsy had higher proportions of behavioral health comorbidities (51.8%) compared with controls with migraine (37.6%) or LEF (21.6%). In young adults with epilepsy compared with migraine, the increased risk of having any behavioral health comorbidity was 76%, and neurodevelopmental comorbidity was 297%. After adjustment, young adults with epilepsy showed significantly higher odds of each behavioral health comorbidity compared with controls with migraine and LEF.

INTERPRETATION

Young adults with epilepsy are particularly susceptible to behavioral health and neurodevelopmental disorders. Results are discussed within the context of transition to adult care.

The Cyclic Vomiting Syndrome Threshold: A Framework for Understanding Pathogenesis and Predicting Successful Treatments

Cyclic vomiting syndrome (CVS) is an uncommon, idiopathic disorder defined by recurrent, sudden-onset attacks of repetitive retching and vomiting that are separated by symptom-free intervals. CVS was long regarded as a disorder primarily experienced by children but is now known to present de novo in adulthood. Adult CVS has garnered more research attention over the past 20 years, and these efforts have identified some acute and prophylactic treatments for this disorder. However, CVS still lacks a unifying disease model, and this has hindered the development of new therapies. Here adult CVS is reframed as a neurogenic disorder, driven by various endophenotypic factors that shape patterns of activity within the neural circuits required for disease expression. The concept of the "CVS threshold" is put forth in parallel with exploring the remarkable similarity of adult CVS with features of chronic migraine, epilepsy, and panic disorder. Because of such shared neural mechanisms and overlapping endophenotypes, many therapies that have been developed for these other disorders could also be useful in managing CVS. This review seeks to achieve three primary aims: (1) to develop a comprehensive, explanatory framework for adult CVS pathogenesis, (2) to use this framework for identifying potentially novel therapies for CVS, and (3) to describe future research directions that are needed to move the field forward.

Anxiety disorders in people with epilepsy

Anxiety disorders are frequent, though probably underdiagnosed, comorbidities in epilepsy. Epilepsy and anxiety may share common neurobiological correlates as shown in animal models and suggested by studies demonstrating anxiety disorders before the manifestation of epilepsy. Comorbid anxiety disorders have a major impact on the affected patients' quality of life and may increase the risk for suicidality. Successful treatment of the epilepsy may alleviate anxiety symptoms. Treatment of anxiety is based on selective serotonin reuptake inhibitors, benzodiazepines (although only as second-line choices), and psychotherapy. Specific AEDs (especially pregabalin) have been shown to have anxiolytic properties. This paper is aimed at reviewing anxiety disorders in patients with epilepsy discussing current scientific evidence about pathophysiology, clinical aspects, and treatment strategies.

The pharmacological management of psychiatric comorbidities in patients with epilepsy

Psychiatric disorders represent a frequent comorbidity in patients with epilepsy affecting quality of life, morbidity and mortality. Evidence-based data on the management of these conditions are limited but a number of recommendations are now available to guide clinical practice. The present paper reviews the pharmacological treatment of psychiatric problems in epilepsy with special attention to data coming from randomised controlled trials (RCTs), pharmacological interactions with AEDs and the issue of seizure worsening during treatment with psychotropic drugs. Epidemiologically or clinically relevant psychiatric conditions are discussed namely mood and anxiety disorders, psychoses and attention deficit hyperactivity disorder.

Prevalence of depression and anxiety among patients with epilepsy attending the epilepsy clinic at Sheikh Khalifa Medical City, UAE: A cross-sectional study

Depression and anxiety are highly prevalent in patients with epilepsy (PWE), with prevalence rates ranging from 20% to 55%. Unfortunately, the rates, patterns, and risk factors have not been well studied in the Middle East and, to our knowledge, have not been studied at all in the UAE. We screened 186 patients attending an epilepsy clinic using standardized screening tools to determine the rates of both depression and anxiety and compared these rates with that of age- and sex-matched controls. Almost one-third of our patients scored in the depression and anxiety ranges, which was significantly higher compared with the age- and sex-matched controls. Using a multiregression model, none of the studied variables were associated with an increased risk of having either disorder. Depression or anxiety symptoms independently and significantly increased the risk of association with the other disorder. Almost two-thirds of patients with depression and anxiety were not prescribed antidepressant or antianxiety medications.

Depression and Anxiety among Patients with Epilepsy and Multiple Sclerosis: UAE Comparative Study

Depression and anxiety are highly prevalent in patients with epilepsy (PWE), with prevalence rates ranging from 20% to 55%. The cause of this increased rate is multifactorial. Depression and epilepsy are thought to share the same pathogenic mechanism. Anxiety, on the other hand, seems to have a prevalence rate among PWE comparable to, or even higher than, those reported for depression, and it is closely linked to epilepsy. To test this hypothesis, we screened for depression and anxiety 186 and 160 patients attending the epilepsy and MS clinics, respectively, using standardized screening tools to determine the rates of both depression and anxiety, comparing these rates to 186 age, sex matched controls. Among the three groups, only patients with epilepsy were at increased risk of having depression (OR = 1.9), whereas anxiety was not. This finding could point to the shared pathogenic mechanisms hypothesis between depression and epilepsy.

Hypoactive sexual desire disorder caused by antiepileptic drugs

Female sexual dysfunction is common but poorly understood sexual problem in women. Sexual dysfunction in female is multi-factorial in origin and also observed with intake of drug acting on central nervous system. This case report describes a female epileptic patient who developed sexual dysfunction with intake of antiepileptic drugs.

Emerging drugs for the treatment of anxiety

INTRODUCTION

Anxiety disorders are among the most prevalent and disabling psychiatric disorders in the United States and worldwide. Basic research has provided critical insights into the mechanism regulating fear behavior in animals and a host of animal models have been developed in order to screen compounds for anxiolytic properties. Despite this progress, no mechanistically novel agents for the treatment of anxiety have come to market in more than two decades.

AREAS COVERED

The current review will provide a critical summary of current pharmacological approaches to the treatment of anxiety and will examine the pharmacotherapeutic pipeline for treatments in development. Anxiety and related disorders considered herein include panic disorder, social anxiety disorder, generalized anxiety disorder and post-traumatic stress disorder. The glutamate, neuropeptide and endocannabinoid systems show particular promise as future targets for novel drug development.

EXPERT OPINION

In the face of an ever-growing understanding of fear-related behavior, the field awaits the translation of this research into mechanistically novel treatments. Obstacles will be overcome through close collaboration between basic and clinical researchers with the goal of aligning valid endophenotypes of human anxiety disorders with improved animal models. Novel approaches are needed to move basic discoveries into new, more effective treatments for our patients.

Sertraline-induced potentiation of the CYP3A4-dependent neurotoxicity of carbamazepine: an in vitro study

OBJECTIVE

Drug toxicity is a hurdle to drug development and to clinical translation of basic research. Antiepileptic drugs such as carbamazepine (CBZ) and selective serotonin reuptake inhibitors such as sertraline (SRT) are commonly co-prescribed to patients with epilepsy and comorbid depression. Because SRT may interfere with cytochrome P450 (CYP) enzyme activity and CYPs have been implicated in the conversion of CBZ to reactive cytotoxic metabolites, we investigated in vitro models to determine whether SRT affects the neurotoxic potential of CBZ and the mechanisms involved.

METHODS

Human fetal brain-derived dopaminergic neurons, human brain microvascular endothelial cells (HBMECs), and embryonic kidney (HEK) cells were used to evaluate cytotoxicity of CBZ and SRT individually and in combination. Nitrite and glutathione (GSH) levels were measured with drug exposure. To validate the role of CYP3A4 in causing neurotoxicity, drug metabolism was compared to cell death in HEK CYP3A4 overexpressed and cells pretreated with the CYP3A4 inhibitor ketoconazole.

RESULTS

In all cellular systems tested, exposure to CBZ (127 μM) or SRT (5 μM) alone caused negligible cytotoxicity. By contrast CBZ, tested at a much lower concentration (17 μM) in combination with SRT (5 μM), produced prominent cytotoxicity within 15 min exposure. In neurons and HBMECs, cytotoxicity was associated with increased nitrite levels, suggesting involvement of free radicals as a pathogenetic mechanism. Pretreatment of HBMECs with reduced GSH or with the GSH precursor N-acetyl-L-cysteine prevented cytotoxic response. In HEK cells, the cytotoxic response to the CBZ + SRT combination correlated with the rate of CBZ biotransformation and production of 2-hydroxy CBZ, further suggesting a causative role of reactive metabolites. In the same system, cytotoxicity was potentiated by overexpression of CYP3A4, and prevented by CYP3A4 inhibitor.

SIGNIFICANCE

These results demonstrate an unexpected neurotoxic interaction between CBZ and SRT, apparently related to increased CYP3A4-mediated production of reactive CBZ metabolites. The potential clinical implications of these findings are discussed.

Anxiety in epilepsy: a neglected disorder

OBJECTIVE

Anxiety disorders and symptoms are highly prevalent and problematic comorbidities in people with epilepsy (PWE), yet they remain poorly understood and often go undetected. This research aimed to further our understanding about anxiety in PWE.

METHODS

Study 1 assessed the effectiveness of the commonly utilised yet unvalidated measure (Hospital Anxiety Depression Scale-Anxiety subscale; HADS-A) to identify DSM-IV anxiety disorders in 147 adult epilepsy outpatients.

RESULTS

This study found that although the HADS-A had reasonable specificity (75%), its poor sensitivity (61%) and inadequate area under the curve (.68) deemed it unreliable as a screener for anxiety disorders in this population.

METHODS

Study 2 aimed to further our understanding of the relationship between anxiety disorders, as defined by clinical interview, and psychosocial correlates in PWE. One hundred and twenty-two participants from Study 1 completed a battery of psychosocial measures.

RESULTS

Multivariate analysis revealed that the presence of an anxiety disorder was associated with unemployment, which was found to be the only independent predictor. That is, despite the fact that psychosocial factors together contributed to the variance in anxiety disorders none were revealed to be significant independent predictors.

CONCLUSION

These findings add to the literature indicating that the HADS may indicate distress, but does not adequately identify people with anxiety disorders and highlights the urgent need for the development of a reliable anxiety screening measure for PWE. Further, the results suggest that anxiety disorders in PWE are likely to be multiply determined with respect to psychosocial factors and require further investigation.

Kainate-induced epileptogenesis alters circular hole board learning strategy but not the performance of C57BL/6J mice

Patients with mesial temporal lobe epilepsy (mTLE) frequently show cognitive deficits. However, the relation between mTLE and cognitive impairment is poorly understood. To gain more insight into epilepsy-associated alterations in cognitive performance, we studied the spatial learning of C57BL/6J mice five weeks after kainate-induced status epilepticus (SE). Typically, structural hippocampal rearrangements take place within five weeks after SE. Mice were monitored by exposing them to four tasks with a focus on spatial memory and anxiety: the circular hole board, modified hole board, novel object-placement task, and elevated plus maze. On the circular hole board, animals showed a higher preference for hippocampus-independent strategies after SE. In contrast, no change in strategy was seen on the modified hole board, but animals with SE were able to finish the task more often. Animals did not have an increased preference for a relocated object in the novel object-placement task but showed an increased locomotion after SE. No indications for altered anxiety were found when tested on the elevated plus maze following SE. These data suggest that the circular hole board is a well-suited paradigm to detect subtle SE-induced hippocampal deficits.

Treating anxiety disorders in children and adolescents with epilepsy: what do we know?

Children with epilepsy are at significant risk of psychiatric disorders, which can in turn negatively impact social skills development, academic achievement, and quality of life. The most commonly reported psychiatric comorbidities in pediatric epilepsy are ADHD, depression, and anxiety. The prevalence rates of anxiety disorders in pediatric epilepsy range from 5 to 49%, and in the general population, anxiety disorders are the most common psychiatric disorder in childhood. For the purposes of this review, anxiety disorders will be examined in order to 1) examine rates of anxiety disorders in children and adolescents with epilepsy, 2) review treatment options for anxiety disorders in children with epilepsy, and 3) identify future avenues for the development of evidence-based practices for the treatment of anxiety disorders in youth with epilepsy.

Depression and anxiety in people with epilepsy

Many recent epidemiological studies have found the prevalence of depression and anxiety to be higher in people with epilepsy (PWE) than in people without epilepsy. Furthermore, people with depression or anxiety have been more likely to suffer from epilepsy than those without depression or anxiety. Almost one-third of PWE suffer from depression and anxiety, which is similar to the prevalence of drug-refractory epilepsy. Various brain areas, including the frontal, temporal, and limbic regions, are associated with the biological pathogenesis of depression in PWE. It has been suggested that structural abnormalities, monoamine pathways, cerebral glucose metabolism, the hypothalamic-pituitary-adrenal axis, and interleukin-1b are associated with the pathogenesis of depression in PWE. The amygdala and the hippocampus are important anatomical structures related to anxiety, and γ-aminobutyric acid and serotonin are associated with its pathogenesis. Depression and anxiety may lead to suicidal ideation or attempts and feelings of stigmatization. These experiences are also likely to increase the adverse effects associated with antiepileptic drugs and have been related to poor responses to pharmacological and surgical treatments. Ultimately, the quality of life is likely to be worse in PWE with depression and anxiety than in PWE without these disorders, which makes the early detection and appropriate management of depression and anxiety in PWE indispensable. Simple screening instruments may be helpful for in this regard, particularly in busy epilepsy clinics. Although both medical and psychobehavioral therapies may ameliorate these conditions, randomized controlled trials are needed to confirm that.