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Socanski D, Ogrim G, Duric N. Children with ADHD and EEG abnormalities at baseline assessment, risk of epileptic seizures and maintenance on methylphenidate three years later. Ann Gen Psychiatry 2024; 23:22. [PMID: 38907242 PMCID: PMC11193234 DOI: 10.1186/s12991-024-00510-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
PURPOSE This study aimed to assess the incidence of EEG abnormalities (EEG-ab) in children diagnosed with ADHD, investigate the risk of epileptic seizures (SZ) and maintenance on methylphenidate (MPH) over a three-year period. METHODS A total of 517 ADHD children aged 6-14 years were included. Baseline assessments included the identification of EEG-ab, ADHD inattentive subtype (ADHD-I), comorbid epilepsy, the use of antiepileptic drugs (AEDs) and the use of MPH. At the 3-year follow-up, assessments included the presence of EEG-ab, maintenance on MPH, AED usage, SZ risk in cases with EEG-epileptiform abnormalities (EEG-epi-ab), compared with control ADHD cases without EEG-epi-ab matched for age and gender. RESULTS EEG-ab were identified in 273 (52.8%) cases. No statistically significant differences were observed between the EEG-ab and EEG-non-ab groups in terms of age, gender, ADHD-I type or initial use of MPH. EEG non-epileptiform abnormalities (EEG-non-epi-ab) were found in 234 out of 478 (49%) cases without EEG-epi-ab. Notably, EEG-non-epi-ab occurred more frequently in the group of 39 cases with EEG-epi-ab (30/39 (76.9%) vs. 9/39, (21.3%), a subset selected for 3-year follow-up. At 3-year-follow-up no statistically significant difference was found in maintenance on MPH in ADHD cases with and without EEG-epi-ab. Nobody of ADHD cases without comorbid epilepsy or with comorbid epilepsy with achieved SZ freedom developed new SZ. Only 3 children with drug resistant epilepsy experienced SZs, without increase in SZ frequency. The disappearance rate of EEG-epi-ab was higher than that EEG-non-epi-ab (71.8% vs. 33.3%). CONCLUSIONS Children with and without EEG-ab exhibited similar patterns of MPH use (initial use, positive response, and maintenance on MPH). The presence of comorbid epilepsy and EEG-ab, with or without EEG-epi-ab, was not associated with an increased risk of SZ despite the use of MPH.
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Affiliation(s)
- Dobrinko Socanski
- Department of Child and Adolescent Psychiatry, Østfold Hospital Trust, Fredrikstad, Norway.
- Department of Child and Adolescent Psychiatry, Stavanger University Hospital, Stavanger, Norway.
| | - Geir Ogrim
- Neuropsychiatric Team, Åsebråten Clinic, Østfold Hospital Trust, Fredrikstad, Norway
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Nezla Duric
- Department of Child and Adolescent Psychiatry, Fonna Health Trust, Haugesund, Norway
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2
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Gopaul M, Altalib H. Do psychotropic drugs cause seizures? Epilepsy Behav Rep 2024; 27:100679. [PMID: 38881884 PMCID: PMC11179069 DOI: 10.1016/j.ebr.2024.100679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
Patients with epilepsy often present with concurrent psychiatric disorders, posing unique challenges for healthcare providers. This review explores the intricate relationship between psychiatric comorbidities, epilepsy, and psychotropic medications to inform clinical decision-making. The bidirectional association between epilepsy and psychiatric conditions complicates treatment, with psychiatric symptoms preceding or following seizure onset. The review discusses the seizure risks associated with antidepressants, CNS stimulants, and antipsychotics, shedding light on both historical perspectives and recent empirical evidence. Antidepressants, particularly tricyclic antidepressants (TCAs), are known to pose seizure risks, while newer agents like selective serotonin reuptake inhibitors (SSRIs) exhibit lower incidences and even potential anticonvulsant effects. Contrary to common beliefs, CNS stimulants used in attention-deficit/hyperactivity disorder (ADHD) treatment show efficacy without significantly increasing seizure risk. However, the association between ADHD and seizures warrants careful consideration. Among antipsychotics, clozapine stands out for its heightened seizure risks, especially during titration and at high doses, necessitating close monitoring and individualized approaches. Understanding the nuanced seizure risks associated with different psychotropic medications is crucial for optimizing patient care and minimizing iatrogenic seizures in this vulnerable population. By recognizing the complexities of psychiatric comorbidities in epilepsy and considering the unique challenges they pose, healthcare providers can make informed decisions to enhance patient safety and treatment outcomes. This review offers practical insights to guide clinicians in navigating the intricate landscape of managing psychiatric comorbidities in patients with epilepsy.
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Affiliation(s)
- Margaret Gopaul
- Yale Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Veteran Administration (VA) Epilepsy Center of Excellence in West Haven, CT, USA
| | - Hamada Altalib
- Yale Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Veteran Administration (VA) Epilepsy Center of Excellence in West Haven, CT, USA
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3
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Nguyen T, Xiao E, Clark A, Shamim A, Maheshwari A. Screening for ADHD in Adult Patients With Epilepsy: Prevalence of Symptoms and Challenges to Diagnosis. J Atten Disord 2024; 28:51-57. [PMID: 37694675 PMCID: PMC10676030 DOI: 10.1177/10870547231197215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
OBJECTIVE Given the complex nature of seizure disorders and their treatments, ADHD may be underdiagnosed in this population. We hypothesized that a higher percentage of patients presenting to a seizure clinic would endorse ADHD symptoms compared to rates reported in the general population and that formal screening for ADHD symptoms would identify patients with previously undiagnosed comorbid ADHD. METHODS In this study, we surveyed 312 adults in a seizure clinic using the Adult ADHD Self-Report Scale (ASRS-v1.1). RESULTS We found that 90 patients (28.8%) screened positive with the ASRS-v1.1, but only nine of these patients were able to complete neuropsychological testing,. Out of these patients, only one was diagnosed with possible ADHD. CONCLUSION Through this process, we identified many challenges to making a new ADHD diagnosis in this population, including attention deficits due to other medical or psychiatric diagnoses, a positive urine drug screen, lack of collateral report/information about developmental history, and barriers to neuropsychological evaluation.
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Affiliation(s)
| | - Emily Xiao
- Baylor College of Medicine, Houston, TX, USA
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Kasahara S, Kanda S, Takahashi M, Fujioka M, Morita T, Matsudaira K, Sato N, Hattori M, Momose T, Niwa SI, Uchida K. Case Report: Guanfacine and methylphenidate improved chronic lower back pain in autosomal dominant polycystic kidney disease with comorbid attention deficit hyperactivity disorder and autism spectrum disorder. Front Pediatr 2023; 11:1283823. [PMID: 38027301 PMCID: PMC10646415 DOI: 10.3389/fped.2023.1283823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is an inherited renal disease characterized by the bilateral development of multiple cysts in the kidneys. Pain management is a clinically important issue, especially because approximately 60% of patients with ADPKD experience chronic pain related to hemorrhage from renal cysts, which significantly reduces their daily life. The cystic fibrosis transmembrane conductance regulator, the molecule responsible for cyst formation in ADPKD, is also the cause of cystic fibrosis. Since attention deficit hyperactivity disorder (ADHD) is known to occur frequently in conjunction with cystic fibrosis, ADPKD may be associated with ADHD. However, to our knowledge, no study has investigated 1) ADHD or autism spectrum disorder (ASD) as comorbidities with ADPKD, 2) the effects of ADHD medications on chronic pain in ADPKD, or 3) cerebral blood flow corresponding to guanfacine (GF) or methylphenidate (MP) treatment for chronic pain. We report the case of a 15-year-old girl with ADPKD, who had chronic back pain associated with ADPKD and had to withdraw from high school because the pain interfered with her daily life. Although she took antihypertensive medications to prevent bleeding, they did not provide adequate blood pressure control. The patient was referred to a child psychiatrist and diagnosed with ASD; however, the pain did not improve. Subsequently, she was referred to our pain center. The diagnosis of ADHD was confirmed and treatment with ADHD medications was initiated. Monotherapy with MP, atomoxetine, and GF resulted in hypertension and hypotension as side effects; however, a combination of MP 18 mg and GF 4 mg provided pain relief and moderate blood pressure control, and the patient was able to go on to college. During the course of treatment, there was an improvement in the distribution of cerebral blood flow in the prefrontal and insular cortices. Confirmation of an ADHD diagnosis comorbid with ASD enabled the use of ADHD medications. The combination of MP and GF improved chronic back pain and high blood pressure due to ADPKD and cerebral blood flow. Screening for ADHD is important in the treatment of ADPKD.
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Affiliation(s)
- Satoshi Kasahara
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shoichiro Kanda
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Miwako Takahashi
- Institute for Quantum Medical Science, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Mao Fujioka
- Department of Neuropsychiatry, The University of Tokyo Hospital, Tokyo, Japan
| | - Taito Morita
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Ko Matsudaira
- Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoko Sato
- Nursing Department, The University of Tokyo Hospital, Tokyo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Toshimitsu Momose
- Institute of Engineering Innovation, School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Shin-Ichi Niwa
- Department of Psychiatry, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Kanji Uchida
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
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Ryst E, Childress A. An updated safety review of the current drugs for managing ADHD in children. Expert Opin Drug Saf 2023; 22:1025-1040. [PMID: 37843488 DOI: 10.1080/14740338.2023.2271392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/12/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Attention-Deficit/Hyperactivity Disorder (ADHD) is a highly prevalent condition that causes persistent problems with attention and/or hyperactivity-impulsivity and often results in significant impairment when left untreated. Medications for this disorder continue to evolve and provide new treatment options. Ongoing review of related medication safety and tolerability remains an important task for prescribers. AREAS COVERED This manuscript provides an updated safety review of medications used to treat ADHD in children and adolescents. PubMed and OneSearch online databases were utilized to search for literature relevant to the topic of ADHD medications and safety. Clinical trials of medications used to treat ADHD, systematic reviews and meta-analyses, and articles covering specific safety issues (adverse or unfavorable events) such as cardiovascular effects, seizures, impact on growth, depression, suicidal ideation, substance use disorders, psychosis, and tics are described. EXPERT OPINION Available pharmacologic treatments for ADHD have favorable efficacy, safety and tolerability and allow many patients to achieve significant improvement of their symptoms. Despite the availability of multiple stimulant and non-stimulant formulations, some individuals with ADHD may not tolerate available medications or attain satisfactory improvement. To satisfy unmet clinical needs, ADHD pharmaceutical research with stimulant and nonstimulant formulations targeting dopamine, norepinephrine, and novel receptors is ongoing.
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Affiliation(s)
- Erika Ryst
- College of Education and Human Development, University of Nevada, Reno, USA
| | - Ann Childress
- Center for Psychiatry and Behavioral Medicine, Inc, Las Vegas, NV, USA
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Mula M. Impact of psychiatric comorbidities on the treatment of epilepsies in adults. Expert Rev Neurother 2023; 23:895-904. [PMID: 37671683 DOI: 10.1080/14737175.2023.2250558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/17/2023] [Indexed: 09/07/2023]
Abstract
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.
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Affiliation(s)
- Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospital, London, UK of Great Britain and Northern Ireland
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
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7
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Uliel-Sibony S, Chernuha V, Tokatly Latzer I, Leitner Y. Epilepsy and attention-deficit/hyperactivity disorder in children and adolescents: An overview of etiology, prevalence, and treatment. Front Hum Neurosci 2023; 17:1021605. [PMID: 37113319 PMCID: PMC10126237 DOI: 10.3389/fnhum.2023.1021605] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 03/16/2023] [Indexed: 04/29/2023] Open
Abstract
Epilepsy and attention-deficit/hyperactivity disorder (ADHD) are closely connected and commonly seen in both children and adults. Each of the disorders has major psychosocial and quality of life (QOL) effects, and their co-occurrence makes coping even more challenging for both the patients and their families. Moreover, an adverse effect of some anti-seizure medications can potentially induce or exacerbate symptoms of ADHD on the one hand, while some ADHD medications may increase seizure risk on the other. The combination of proper diagnosis and appropriate treatment may improve or even prevent many of the complications associated with these conditions. The objectives of this review are to present the complex relationship between epilepsy and ADHD, looking into the pathophysiological, anatomical, and functional perspectives along with the psychosocial and QOL influences and the recommended treatment approaches in accordance with the latest literature.
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Affiliation(s)
| | - Veronika Chernuha
- Pediatric Neurology Institute, Dana-Dwek Children’s Hospital, Tel Aviv, Israel
| | - Itay Tokatly Latzer
- Pediatric Neurology Institute, Dana-Dwek Children’s Hospital, Tel Aviv, Israel
| | - Yael Leitner
- The Pediatric ADHD Clinic, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Svanström K, Hallböök T, Rezanova J, Olsson I, Carlén C, Reilly C. Supporting Attention in Children with Epilepsy (SPACE): Pilot of a psychoeducational intervention. Epilepsy Behav 2023; 138:108996. [PMID: 36459814 DOI: 10.1016/j.yebeh.2022.108996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/08/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Children with epilepsy are at high risk for impairing symptoms of attention deficit hyperactivity disorder (ADHD), especially difficulties with attention. There is limited evidence regarding the use of psychological interventions for children with epilepsy and attention difficulties. We developed and piloted a novel psychoeducational intervention -Supporting Attention in Children with Epilepsy (SPACE). METHODS Eligible children with epilepsy (8-13 years) and difficulties with attention underwent a comprehensive psychological assessment and took part in a single-arm trial of the SPACE intervention. The first three sessions of SPACE took place in groups of 3-5 children and two psychologists. The final three sessions involved one psychologist meeting the child and parent(s). The child's teacher joined for one of the final three sessions. The first group of participants participated in the intervention in person. Subsequent groups took part online due to COVID-19-related restrictions. Measures of ADHD -inattention symptoms (parent and teacher), executive functioning (child, parent, and teacher), and epilepsy-specific and general Health-Related Quality of Life (HRQOL) (child and parent) were administered before and three months after completing the intervention. RESULTS Twenty-seven children with epilepsy expressed an interest in participating. Sixteen children met eligibility criteria and participated in a single-arm pilot of the intervention. All 16 participants completed the intervention. Pre- and post-intervention data were available for 15 of the 16 children. Improvement in function was noted on all measures and reached statistical significance for child ratings of executive functioning (p = 0.030) and HRQOL (p = 0.043), and parent-rated child HRQOL (p < 0.001). Qualitative feedback regarding content and acceptability was positive. CONCLUSION A psychoeducational intervention for children with epilepsy and difficulties with attention can lead to improved executive functioning and HRQOL. Such an intervention may be a useful first-line intervention for children with epilepsy at risk for or diagnosed with ADHD and/or be used in combination with pharmacological treatment with children with epilepsy and ADHD. However, more robustly designed studies are needed.
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Affiliation(s)
- Klara Svanström
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Tove Hallböök
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden; Dept. of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Julia Rezanova
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Ingrid Olsson
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden; Dept. of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clara Carlén
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden
| | - Colin Reilly
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Member of the ERN EpiCARE, Gothenburg, Sweden; Dept. of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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9
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Barra ME, Edlow BL, Brophy GM. Pharmacologic Therapies to Promote Recovery of Consciousness. Semin Neurol 2022; 42:335-347. [PMID: 36100228 DOI: 10.1055/s-0042-1755271] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pharmacologic interventions are commonly used to support rehabilitation efforts of patients with disorders of consciousness (DoC). The 2018 practice guidelines recommend amantadine in adults with traumatic DoC to promote functional recovery, though several other stimulants are used off-label in clinical practice and trials, such as methylphenidate, bromocriptine, levodopa, and zolpidem. Differences in the mechanisms of action, adverse effects, pharmacokinetics, and drug-drug interactions should be considered when selecting the best agent for each individual patient. Overall, pharmacologic stimulants may provide a safe and inexpensive pathway to increased functionality and participation in rehabilitation. This article provides a concise summary of scientific evidence supporting the use of pharmacologic therapies to stimulate recovery of consciousness in patients with DoC.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts.,Department of Neurology, Center for Neurotechnology and Neurorecovery (CNTR), Massachusetts General Hospital, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery (CNTR), Massachusetts General Hospital, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia
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Mula M, Coleman H, Wilson SJ. Neuropsychiatric and Cognitive Comorbidities in Epilepsy. Continuum (Minneap Minn) 2022; 28:457-482. [PMID: 35393966 DOI: 10.1212/con.0000000000001123] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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11
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Sleep disorders and ADHD symptoms in children and adolescents with typical absence seizures: An observational study. Epilepsy Behav 2022; 128:108513. [PMID: 35085916 DOI: 10.1016/j.yebeh.2021.108513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the occurrence of sleep disorders (SD) and attention deficit hyperactivity disorder (ADHD) symptoms in children with typical absence seizures (TAS) compared to control children and to evaluate the impact of epilepsy-related factors on sleep and attention in children with TAS. METHODS The Sleep Disturbance Scale for Children (SDSC) and the ADHD rating scale were filled in by parents of a cohort composed by 82 children aged from 5 to 15.6 years, 49% of boys (41 with TAS with a syndromic diagnosis of childhood absence epilepsy and 41 controls). For children with TAS, the Pediatric Epilepsy Side Effects Questionnaire was completed. Statistical analyses were conducted in order to compare sleep and attention scores between groups. In children with TAS, a correlation was computed between these scores. Logistics regression models were conducted to identify predictors of excessive diurnal sleepiness and inattention in children with TAS. RESULTS Compared to controls, children with TAS had higher total scores for subjective sleep (mean 42.9 vs 38.3, p = 0.05) and attention disorders (mean 16.8 vs 11.6, p = 0.01), especially for excessive diurnal sleepiness (mean 3.9 vs 3.2, p = 0.02) and inattention (mean 9.3 vs 5.6, p = 0.003) components. In children with TAS, sleep problems were significantly under-reported by parents. Sleep disorders symptoms as breathing-related sleep disturbance, excessive diurnal sleepiness or naps at or after 7 years of age were reported. Subjective sleep and attention disorders were significantly correlated (r = 0.43, p = 0.01). Subjective excessive diurnal sleepiness may be the result of a polytherapy (p = 0.05) or a side effect of anti-seizure medication (ASM) (p = 0.03) but children without medication side effects also reported subjective SD. In children with TAS, the risk of inattention symptoms was increased in boys (p = 0.02), with a high BMI (p = 0.05), or with ASM side effects (p = 0.03). CONCLUSIONS This study demonstrates that children with TAS are at risk of sleep and attention disorder symptoms. If attention disorders in a context of epilepsy are now widely assessed and identified, sleep disorders are still under-estimated. An accurate identification and management of sleep disorders could improve academic performances, quality of life, and seizure management in children with TAS.
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Crooms RC, Johnson MO, Leeper H, Mehta A, McWhirter M, Sharma A. Easing the Journey-an Updated Review of Palliative Care for the Patient with High-Grade Glioma. Curr Oncol Rep 2022; 24:501-515. [PMID: 35192120 DOI: 10.1007/s11912-022-01210-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW High-grade gliomas (HGG) are rare brain tumors that cause disproportionate suffering and mortality. Palliative care, whose aim is to relieve the symptoms and stressors of serious illness, may benefit patients with HGG and their families. In this review, we summarize the extant literature and provide recommendations for addressing the symptom management and communication needs of brain tumor patients and their caregivers at key points in the illness trajectory: initial diagnosis; during upfront treatment; disease recurrence; end-of-life period; and after death during bereavement. RECENT FINDINGS Patients with HGG experience highly intrusive symptoms, cognitive and functional decline, and emotional and existential distress throughout the disease course. The caregiver burden is also substantial during the patient's illness and after death. There is limited evidence to guide the palliative management of these issues. Palliative care is likely to benefit patients with HGG, yet further research is needed to optimize the delivery of palliative care in neuro-oncology.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, 1052, NY, 10029, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret O Johnson
- Department of Neurosurgery, Duke University Medical Center, Trent Drive 047 Baker House, Durham, NC, 27710, USA.,The Preston Robert Tirsch Brain Tumor Center, Duke University Medical Center, Trent Drive 047 Baker House, NC, 27710, Durham, USA
| | - Heather Leeper
- Neuro-Oncology Branch, National Institutes of Health, National Cancer Institute, 9030 Old Georgetown Rd, Bloch Bldg 82, Bethesda, MD, 20892, USA
| | - Ambereen Mehta
- Palliative Care Program, Division of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, 21224, MD, USA.,Division of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, 21224, MD, USA
| | - Michelle McWhirter
- Palliative Care Program, Division of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, 21224, MD, USA.,Department of Social Work, Johns Hopkins Bayview Medical Center, Baltimore, 21224, MD, USA
| | - Akanksha Sharma
- Department of Translational Neurosciences, Pacific Neuroscience Institute/Saint John's Cancer Institute, 2200 Santa Monica Blvd, Santa Monica, CA, 90404, USA.
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Methylphenidate and TBI in ADHD and co-occurring epilepsy and mental disorders: a self-controlled case series study. Eur Child Adolesc Psychiatry 2022; 31:361-368. [PMID: 33389157 DOI: 10.1007/s00787-020-01694-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 11/20/2020] [Indexed: 01/28/2023]
Abstract
It is suggested that medication for attention-deficit hyperactivity disorder (ADHD) links to lower risk of traumatic brain injury (TBI). Little is known about whether the beneficial effect of methylphenidate is persistent in individuals with other comorbid mental disorders and epilepsy. We identified 90,634 participants who were less than 18 years old and diagnosed with ADHD from Taiwan's National Health Insurance Research Database (NHIRD) from January 1, 2000 to December 31, 2013. Cox proportional hazards models with hazard ratio (HR) and 95% confidence interval were conducted to compare the risks of TBI event between groups of ADHD-only and ADHD with co-occurring other mental disorders. Within-individual comparisons using a self-controlled case series study design were conducted using conditional Poisson regression models with relative incidence (RR) and 95% CI to examine the effect of methylphenidate on TBI with adjustment for medication of psychotropics and anticonvulsants. For children and adolescents with ADHD, we found comorbid mental disorders and epilepsy increase the risk of TBI, with HRs ranged from 1.21 to 1.75. For the effect of MPH, we found reduced risks for TBI in ADHD (RR = 0.83, 95% CI = 0.70-0.98). Similar results were found among individuals with co-occurring oppositional defiant disorders or conduct disorder, MDD, tic disorders and epilepsy. Methylphenidate treatment was linked to lower risk for TBI in patients with ADHD and the inverse association was persistent among those with other comorbid mental disorders and epilepsy.
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Åndell Jason E. Neurodevelopmental and psychiatric comorbidities negatively affect outcome in children with unprovoked seizures-A non-systematic review. Acta Paediatr 2021; 110:2944-2950. [PMID: 34337792 DOI: 10.1111/apa.16026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 12/18/2022]
Abstract
Children with epilepsy have at least one comorbidity in 80% of cases. This unstructured review provides insights into the most common comorbidities, their effects on seizure prognosis and treatment. We also review the epilepsy terminology and classifications. Neurodevelopmental and psychiatric comorbidities were common in children with seizures and had a negative effect on quality of life, and seizure freedom. Children with seizures were treated with drugs used for attention deficit hyperactivity disorder (ADHD), depression or psychosis, more often than the general population but less often than prevalence rates would suggested. CONCLUSION: Multidisciplinary teams should assess comorbidities in children with epilepsy to improve their care and outcomes.
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Affiliation(s)
- Eva Åndell Jason
- Neuropediatric Unit Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
- Centre for Clinical Research Sörmland Uppsala University Eskilstuna Sweden
- Department of Pediatrics Nyköping HospitalRegion Sörmland Nyköping Sweden
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15
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Kittel-Schneider S, Arteaga-Henriquez G, Vasquez AA, Asherson P, Banaschewski T, Brikell I, Buitelaar J, Cormand B, Faraone SV, Freitag CM, Ginsberg Y, Haavik J, Hartman CA, Kuntsi J, Larsson H, Matura S, McNeill RV, Ramos-Quiroga JA, Ribases M, Romanos M, Vainieri I, Franke B, Reif A. Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity? Neurosci Biobehav Rev 2021; 132:1157-1180. [PMID: 34757108 DOI: 10.1016/j.neubiorev.2021.10.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 12/16/2022]
Abstract
Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.
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Affiliation(s)
- Sarah Kittel-Schneider
- Center of Mental Health, Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Würzburg, Margarete-Höppel-Platz 1, D-97080 Würzburg, Germany; Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann-Str. 10, D-60528 Frankfurt am Main, Germany.
| | - Gara Arteaga-Henriquez
- Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain; Psychiatric Genetics Unit, Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Catalonia, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Madrid, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autonoma de Barcelona, Barcelona, Catalonia, Spain
| | - Alejandro Arias Vasquez
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Departments of Psychiatry and Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Phil Asherson
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, SE5 8AF, London, UK
| | - Tobias Banaschewski
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Heidelberg University, Medical Faculty Mannheim, Mannheim, Germany
| | - Isabell Brikell
- National Centre for Register-based Research, Department of Economics and Business Economics Aarhus BSS, Aarhus University, Fuglesangs Allé 26, DK-8210 Aarhus V, Aarhus, Denmark; iPSYCH - The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Copenhagen and Aarhus, Denmark; Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Box 281, 171 77, Stockholm, Sweden
| | - Jan Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; Karakter Child and Adolescent Psychiatry University Center, Nijmegen, the Netherlands
| | - Bru Cormand
- Departament de Genètica, Microbiologia i Estadística, Facultat de Biologia, Universitat de Barcelona, Catalonia, Spain; Institut de Biomedicina de la Universitat de Barcelona (IBUB), Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain; Institut de Recerca Sant Joan de Déu (IR-SJD), Esplugues de Llobregat, Catalonia, Spain
| | - Stephen V Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Christine M Freitag
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Frankfurt, Goethe University, Deutschordenstraße 50, D-60528 Frankfurt am Main, Germany
| | - Ylva Ginsberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Norra Stationsgatan 69, SE-113 64 Stockholm, Sweden
| | - Jan Haavik
- Bergen Center of Brain Plasticity, Division of Psychiatry, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway; Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Catharina A Hartman
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Jonna Kuntsi
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, SE5 8AF, London, UK
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Box 281, 171 77, Stockholm, Sweden; Örebro University, School of Medical Sciences, Campus USÖ, S-701 82 Örebro, Sweden
| | - Silke Matura
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann-Str. 10, D-60528 Frankfurt am Main, Germany
| | - Rhiannon V McNeill
- Center of Mental Health, Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Würzburg, Margarete-Höppel-Platz 1, D-97080 Würzburg, Germany
| | - J Antoni Ramos-Quiroga
- Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain; Psychiatric Genetics Unit, Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Catalonia, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Madrid, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autonoma de Barcelona, Barcelona, Catalonia, Spain
| | - Marta Ribases
- Department of Psychiatry, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain; Psychiatric Genetics Unit, Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Catalonia, Spain; Biomedical Network Research Centre on Mental Health (CIBERSAM), Madrid, Spain; Departament de Genètica, Microbiologia i Estadística, Facultat de Biologia, Universitat de Barcelona, Catalonia, Spain
| | - Marcel Romanos
- Center of Mental Health, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic Medicine, University Hospital of Würzburg, Margarete-Höppel-Platz 1, D-97080 Würzburg, Germany
| | - Isabella Vainieri
- Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, SE5 8AF, London, UK
| | - Barbara Franke
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, the Netherlands; Departments of Psychiatry and Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Heinrich-Hoffmann-Str. 10, D-60528 Frankfurt am Main, Germany
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Wagner JL, Mueller M, Hellier TS, Smith G, Modi A. ADHD and epilepsy-related QoL in youth with epilepsy. Epilepsy Behav 2021; 123:108250. [PMID: 34399393 DOI: 10.1016/j.yebeh.2021.108250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pediatric epilepsy and attention-deficit/hyperactivity disorder (ADHD) present a cumulative vulnerability to youth, particularly in the domains of executive function (EF) and quality of life (QoL). The aim of this study was to explore the relationships between EF and epilepsy-specific QoL in youth with epilepsy (YWE) who also have ADHD. METHODS Youth with epilepsy aged 5-18 years and caregivers participated in a large multi-site national validation of the PedsQL™ Epilepsy Modules. YWE and their caregivers were asked to complete measures of epilepsy-specific QoL, ADHD symptoms, and EF. Previous ADHD diagnosis was reported by caregivers as well as abstracted from the medical record. RESULTS Caregiver and YWE reports of current ADHD symptoms significantly predicted all epilepsy-specific QoL domains. Suboptimal QoL was reported for those YWE whose ADHD symptoms were above the clinical threshold compared to YWE whose ADHD symptoms were within the average range. Results were similar for YWE with a documented ADHD vs no ADHD diagnosis. In addition, poorer metacognition and behavioral regulation EF was associated with lower epilepsy-specific QoL for both YWE with ADHD and without ADHD diagnosis. However, in YWE with ADHD, effect sizes were consistently larger for behavioral regulation compared to metacognition across epilepsy-specific QoL domains, with behavioral regulation accounting for 50% of the variance in each of the EF and mood QoL domains. SIGNIFICANCE Addressing ADHD symptoms, epilepsy-specific, QoL, and EF as part of routine epilepsy care may promote optimal outcomes for YWE with ADHD as well as relieve burden on the healthcare system.
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Affiliation(s)
- Janelle L Wagner
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA.
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Tanja S Hellier
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Gigi Smith
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Avani Modi
- Department of Pediatrics, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Detyniecki K. Do Psychotropic Drugs Cause Epileptic Seizures? A Review of the Available Evidence. Curr Top Behav Neurosci 2021; 55:267-279. [PMID: 34241816 DOI: 10.1007/7854_2021_226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Psychiatric comorbidities in patients with epilepsy are common. A bidirectional relationship has been well described where not only patients with epilepsy have a higher prevalence of psychiatric comorbidities but also patients with primary psychiatric disorders are at an increased risk of developing seizures. The aim of this review is to highlight the complex relationship between epilepsy and common psychiatric disorders and to answer the question whether psychotropic medications are proconvulsant by reviewing the preclinical and clinical literature. The evidence shows that the majority of psychotropic medications are not proconvulsant when used in therapeutic doses with the exception of a subset of medications, mainly bupropion IR and certain antipsychotic drugs such as clozapine. An effective treatment of psychiatric comorbidities in patients with epilepsy must consider not only the potential therapeutic effect of the drug, but also its potential iatrogenic effects on the seizure disorder.
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Affiliation(s)
- Kamil Detyniecki
- Comprehensive Epilepsy Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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18
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Zhuang C, Wu H, Lin B, An X. The effect of Omaha System-based continuous nursing care on the psychological status, self-esteem, and quality of life in epileptic children. Am J Transl Res 2021; 13:3435-3442. [PMID: 34017519 PMCID: PMC8129271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES This study explored and analyzed the effect of Omaha System-based continual nursing care on the psychological status, self-esteem and quality of life in epileptic children. METHODS 127 epileptic children hospitalized from March 2018 to September 2019 were recruited as the study cohort and stochastically divided into an observation group (n=65) and a control group (n=62). The control group children were given regular out-of-hospital guidance after discharge, and the observation-group were treated with Omaha System-based continuous nursing intervention in addition to the routine out-of-hospital guidance the control group underwent. The two groups' psychological statuses, self-esteem, sense of defect, and quality of life were compared both pre- and post-intervention. RESULTS The SAS and SDS scores in the two groups after the intervention were significantly lower than their pre-intervention scores (P<0.05), and the scores in the observation group after the intervention were evidently lower than the scores in the control group (P<0.05). The two groups' post-intervention SES and FIS scores were significantly higher than their pre-intervention scores (P<0.05), and the scores in the observation group were notably lower than the scores in the control group (P<0.05). The post-intervention quality of life scores in the two groups were dramatically higher than the pre-intervention scores (P<0.05), and the quality of life scores in the observation group were notably higher than the quality of life scores in the control group (P<0.05). CONCLUSION The Omaha System-based continual nursing care can efficaciously elevate the psychological status of children with epilepsy, improve their self-esteem, reduce their sense of self-defect, and contribute to the improvement of their quality of life, so it is worthy of clinical promotion and application.
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Affiliation(s)
- Cong Zhuang
- Department of Nursing, Haikou Hospital Affiliated to Xiangya Medical College of Central South UniversityHaikou 570208, Hainan, China
| | - Haiyan Wu
- Department of Neurology, Haikou Hospital Affiliated to Xiangya Medical College of Central South UniversityHaikou 570208, Hainan, China
| | - Bailang Lin
- Department of Nursing, Haikou Hospital of The Maternal and Child HealthHaikou 570208, Hainan, China
| | - Xuefang An
- Department of Nursing, Haikou Hospital Affiliated to Xiangya Medical College of Central South UniversityHaikou 570208, Hainan, China
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Abstract
PURPOSE OF REVIEW Attention deficit/hyperactivity disorder (ADHD) is a frequent comorbidity in patients with epilepsy and is associated with important psychosocial and academic consequences. Evidence are now available to guide diagnosis and treatment of patients with both ADHD and epilepsy. RECENT FINDINGS The prevalence of ADHD varies from 12 to 39% in patients with newly diagnosed epilepsy to 70% in drug-resistant epilepsy. The diagnosis of ADHD requires parent-validated and teacher-validated rating scales, based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and DSM-V, to confirm the information in the rating scales by interviewing parents and to exclude other causes of symptoms. Treatment with methylphenidate is associated with clinically significant improvement of ADHD symptoms in 60-75% of patients. Recent data reinforce the hypothesis that ADHD medications do not increase risk of seizures, even in patients with epilepsy. Beyond pharmacological management, experts have recommended to include multidisciplinary involvement in transition clinics for patients with both comorbid ADHD and epilepsy. SUMMARY Management of ADHD in patients with epilepsy requires implementation of evidence-based data in clinical practice both for diagnosis and treatment. Currently, there is no specific treatment of ADHD associated with epilepsy and its treatment is based on the usual treatments of ADHD, with reassuring data about their safety in epilepsy.
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20
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Leeman-Markowski BA, Adams J, Martin SP, Devinsky O, Meador KJ. Methylphenidate for attention problems in epilepsy patients: Safety and efficacy. Epilepsy Behav 2020; 115:107627. [PMID: 33360744 PMCID: PMC7884102 DOI: 10.1016/j.yebeh.2020.107627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
Abstract
Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of seizures, and children with epilepsy have an increased prevalence of ADHD. Adults with epilepsy often have varying degrees of attentional dysfunction due to multiple factors, including anti-seizure medications, frequent seizures, interictal discharges, underlying lesions, and psychiatric comorbidities. Currently, there are no approved medications for the treatment of epilepsy-related attentional dysfunction. Methylphenidate (MPH) is a stimulant, FDA-approved for the treatment of ADHD, and often used for ADHD in the setting of pediatric epilepsy. Large database and registry studies indicate safety of MPH in children with ADHD and epilepsy, with no significant effect on seizure frequency. Small single-dose and open-label studies suggest efficacy of MPH in adults with epilepsy-related attention deficits. Methylphenidate represents a possible treatment for attentional dysfunction due to epilepsy, but large, randomized, placebo-controlled, double-blinded studies are needed.
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Affiliation(s)
- Beth A. Leeman-Markowski
- Research Service, VA New York Harbor Healthcare System, 423 E. 23rd St., New York, NY, US 10010,Comprehensive Epilepsy Center, Department of Neurology, New York University Langone Health, 223 E. 34th St., New York, NY, US 10016,Corresponding author, Beth A. Leeman-Markowski,
| | - Jesse Adams
- Department of Psychiatry and Behavioral Sciences, 401 Quarry Road, Stanford, CA 94305-5723, United States.
| | - Samantha P. Martin
- Research Service, VA New York Harbor Healthcare System, 423 E. 23rd St., New York, NY, US 10010,Comprehensive Epilepsy Center, Department of Neurology, New York University Langone Health, 223 E. 34th St., New York, NY, US 10016
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, Department of Neurology, New York University Langone Health, 223 E. 34th St., New York, NY 10016, United States; Department of Neurosurgery, New York University Langone Health, 660 1st Ave. #5, New York, NY 10016, United States; Department of Psychiatry, New York University Langone Health, 550 1st Ave., New York, NY 10016, United States.
| | - Kimford J. Meador
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, 213 Quarry Road, MC 5979 (room 2856), Palo Alto, CA, US 94304-5979
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Kanner AM, Helmstaedter C, Sadat-Hossieny Z, Meador K. Cognitive disorders in epilepsy I: Clinical experience, real-world evidence and recommendations. Seizure 2020; 83:216-222. [DOI: 10.1016/j.seizure.2020.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 01/14/2023] Open
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Abstract
PURPOSE OF REVIEW Psychiatric comorbidities are close to 5-times higher in children and youth with epilepsy (CYE) compared to general population. With epilepsy being one of the most common neurological disorders in children, we provide a timely review of psychiatric issues in CYE. RECENT FINDINGS A meta-analysis found a pooled prevalence of anxiety in 18.9% and depression in 13.5% of CYE. Attention deficit hyperactivity disorder (ADHD) is 2.5 to 5.5 times higher in CYE compared to healthy counterparts. Recent evidence highlights that behavioral adverse effects may lead to discontinuation of anti-epileptic drugs (AEDs) in more than 10% of CYE. Up to 70% CYE shows elevation in baseline psychological symptoms after AED initiation. Identifying psychiatric symptoms can be easily accomplished by the routine use of psychiatric screening instruments in CYE clinics, which is associated with improved health-related quality of life (HRQOL). Psychoeducation is a key component for any visit with CYE. There is some evidence of the effectiveness of behavioral psychological interventions for CYE. There are no therapeutic trials of psychotropics in CYE, but treatment recommendations based on the experience in adults with epilepsy and general population are applicable. Early diagnosis and management of psychiatric comorbidities leads to improvement in HRQOL of CYE. This requires routine screening and a multidisciplinary teamwork.
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Affiliation(s)
- Anjali Dagar
- Department of Psychiatry and Epilepsy, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, P57, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Tatiana Falcone
- Department of Psychiatry and Epilepsy, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, P57, Cleveland Clinic, Cleveland, OH, 44195, USA.
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23
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Association between methylphenidate treatment and risk of seizure: a population-based, self-controlled case-series study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:435-443. [PMID: 32450123 DOI: 10.1016/s2352-4642(20)30100-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Individuals with attention-deficit hyperactivity disorder (ADHD) are at increased risk of seizures. Stimulant medications such as methylphenidate are the most commonly prescribed treatment for ADHD, but the association between their therapeutic use and the risk of seizures is unclear. We aimed to investigate the association between methylphenidate treatment and the risk of seizure. METHODS For this population-based observational study, we used the electronic medical record database of the Hong Kong Clinical Data Analysis And Reporting System to identify individuals aged 6-25 years who received at least one methylphenidate prescription during the study period. Individuals with records of seizure or epilepsy before the study period were excluded. Individuals treated with methylphenidate who had seizures during the study period were included in the subsequent analyses, and a self-controlled case-series design was used to control for time-invariant individual characteristics. We did additional analyses using skin infection as a negative control outcome. We compared relative incidence of seizure during periods when individuals were exposed to methylphenidate with that during non-exposed periods. FINDINGS Of 29 604 individuals prescribed methylphenidate between Jan 1, 2001, and Dec 31, 2017, 269 (199 males and 70 females) had incident seizures. The mean age at baseline was 6·66 years (SD 2·01) and the median age at the incident seizure was 9·69 years (IQR 7·62-12·99). The overall incidence of seizure during methylphenidate treatment was 4·4 per 10 000 patient-years. We detected an increased risk of seizure during the first 30 days of methylphenidate treatment compared with that during non-exposed periods, with an incidence rate ratio of 4·01 (95% CI 2·09-7·68). No increase in risk was identified during the following 31-180 days of treatment (1·13, 0·56-2·25) or during subsequent treatment (1·38, 0·92-2·07). We did not identify an increased risk in any risk window for the negative control outcome analysis. No individuals died because of a seizure during the study period. INTERPRETATION The incidence of seizures was higher in the period immediately after the start of methylphenidate treatment than in the non-exposed period. No increased risk was observed during continuation of methylphenidate treatment. The association between methylphenidate treatment and seizures immediately after initiation of medication can be seen as a potential safety signal. Monitoring of neurological outcomes in individuals with ADHD is recommended when they first start methylphenidate treatment. FUNDING Hong Kong Research Grants Council.
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Mula M, Kanner AM, Jetté N, Sander JW. Psychiatric Comorbidities in People With Epilepsy. Neurol Clin Pract 2020; 11:e112-e120. [PMID: 33842079 DOI: 10.1212/cpj.0000000000000874] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/17/2020] [Indexed: 02/07/2023]
Abstract
Purpose of Review To review the latest evidence concerning the epidemiology, clinical implications, and management of psychiatric disorders in epilepsy. Recent Findings People with epilepsy have a 2-5 times increased risk of developing any psychiatric disorder, and 1 in 3 patients with epilepsy have a lifetime psychiatric diagnosis. Psychiatric comorbidities represent a poor prognostic marker as they have been associated with a poor response to treatment (drugs and surgery), increased morbidity, and mortality. Validated screening instruments are available for mood and anxiety disorders in adults as well as attention-deficit hyperactivity disorder in children with epilepsy. Summary All patients with epilepsy should be routinely screened for psychiatric disorder at the onset and at least once a year. Patients with epilepsy and their relatives should be informed of the risk of mental health problems and the implications.
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Affiliation(s)
- Marco Mula
- Institute of Medical and Biomedical Education (MM), St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Neurology (AMK), Comprehensive Epilepsy Center and Epilepsy Division, University of Miami, Miller School of Medicine, FL; Division of Epilepsy and Division of Health Outcomes and Knowledge Translation Research (NJ), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York; NIHR UCL Hospitals Biomedical Research Centre (JWS), UCL Queen Square Institute of Neurology, London, and Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom; and Stichting Epilepsie Instellingen Nederland-SEIN (JWS), Heemstede, the Netherlands
| | - Andres M Kanner
- Institute of Medical and Biomedical Education (MM), St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Neurology (AMK), Comprehensive Epilepsy Center and Epilepsy Division, University of Miami, Miller School of Medicine, FL; Division of Epilepsy and Division of Health Outcomes and Knowledge Translation Research (NJ), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York; NIHR UCL Hospitals Biomedical Research Centre (JWS), UCL Queen Square Institute of Neurology, London, and Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom; and Stichting Epilepsie Instellingen Nederland-SEIN (JWS), Heemstede, the Netherlands
| | - Nathalie Jetté
- Institute of Medical and Biomedical Education (MM), St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Neurology (AMK), Comprehensive Epilepsy Center and Epilepsy Division, University of Miami, Miller School of Medicine, FL; Division of Epilepsy and Division of Health Outcomes and Knowledge Translation Research (NJ), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York; NIHR UCL Hospitals Biomedical Research Centre (JWS), UCL Queen Square Institute of Neurology, London, and Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom; and Stichting Epilepsie Instellingen Nederland-SEIN (JWS), Heemstede, the Netherlands
| | - Josemir W Sander
- Institute of Medical and Biomedical Education (MM), St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Neurology (AMK), Comprehensive Epilepsy Center and Epilepsy Division, University of Miami, Miller School of Medicine, FL; Division of Epilepsy and Division of Health Outcomes and Knowledge Translation Research (NJ), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York; NIHR UCL Hospitals Biomedical Research Centre (JWS), UCL Queen Square Institute of Neurology, London, and Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom; and Stichting Epilepsie Instellingen Nederland-SEIN (JWS), Heemstede, the Netherlands
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25
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Ghirardi L, Chen Q, Chang Z, Kuja-Halkola R, Skoglund C, Quinn PD, D’Onofrio BM, Larsson H. Use of medication for attention-deficit/hyperactivity disorder and risk of unintentional injuries in children and adolescents with co-occurring neurodevelopmental disorders. J Child Psychol Psychiatry 2020; 61:140-147. [PMID: 31625605 PMCID: PMC6980200 DOI: 10.1111/jcpp.13136] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is often associated with other neurodevelopmental disorders (NDs) and with risky behaviors and adverse health outcomes, including injuries. Treatment with ADHD medication has been associated with reduced risk of injuries. However, it is unknown whether the association is present in individuals with co-occurring NDs. The aim of the present study was to estimate the association between ADHD medication use and unintentional injuries in Sweden in children and adolescents with ADHD, including those with co-occurring NDs. METHODS Using a linkage of several national registers via the unique personal identification number, we identified individuals with a diagnosis of ADHD and of other NDs, including autism spectrum disorder, intellectual disability, communication disorders, learning disorders and motor disorders. The primary outcome was unintentional injuries. Secondary outcome was traumatic brain injury (TBI). Individuals were followed from January 1st 2006 or their 5th birthday or the date of the first unintentional injury, whichever came last, to December 31st 2013 or their 18th birthday or death, whichever came first. We compared the rate of injuries during periods on-treatment with the rate of injuries during periods off-treatment within the same individual using stratified Cox regression to calculate hazard ratio (HR) with 95% confidence intervals (CIs). RESULTS For children and adolescents with ADHD (N = 9,421) the rate of any unintentional injuries (HR = 0.85; 95% CI = 0.78-0.92) and TBIs (HR = 0.27; 95% CIs = 0.20-0.38) during medicated periods was lower than during non-medicated periods. Similar results were found among individuals with co-occurring NDs (N = 2,986), for unintentional injuries (HR = 0.88; 95% CI = 0.77-1.01) and for TBIs (HR = 0.27; 95% CI = 0.16-0.44). CONCLUSIONS Beneficial effects of ADHD medication may extend beyond reduction of ADHD core symptoms to prevention of unintentional injuries in children and adolescents, including individuals with co-occurring NDs.
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Affiliation(s)
- Laura Ghirardi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Qi Chen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Skoglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden;,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden;,School of Medical Sciences, Örebro University, Örebro, Sweden
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26
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Mula M. Psychiatric aspects of posttraumatic epilepsy: A still unexplored area. Epilepsy Behav 2019; 101:106598. [PMID: 31677996 DOI: 10.1016/j.yebeh.2019.106598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
Traumatic brain injury (TBI) represents one of the most common causes of death and disability in young people, and posttraumatic epilepsy (PTE) accounts for 10% to 20% of all symptomatic epilepsies. However, PTE is still a relatively underappreciated condition. This paper aimed at reviewing current knowledge about psychiatric comorbidities of PTE, looking in particular at the nature of the relationship between TBI, psychiatric problems, and epilepsy, at the phenomenology of psychiatric disorders in PTE, and how to manage them. Data on psychiatric comorbidities of PTE are almost nonexistent, and this is a paradox considering that TBI itself is burdened by a number of cognitive and psychiatric sequelae, which can profoundly affect the everyday life of these patients. Preliminary data seem to suggest that the bidirectional relationship between epilepsy and psychiatric disorders is maintained in TBI and people with a psychiatric condition at the time of the TBI, or as a consequence of it, are at increased risk of developing PTE and vice versa. However, a number of questions are still unanswered concerning the genetic and environmental contributors, the phenomenology of psychiatric disorders in PTE, and how to prevent and address them properly. Further research in this area is urgently needed in order to provide the best possible care to people with PTE. Special Issue: Epilepsy & Behavior's 20th Anniversary.
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Affiliation(s)
- Marco Mula
- Institute of Medical and Biomedical Education, St George's University of London, London, United Kingdom; Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom.
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27
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BLAST paradigm: A new test to assess brief attentional fluctuations in children with epilepsy, ADHD, and normally developing children. Epilepsy Behav 2019; 99:106470. [PMID: 31430660 DOI: 10.1016/j.yebeh.2019.106470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/18/2019] [Accepted: 07/26/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pure attentional deficits are still underdiagnosed in children with epilepsy. While attention-deficit hyperactivity disorder (ADHD) is historically the most studied cause of attentional disorders, an important number of children with epilepsy and attentional complaints do not fully meet the DSM-V (Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition) criteria for ADHD and may be excluded from specific care. Clinical tools currently available are insufficient to detect more subtle but clinically relevant attentional fluctuations. OBJECTIVE/METHODS The recently developed Bron-Lyon Attention Stability Test (BLAST) was used to evaluate brief attentional fluctuations with a high temporal precision. Drawing on two new attentional indices, we evaluated spontaneous fluctuations of response accuracy and timing, underlying attentional stability. The main objective was to assess attentional stability in children with i) epilepsy with comorbid ADHD, ii) epilepsy without comorbid ADHD, iii) ADHD not medicated and without epilepsy, and iv) normal development. Further objectives were to assess the main determinants of attentional stability in those groups, including the effect of factors related to the epileptic condition. RESULTS In 122 children with epilepsy (67 with comorbid ADHD), 52 children with ADHD, and 53 healthy controls, we demonstrated lower attentional stability in both the groups with epilepsy and ADHD compared with healthy children. In children with epilepsy, BLAST scores were negatively associated with earlier seizure onset and AED (antiepileptic drug) polytherapy, while the seizure frequency, epilepsy duration, or type did not influence BLAST scores. CONCLUSIONS This study demonstrates that attentional stability is impaired in children with epilepsy and/or ADHD. Bron-Lyon Attention Stability Test seems to be a sensitive test to detect attentional stability deficit in children with epilepsy and with attentional complaints who did not meet all criteria of ADHD. We propose that BLAST could be a useful clinical neuropsychological tool to assess attentional disorders in children.
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28
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Chang Z, Ghirardi L, Quinn PD, Asherson P, D’Onofrio BM, Larsson H. Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases. Biol Psychiatry 2019; 86:335-343. [PMID: 31155139 PMCID: PMC6697582 DOI: 10.1016/j.biopsych.2019.04.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/02/2019] [Accepted: 04/07/2019] [Indexed: 12/24/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) medication is one of the most commonly prescribed medication classes in child and adolescent psychiatry, and its use is increasing rapidly in adult psychiatry. However, major questions and concerns remain regarding the benefits and risks of ADHD medication, especially in real-world settings. We conducted a qualitative systematic review of studies that investigated the effects of ADHD medication on behavioral and neuropsychiatric outcomes using linked prescription databases from the last 10 years and identified 40 studies from Europe, North America, and Asia. Among them, 18 used within-individual designs to account for confounding by indication. These studies suggested short-term beneficial effects of ADHD medication on several behavioral or neuropsychiatric outcomes (i.e., injuries, motor vehicle accidents, education, substance use disorder), with estimates suggesting relative risk reduction of 9% to 58% for these outcomes. The within-individual studies found no evidence of increased risks for suicidality and seizures. Replication studies are needed for several other important outcomes (i.e., criminality, depression, mania, psychosis). The available evidence from pharmacoepidemiology studies on long-term effects of ADHD medication was less clear. We discuss time-varying confounding and other limitations that should be considered when interpreting results from pharmacoepidemiology studies. Furthermore, we highlight several knowledge gaps to be addressed in future research and implications for research on mechanisms of outcomes of ADHD medications.
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Affiliation(s)
- Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Laura Ghirardi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, IN
| | - Philip Asherson
- Social Genetic and Developmental Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
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