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Meador KJ, Dimova S, Bourikas D, Elmoufti S, Floricel F, Laloyaux C, Moseley B, Nondonfaz X, Klein P. Time-course of drug-related psychiatric and behavioral treatment-emergent adverse events during brivaracetam treatment in adults with focal-onset seizures. Epilepsy Behav 2024; 156:109844. [PMID: 38788664 DOI: 10.1016/j.yebeh.2024.109844] [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: 02/21/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE We previously analyzed data from three phase lll trials of adjunctive brivaracetam (BRV) in adults showing that the incidence and prevalence of drug-related central nervous system treatment-emergent adverse events (TEAEs) quickly peaked and decreased over several weeks following BRV treatment initiation. However, that analysis did not assess psychiatric and behavioral side effects which can occur with antiseizure medication (ASM) treatment. Here, we investigate the time-course of psychiatric and behavioral TEAEs by week of BRV treatment and how these TEAEs were managed. METHODS Data were pooled from three trials (N01252 [NCT00490035]; N01253 [NCT00464269]; N01358 [NCT01261325]) in adult patients (≥16 years of age) with focal-onset seizures receiving BRV adjunctive therapy. This post hoc analysis reports data on the incidence and prevalence of drug-related psychiatric or behavioral TEAEs over time in patients who received BRV doses of 50-200 mg/day (without titration) or placebo (PBO) during the 12-week treatment period. A logistic regression model was used to determine if psychiatric or behavioral comorbid conditions were predictors for drug-related psychiatric or behavioral TEAEs, or BRV discontinuation due to psychiatric or behavioral TEAEs. RESULTS A total of 803 patients received BRV 50-200 mg/day, and 459 patients received PBO. Drug-related psychiatric or behavioral TEAEs were reported by 11.0 % of patients during adjunctive BRV treatment (PBO: 4.8 %) with onset early after BRV initiation (median time to onset of first drug-related psychiatric or behavioral TEAE: 15 days). Incidence peaked at week 1 and decreased over the first 4 weeks following BRV initiation. Prevalence peaked at week 4 and then remained stable between weeks 5-12. In an analysis excluding patients on concomitant levetiracetam (BRV: n = 744; PBO: n = 422), the incidence of drug-related psychiatric or behavioral TEAEs was similar to the incidence in the overall population. The most common drug-related psychiatric or behavioral TEAEs were irritability, insomnia, depression, and anxiety. Only 2 % of patients discontinued BRV due to psychiatric or behavioral TEAEs (PBO: 1.3 %), while most patients on BRV who reported drug-related psychiatric or behavioral TEAEs did not require a change in dose (84.1 %; PBO: 63.6 %). A history of psychiatric or behavioral comorbid conditions (not ongoing at BRV initiation) was not associated with an increased likelihood of drug-related psychiatric or behavioral TEAEs, or BRV discontinuation due to psychiatric or behavioral TEAEs. Ongoing psychiatric or behavioral comorbid conditions at BRV initiation increased the likelihood of drug-related psychiatric or behavioral TEAEs, but not the likelihood of BRV discontinuation due to psychiatric or behavioral TEAEs. CONCLUSIONS Drug-related psychiatric and behavioral TEAEs occurred early during BRV treatment, and most patients did not require a change in BRV dose. These data can help guide clinician monitoring and patient expectations after starting BRV.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA.
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Argyrou A, Lappas AS, Bakaloudi DR, Tsekitsidi E, Mathioudaki E, Michou N, Polyzopoulou Z, Christodoulou N, Papazisis G, Chourdakis M, Samara MT. Pharmacotherapy compared to placebo for people with Bulimia Nervosa: A systematic review and meta-analysis. Psychiatry Res 2023; 327:115357. [PMID: 37562154 DOI: 10.1016/j.psychres.2023.115357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/15/2023] [Accepted: 07/21/2023] [Indexed: 08/12/2023]
Abstract
Bulimia Nervosa is a disorder with high rates of psychiatric and medical comorbidity and substantial societal costs. Cognitive Behavioural Therapy is considered the preferred treatment, but access can be problematic. Pharmacotherapy is more accessible but remains significantly underutilised. We aimed to assess the efficacy, tolerability, and safety of all available forms of pharmacotherapy for the treatment of bulimia nervosa. We conducted a comprehensive search of PubMed, EMBASE, CENTRAL, ClinicalTrials.gov, and reference lists of relevant articles up until April 2023. The primary outcomes were remission and binge frequency. 52 randomised controlled trials (RCTs) involving 3313 participants were included in the meta-analysis. Overall, no significant difference was observed between drugs and placebo in terms of remission; however, the available data were limited. Notably, drugs, particularly antidepressants, demonstrated a significant reduction in the frequency of binge episodes compared to placebo. Antidepressants were also found to be more effective than placebo in terms of treatment response and other clinically meaningful outcomes. An important limitation is that few RCTs were available for individual drugs. Our findings provide evidence supporting the increased utilisation of pharmacotherapy in clinical practice and underscore the need for further research involving larger populations and a broader range of outcomes.
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Affiliation(s)
- Aikaterini Argyrou
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Andreas S Lappas
- Department of Psychiatry, Faculty of Medicine, University of Thessaly, Larisa 41334, Greece; Department of Geriatric Liaison Psychiatry, Royal Gwent Hospital, Aneurin Bevan University Health Board, United Kingdom
| | - Dimitra Rafailia Bakaloudi
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Eirini Tsekitsidi
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Elissavet Mathioudaki
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Niki Michou
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Zoi Polyzopoulou
- Department of Psychology, University of Western Macedonia, Florina 53100, Greece
| | - Nikos Christodoulou
- Department of Psychiatry, Faculty of Medicine, University of Thessaly, Larisa 41334, Greece
| | - Georgios Papazisis
- Department of Clinical Pharmacology, Department of Medicine, School of Medicine, Faculty of Health Sciences, School of Health Sciences, Aristotle University, University Campus, Thessaloniki 54124, Greece
| | - Michail Chourdakis
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Myrto T Samara
- Department of Psychiatry, Faculty of Medicine, University of Thessaly, Larisa 41334, Greece; Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich 81675, Germany.
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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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Tallarico M, Pisano M, Leo A, Russo E, Citraro R, De Sarro G. Antidepressant Drugs for Seizures and Epilepsy: Where do we Stand? Curr Neuropharmacol 2023; 21:1691-1713. [PMID: 35761500 PMCID: PMC10514547 DOI: 10.2174/1570159x20666220627160048] [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: 02/26/2022] [Revised: 06/13/2022] [Accepted: 06/18/2022] [Indexed: 11/22/2022] Open
Abstract
People with epilepsy (PWE) are more likely to develop depression and both these complex chronic diseases greatly affect health-related quality of life (QOL). This comorbidity contributes to the deterioration of the QOL further than increasing the severity of epilepsy worsening prognosis. Strong scientific evidence suggests the presence of shared pathogenic mechanisms. The correct identification and management of these factors are crucial in order to improve patients' QOL. This review article discusses recent original research on the most common pathogenic mechanisms of depression in PWE and highlights the effects of antidepressant drugs (ADs) against seizures in PWE and animal models of seizures and epilepsy. Newer ADs, such as selective serotonin reuptake inhibitors (SRRI) or serotonin-noradrenaline reuptake inhibitors (SNRI), particularly sertraline, citalopram, mirtazapine, reboxetine, paroxetine, fluoxetine, escitalopram, fluvoxamine, venlafaxine, duloxetine may lead to improvements in epilepsy severity whereas the use of older tricyclic antidepressant (TCAs) can increase the occurrence of seizures. Most of the data demonstrate the acute effects of ADs in animal models of epilepsy while there is a limited number of studies about the chronic antidepressant effects in epilepsy and epileptogenesis or on clinical efficacy. Much longer treatments are needed in order to validate the effectiveness of these new alternatives in the treatment and the development of epilepsy, while further clinical studies with appropriate protocols are warranted in order to understand the real potential contribution of these drugs in the management of PWE (besides their effects on mood).
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Affiliation(s)
- Martina Tallarico
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Maria Pisano
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Antonio Leo
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Rita Citraro
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Giovambattista De Sarro
- System and Applied Pharmacology, Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
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Shishmanova-Doseva M, Atanasova D, Ioanidu L, Uzunova Y, Atanasova M, Peychev L, Tchekalarova J. The anticonvulsant effect of chronic treatment with topiramate after pilocarpine-induced status epilepticus is accompanied by a suppression of comorbid behavioral impairments and robust neuroprotection in limbic regions in rats. Epilepsy Behav 2022; 134:108802. [PMID: 35792414 DOI: 10.1016/j.yebeh.2022.108802] [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: 03/24/2022] [Revised: 06/04/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
Abstract
Epilepsy is a widespread neurological disorder frequently associated with a lot of comorbidities. The present study aimed to evaluate the effects of the antiseizure medication topiramate (TPM) on spontaneous motor seizures, the pathogenesis of comorbid mood and cognitive impairments, hippocampal neuronal loss, and oxidative stress and inflammation in a rat model of temporal lobe epilepsy (TLE). Vehicle/TPM treatment (80 mg/kg, p.o.) was administered 3 h after the pilocarpine (pilo)-induced status epilepticus (SE) and continued for up to 12 weeks in Wistar rats. The chronic TPM treatment caused side effects in naïve rats, including memory disturbance, anxiety, and depressive-like responses. However, the anticonvulsant effect of this drug, administered during epileptogenesis, was accompanied by beneficial activity against comorbid behavioral impairments. The drug treatment suppressed the SE-induced neuronal damage in limbic structures, including the dorsal (CA1 and CA2 subfield), the ventral (CA1, CA2 and CA3) hippocampus, the basolateral amygdala, and the piriform cortex, while was ineffective against the surge in the oxidative stress and inflammation. Our results suggest that neuroprotection is an essential mechanism of TPM against spontaneous generalized seizures and concomitant emotional and cognitive impairments.
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Affiliation(s)
- Michaela Shishmanova-Doseva
- Department of Pharmacology, Toxicology and Pharmacotherapy, Medical University of Plovdiv, Plovdiv 4002, Bulgaria.
| | - Dimitrinka Atanasova
- Institute of Neurobiology, Bulgarian Academy of Sciences (BAS), Sofia 1113, Bulgaria; Department of Anatomy, Faculty of Medicine, Trakia University, Stara Zagora 6003, Bulgaria
| | - Lyubka Ioanidu
- Department of Bioorganic Chemistry, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Yordanka Uzunova
- Department of Bioorganic Chemistry, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Milena Atanasova
- Department of Biology, Medical University of Pleven, Pleven 5800, Bulgaria
| | - Lyudmil Peychev
- Department of Pharmacology, Toxicology and Pharmacotherapy, Medical University of Plovdiv, Plovdiv 4002, Bulgaria
| | - Jana Tchekalarova
- Institute of Neurobiology, Bulgarian Academy of Sciences (BAS), Sofia 1113, Bulgaria.
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Kanner AM. Suicidality in Patients With Epilepsy: Why Should Neurologists Care? Front Integr Neurosci 2022; 16:898547. [PMID: 35712347 PMCID: PMC9196893 DOI: 10.3389/fnint.2022.898547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022] Open
Abstract
Suicidality is a relatively common comorbidity in patients with epilepsy (PWE). Population-based studies have revealed lifetime prevalence rates of 25% of suicidal ideation (SI). In addition, PWE without comorbid psychiatric disorders has two to three higher risk of committing suicide and this risk increases by 12- to 32-fold in the presence of various psychiatric disorders. Risk factors are multiple and include socio-demographic, genetic, age and gender, and psychiatric comorbidities. Among the latter, mood, anxiety, and psychotic disorders have been found to be common risk factors for suicidality in PWE, but iatrogenic causes resulting from pharmacotherapy with antiseizure drugs or epilepsy surgery can also cause SI and behavior. Suicidality and epilepsy have a complex bidirectional relation, whereas PWE are at increased risk of suicidality and vice-versa. Common pathogenic mechanisms operant in both conditions may explain this bidirectional relation. SI can be easily identified in outpatient epilepsy clinics with screening instruments and can be treated and thus prevent its escalation to suicidal attempts and completed suicide. The aim of this manuscript is to review these data in detail.
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Sadleir KR, Popovoic J, Zhu W, Reidel CT, Do H, Silverman RB, Vassar R. Pregabalin Treatment does not Affect Amyloid Pathology in 5XFAD Mice. Curr Alzheimer Res 2021; 18:283-297. [PMID: 34259145 PMCID: PMC9527523 DOI: 10.2174/1567205018666210713125333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/18/2021] [Accepted: 04/25/2021] [Indexed: 11/22/2022]
Abstract
Background: Calcium dysregulation has been proposed to play a causative role in the development of Alzheimer’s disease pathology. Pregabalin is a compound already approved for human use, marketed as the prescription drug Lyrica. It binds the α2-δ subunit of P/Q-type voltage-gated calcium channels, lowering calcium influx and providing effective treatment for epilepsy and neuropathic pain. Objective: We hypothesize that increased resting calcium in neuronal processes near amyloid plaques plays a role in the development of neuritic dystrophies and further progression of amyloid pathology. Methods: 5XFAD mice were treated orally for 12 weeks with pregabalin, then immunoblotting and immunofluorescent imaging were used to quantify neuritic dystrophy and amyloid deposition in pregabalin compared to placebo-treated mice. Results: The treatment did not decrease markers of neuritic dystrophy or amyloid deposition. The image analysis of neuritic dystrophy on a plaque-by-plaque basis showed a small non-significant increase in the relative proportion of LAMP1 to Aβ42 in plaques with areas of 50-450 μm2 in the cortex of pregabalin-treated mice. In addition, there was a statistically significant positive correlation between the measured cerebral concentration of pregabalin and the relative levels of BACE1 and Aβ in the cortex. This relationship was not observed in the hippocampus, and there was no increase in average Aβ levels in pregabalin treated mice compared to placebo. We confirmed previous findings that smaller amyloid plaques are associated with a greater degree of neuritic dystrophy. Conclusion: Pregabalin may have an effect on Aβ that merits further investigation, but our study does not suggest that pregabalin contributes substantially to amyloid pathology.
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Affiliation(s)
- Katherine R Sadleir
- Dept of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL. United States
| | - Jelena Popovoic
- Dept of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL. United States
| | - Wei Zhu
- Dept of Chemistry, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Center for Developmental Therapeutics, Northwestern University, Evanston, IL. United States
| | - Cory T Reidel
- Dept of Chemistry, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Center for Developmental Therapeutics, Northwestern University, Evanston, IL. United States
| | - Ha Do
- Dept of Chemistry, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Center for Developmental Therapeutics, Northwestern University, Evanston, IL. United States
| | - Richard B Silverman
- Dept of Chemistry, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Center for Developmental Therapeutics, Northwestern University, Evanston, IL. United States
| | - Robert Vassar
- Dept of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL. United States
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Forthoffer N, Kleitz C, Bilger M, Brissart H. Depression could modulate neuropsychological status in epilepsy. Rev Neurol (Paris) 2020; 176:456-467. [PMID: 32414531 DOI: 10.1016/j.neurol.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
While cognition and depression have often been studied in patients with epilepsy, only a few studies have so far attempted to link these two domains, and more specifically to investigate the specific impact of depression on cognition in epilepsy. In this review, we performed an extensive search of the literature database to provide a better understanding of this subject. Using several inclusion criteria (adult population, quantitative depression/neuropsychological assessment, statistical analyses of the impact of depression on cognitive scores, patients with epilepsy (PWE) and no other neurological disease, and studies including at least 20 patients), we identified 20 articles (out of 712 search results) that investigated both depression and cognition in PWE. Their results were summarized using a narrative and descriptive approach. This review highlights a variable impact of depression on cognition in PWE, depending on the laterality of the seizure onset zone, the type of epilepsy and the surgical context. We emphasize the need for a systematic depression assessment in these patients, especially since depressed PWE will benefit from prompt and appropriate care to help them avoid cognitive decline, particularly in a surgical context.
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Affiliation(s)
- N Forthoffer
- Service de Neurologie, Centre Hospitalier Universitaire de Nancy, 54000 Nancy, France; LNCA, UMR 7364, CNRS et Université de Strasbourg, Strasbourg, France.
| | - C Kleitz
- Service de Neurologie, Hôpital Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - M Bilger
- Service de Neurologie, Hôpital Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - H Brissart
- Service de Neurologie, Centre Hospitalier Universitaire de Nancy, 54000 Nancy, France; CRAN, UMR 7039, CNRS et Université de Lorraine, Vandoeuvre-lès-Nancy, France
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Zapata Barco AM, Restrepo-Martínez M, Restrepo D. Depression in People with Epilepsy. What is the Connection? REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 49:53-61. [PMID: 32081210 DOI: 10.1016/j.rcp.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/25/2017] [Accepted: 10/22/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Depression is the most common psychiatric comorbidity in people with epilepsy. It worsens the prognosis and quality of life of these patients. Despite this, depression is poorly diagnosed and when the treatment is given, it is frequently suboptimal. OBJECTIVE To perform a narrative review of the medical literature, seeking to collect useful information regarding the relationship between epilepsy and depression. RESULTS Narrative reviews, systematic reviews, meta-analyses, clinical trials, and follow-up studies were identified in English and Spanish with no time limit, including epidemiological, clinical, associated factors, etiological explanations, diagnostic and therapeutic approaches to comorbid depression in epilepsy. CONCLUSION The relationship between epilepsy and depression is complex. The available scientific evidence suggests the possibility of a bidirectional relationship that could be explained from common aetiopathogenic mechanisms. Despite the high prevalence of depression in epileptic patients, this mental disorder continues to be poorly identified by clinicians. To improve this, we have easy-to-apply instruments that routinely screen this patient population and contribute substantially to making the problem more visible and seek to improve the quality of life for this population.
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Abstract
INTRODUCTION Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated. Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur. Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.
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Affiliation(s)
- Marco Mula
- a Institute of Medical and Biomedical Education , St George's University of London and The Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust , London , UK
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Theochari E, Cock H, Lozsadi D, Galtrey C, Arevalo J, Mula M. Brivaracetam in adults with drug-resistant epilepsy and psychiatric comorbidities. Epilepsy Behav 2019; 90:129-131. [PMID: 30530134 DOI: 10.1016/j.yebeh.2018.11.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/28/2022]
Abstract
This is a case series of 25 patients with drug-resistant epilepsy and psychiatric comorbidities who started on brivaracetam (BRV) at St George's University Hospitals and Frimley Health in London. Median BRV dose was 150 mg for a median follow-up period of 8 months. Twenty had focal epilepsy, four had generalized epilepsies, and one had unclassified epilepsy; 76% had mood disorders (either depression or bipolar disorder), 12% intellectual disabilities with autism spectrum disorder and challenging behavior, and 12% psychoses. Forty percent of patients presented at least 50% seizure reduction, but none of them became seizure-free. A total of 44% of patients discontinued BRV, 20% because of adverse events, 20% because of inefficacy, and 4% because of both. Depression was reported by 8%, aggressive behavior by 8%, while 4% reported both. A total of 91.6% had received levetiracetam (LEV) before, in whom LEV was discontinued because of psychiatric adverse events (PAEs) in half. Seventy-seven percent of patients who developed PAEs with LEV did not do so on BRV suggesting that BRV is better tolerated than LEV in complex patients with psychiatric comorbidities and that the synaptic vesicle glycoprotein 2A (SV2A) protein modulation is unlikely to be implicated in LEV-related PAEs.
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Affiliation(s)
- Evangelia Theochari
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Hannah Cock
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK; Institute of Medical and Biomedical Education, St George's University of London, UK
| | - Dora Lozsadi
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Jan Arevalo
- Frimley Health NHS Foundation Trust, London, UK
| | - Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK; Institute of Medical and Biomedical Education, St George's University of London, UK.
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Coppola G, Operto FF, Matricardi S, Verrotti A. Monitoring And Managing Depression In Adolescents With Epilepsy: Current Perspectives. Neuropsychiatr Dis Treat 2019; 15:2773-2780. [PMID: 31576132 PMCID: PMC6765392 DOI: 10.2147/ndt.s192714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 09/02/2019] [Indexed: 11/23/2022] Open
Abstract
Epilepsy is associated with a significantly increased risk of developing depressive disorder during adolescence. On the other hand, depression is highly detected in adolescents with epilepsy. These findings highlight the importance of early identification and proper management of comorbid depression in adolescent age. The prevalence of depressive disorders in adolescents with epilepsy ranges between 8 and 35% and is higher than the general population of the same age. The relationship between epilepsy and depression is complex and potentially bidirectional, thereby suggesting a common underlying pathophysiology. Furthermore, failure to detect and treat depressive disorder mostly in adolescence could lead to several negative implications such as an increased risk of suicidal ideation or behavior and poor quality of life. A number of methods are available to detect depressive disorder, such as psychiatric or psychological assessments, structured or semi-structured interviews, and self-report screening tools. Thus, physicians should be able to regularly screen depressive symptoms in youths with epilepsy. Recently, the NDDI-E-.Y inventory has been developed from the adult NDDI-E, and has been validated in many countries. NDDI-E-Y has showed reliable validity, being a brief screening tool (12 items) that can be easily included in routine epilepsy care. The first step to be considered for the management of depressive disorder in adolescents with epilepsy is to consider potential reversible causes of anxiety and depression (i.e., a new AEDs; seizure control). Secondly, great attention has to be given to the education of the child/adolescent and his/her family, trying to improve knowledge about epilepsy as well as to decrease parental stress and improving the child's sense of competence. Pharmacological treatment should also be considered in adolescents diagnosed with depression.
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Affiliation(s)
- Giangennaro Coppola
- Child and Adolescent Neuropsychiatry, Department of Medicine, Surgery, and Odontoiatry, University of Salerno, Salerno, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry, Department of Medicine, Surgery, and Odontoiatry, University of Salerno, Salerno, Italy
| | - Sara Matricardi
- Department of Pediatric Neurology, Ospedali Riuniti, Ancona, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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Shorvon SD, Bermejo PE, Gibbs AA, Huberfeld G, Kälviäinen R. Antiepileptic drug treatment of generalized tonic-clonic seizures: An evaluation of regulatory data and five criteria for drug selection. Epilepsy Behav 2018; 82:91-103. [PMID: 29602083 DOI: 10.1016/j.yebeh.2018.01.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND A generalized tonic-clonic seizure (GTCS) is the most severe form of common epileptic seizure and carries the greatest risk of harm. The aim of this review is to provide an evidence-based guide for the selection of antiepileptic drugs (AEDs) for patients with GTCSs. Eight AEDs are approved in Europe and the USA for the treatment of both primarily GTCSs (PGTCSs) and secondarily GTCSs (SGTCSs) and are considered in this paper. METHODS Each AED is evaluated using five criteria: (1) efficacy, by seizure type (a: PGTCSs and b: SGTCSs); (2) adverse effects; (3) interactions; (4) adherence and dosing; and (5) mechanism of action (MOA). To ensure the inclusions of robust data, only efficacy data accepted by regulatory authorities were considered, and data related to adverse effects, interactions, adherence, and MOA were all extracted from UK Summaries of Product Characteristics (SPCs). RESULTS (1a) There is class 1 evidence of the efficacy of only four AEDs in controlling PGTCSs (lamotrigine, levetiracetam, perampanel, and topiramate). (1b) There is no class 1 evidence of the efficacy of any AED in SGTCSs although some evidence from pooled/subgroup analyses or meta-analyses supports the use of the four AEDs (levetiracetam, perampanel, topiramate, and with less robust data for lamotrigine). (2) AEDs are associated with different, but to some extent overlapping, common adverse effect profiles but have differing idiosyncratic adverse effects. (3) Pharmacokinetic interactions are seen with most, but not all, AEDs and are most common with carbamazepine and phenytoin. (4) Good adherence is important for seizure control and is influenced by frequency of dosing, among other factors. (5) Mechanism of action is also a consideration in rationalising AED selection when switching or combining AEDs. CONCLUSION Ultimately, the choice of AED depends on all these factors but particularly on efficacy and adverse effects. Different patients will weigh the various factors differently, and the role of the treating physician is to provide accurate information to allow patients to make informed choices.
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Affiliation(s)
- Simon D Shorvon
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, WC1N 3BG, UK.
| | - Pedro E Bermejo
- Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | | | - Gilles Huberfeld
- Sorbonne Université, Pitié-Salpêtrière Hospital, Neurophysiology Department, Paris, France; INSERM U1129 "Infantile Epilepsies and Brain Plasticity", Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France
| | - Reetta Kälviäinen
- Epilepsy Center/Neurocenter, Kuopio University Hospital, Kuopio, Finland; Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Depression and Epilepsy: Comorbidity, Pathogenetic Similarity, and Principles of Treatment. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s11055-017-0534-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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15
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Abstract
Purpose of review The pharmacological treatment of patients with epilepsy and psychiatric comorbidities may sometimes represent a therapeutic challenge. This review is focused on the pharmacological management of patients with epilepsy and psychiatric problems in terms of rationalization of the antiepileptic drug (AED) treatment and the pharmacological management of the most clinically relevant psychiatric comorbidities, namely mood and anxiety disorders, psychoses, and attention deficit hyperactivity disorder (ADHD). Recent findings Up to 8% of patients with drug-resistant epilepsy develop treatment-emergent psychiatric adverse events of AED regardless of the mechanism of action of the drug and this is usually related to an underlying predisposition given by the previous psychiatric history and the involvement of mesolimbic structures. Careful history taking, periodic screening for mood and anxiety disorders, low starting doses, and slow titration schedules can reduce the possibility of AED-related problems. A pragmatic checklist for the pharmacological management of patients with epilepsy and psychiatric disorders is presented. Summary patients should be informed of potential behavioral effects of AEDs but no drugs should be excluded a priori. Any psychiatric comorbidity should be addressed in the appropriate setting and full remission and recovery should always represent the first goal of any therapeutic intervention. Neurologists should be aware of the side effects of major psychotropic drug classes in order to fully counsel their patients and other health professionals involved.
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16
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Kanner AM. Psychiatric comorbidities in new onset epilepsy: Should they be always investigated? Seizure 2017; 49:79-82. [PMID: 28532711 DOI: 10.1016/j.seizure.2017.04.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/13/2017] [Indexed: 11/19/2022] Open
Abstract
The new definition of epilepsy establishes that epilepsy is not only a disorder presenting with epileptic seizures but it can be often associated with cognitive and psychiatric comorbidities. In fact, the prevalence of psychiatric comorbidities is relatively high in patients with epilepsy (PWE), as one in three patients will have experienced a psychiatric disorder in the course of their life, with mood and anxiety disorders being the most frequent. Psychiatric comorbidities often precede the onset of the seizure disorder, and affect the life of these patients and the course of the seizure disorder at several levels, including a worse tolerance of pharmacotherapy with antiepileptic drugs (AEDs), in particular the development of iatrogenic psychiatric symptoms from pharmacologic and surgical treatments, an increased mortality risk, a worse quality of life and higher economic burdens of the patient, family and society as a hole. Accordingly, psychiatric comorbidities should be recognized at the time of the initial evaluation of every PWE and their treatment needs to be incorporated within the overall therapeutic plan. This question is addressed in this article.
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Affiliation(s)
- Andres M Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, 1120 NW, 14th Street, Room #1324, Miami, FL 33136, United States.
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17
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Zaccara G, Giovannelli F, Giorgi FS, Franco V, Gasparini S, Benedetto U. Tolerability of new antiepileptic drugs: a network meta-analysis. Eur J Clin Pharmacol 2017; 73:811-817. [PMID: 28378057 DOI: 10.1007/s00228-017-2245-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/28/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of this study was to perform a comparative assessment of tolerability of all licensed new antiepileptic drugs (AEDs) through a network meta-analysis (NMA) including all placebo-controlled double-blind clinical trials (RCTs) in all conditions in which these drugs have been tested. METHODS NMA with a frequentist approach was used to compare proportions of patients withdrawing because of adverse events (AEs). Analyses were conducted for all therapeutic doses pooled and specifically for high therapeutic doses. Patients treated with non-therapeutic doses of each drug were excluded. RESULTS A total of 195 RCTs were included in the current analysis, comprising a total of 28,013 patients treated with AEDs and 17,908 patients treated with placebo. RCTs included in the analysis were 8 for brivaracetam; 5 for eslicarbazepine; 22 for gabapentin; 7 for lacosamide; 14 for levetiracetam; 14 for lamotrigine; 6 for oxcarbazepine; 9 for perampanel; 50 for pregabalin; 5 for tiagabine; 36 for topiramate; 7 for zonisamide; 4 for gabapentin-extended formulation (ER); 2 each for levetiracetam-ER, lamotrigine-ER, and topiramate-ER; and 1 each for oxcarbazepine-ER and pregabalin-ER. Brivaracetam, gabapentin, gabapentin-ER, and levetiracetam had a significantly lower withdrawal rate compared to several other AEDs, while eslicarbazepine, lacosamide, oxcarbazepine, and topiramate had a higher withdrawal rate. Perampanel, lamotrigine, pregabalin, tiagabine, and zonisamide showed an intermediate pattern of tolerability. Additional analysis has been conducted through selection of highly recommended doses for each drug. This analysis has roughly confirmed results of head to head comparisons of the all-dose analysis, with some exceptions. A further analysis has been conducted after exclusion of RCTs in which patients were allocated to the therapeutic dose of the experimental drug without titration, and it failed to show clinically important differences. SIGNIFICANCE Relevant differences in short-term tolerability of AEDs have been observed between AEDs. Brivaracetam, gabapentin, and levetiracetam show the best tolerability profile while other AEDs are at higher risk for intolerable adverse effects.
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Affiliation(s)
- Gaetano Zaccara
- Department of Medicine, Unit of Neurology, Florence Health Authority, Florence, Italy
| | - Fabio Giovannelli
- Department of Medicine, Unit of Neurology, Florence Health Authority, Florence, Italy. .,Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Italy.
| | | | - Valentina Franco
- Department of Internal Medicine and Therapeutics, Division of Clinical and Experimental Pharmacology, University of Pavia, Pavia, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Umberto Benedetto
- School of Clinical Science, Bristol Heart Institute, University of Bristol, Bristol, UK
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18
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Błaszczyk B, Czuczwar SJ. Epilepsy coexisting with depression. Pharmacol Rep 2017; 68:1084-92. [PMID: 27634589 DOI: 10.1016/j.pharep.2016.06.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/14/2016] [Accepted: 06/17/2016] [Indexed: 12/15/2022]
Abstract
Depression episodes in epilepsy is the most common commorbidity, affecting between 11% and 62% of patients with epilepsy. Although researchers have documented a strong association between epilepsy and psychiatric comorbidities, the nature of this relationship is poorly understood. The manifestation of depression in epilepsy is a complex issue having many interacting neurobiological and psychosocial determinants, including clinical features of epilepsy (seizure frequency, type, foci, or lateralization of foci) and neurochemical or iatrogenic mechanisms. Other risk factors are a family history of psychiatric illness, particularly depression, a lack of control over the seizures and iatrogenic causes (pharmacologic and surgical). In addition, treatment with antiepileptic drugs (AEDs) as well as social coping and adaptation skills have also been recognised as risk factors of depression associated with epilepsy. Epilepsy may foster the development of depression through being exposed to chronic stress. The uncertainty and unpredictability of seizures may instigate sadness, loneliness, despair, low self-esteem, and self-reproach in patients with epilepsy and lead to social isolation, stigmatization, or disability. Often, depression is viewed as a reaction to epilepsy's stigma and the associated poor quality of life. Moreover, patients with epilepsy display a 4-5 higher rate of depression and suicide compared with healthy population.
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Affiliation(s)
- Barbara Błaszczyk
- Faculty of Health Sciences, High School of Economics, Law and Medical Sciences, Kielce, Poland; Private Neurological Practice, Kielce, Poland.
| | - Stanisław J Czuczwar
- Department of Pathophysiology, Medical University of Lublin, Lublin, Poland; Department of Physiopathology, Institute of Rural Health, Lublin, Poland.
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19
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Rider FK, Danilenko OA, Grishkina MN, Kustov GV, Akzhigitov RG, Lebedeva AV, Guekht AB. [Depression and epilepsy: comorbidities, pathogenesis, principles of therapy]. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:19-24. [PMID: 28005042 DOI: 10.17116/jnevro20161169219-24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Numerous trials of last years confirm the bilateral link between depression and epilepsy with mutual complication of both diseases. Depression increases the risk of the first unprovoked paroxysm, worsens the compliance of epileptic patients, leads to decrease of the response both to therapeutic and surgical treatment and to increase of side effects of antiepileptic drugs. Depression is associated with high risk of suicidal behavior and reduces the quality of life level. Depression in epileptic patients is characterized by atypical clinical course in most cases what makes its diagnostics difficult and becomes the reason of the absence of the necessary pharmacologic and psychotherapeutic treatment. All of the above creates significant economical burden for the community because the epileptic patient with comorbid depression visits the physicians 2-4 times more often.
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Affiliation(s)
- F K Rider
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia
| | - O A Danilenko
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia
| | - M N Grishkina
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia
| | - G V Kustov
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia
| | - R G Akzhigitov
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia
| | - A V Lebedeva
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia; Pirogov Russian Natural Research Medical Univercity, Moscow, Russia
| | - A B Guekht
- Soloviev Moscow Research and Clinical for Neuropsychiatry, Moscow, Russia; Pirogov Russian Natural Research Medical Univercity, Moscow, Russia
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20
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Kanner AM. Psychiatric comorbidities in epilepsy: Should they be considered in the classification of epileptic disorders? Epilepsy Behav 2016; 64:306-308. [PMID: 27884642 DOI: 10.1016/j.yebeh.2016.06.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/27/2016] [Indexed: 02/05/2023]
Abstract
The prevalence of psychiatric comorbidities is relatively high in people with epilepsy (PWE), as one in three patients will have experienced a psychiatric disorder in the course of their life. The new definition of epilepsy recognizes these comorbidities as part of the seizure disorder, which need to be recognized and treated together with the actual epileptic seizures. Psychiatric comorbidities have a complex relation with epilepsy, being associated with a negative course of the seizure disorder, worse tolerance of pharmacotherapy with AEDs, development of iatrogenic psychiatric complications from pharmacologic and surgical treatments, and increased mortality risks. Given their negative impact at several levels of the lives of PWE, should psychiatric comorbidities be included in a classification of the epilepsies? This question is addressed in this article. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".
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Affiliation(s)
- Andres M Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, 1120 NW, 14th Street, Room #1324, Miami, FL 33136, United States.
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21
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Tao K, Wang X. The comorbidity of epilepsy and depression: diagnosis and treatment. Expert Rev Neurother 2016; 16:1321-1333. [PMID: 27327645 DOI: 10.1080/14737175.2016.1204233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Kaiyan Tao
- Chongqing Key Laboratory of Neurology, Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuefeng Wang
- Chongqing Key Laboratory of Neurology, Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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22
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Abstract
The treatment of epileptic seizure disorders is not restricted to the achievement of seizure-freedom, but must also include the management of comorbid medical, neurological, psychiatric and cognitive comorbidities. Psychiatric and neurological comorbidities are relatively common and often co-exist in people with epilepsy (PWE). For example, depression and anxiety disorders are the most common psychiatric comorbidities in PWE, and they are particularly common in PWE who also have a neurological comorbidity, such as migraine, stroke, traumatic brain injury or dementia. Moreover, psychiatric and neurological comorbodities often have a more severe impact on the quality of life in patients with treatment-resistant focal epilepsy than do the actual seizures. Epilepsy and psychiatric and neurological comorbidities have a complex relationship, which has a direct bearing on the management of both seizures and the comorbidities: the comorbidities have to be factored into the selection of antiepileptic drugs, and the susceptibility to seizures has to be considered when choosing the drugs to treat comorbidities. The aim of this Review is to highlight the complex relationship between epilepsy and common psychiatric and neurological comorbidities, and provide an overview of how treatment strategies for epilepsy can positively and negatively affect these comorbidities and vice versa.
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23
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24
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Pohlmann-Eden B, Aldenkamp A, Baker GA, Brandt C, Cendes F, Coras R, Crocker CE, Helmstaedter C, Jones-Gotman M, Kanner AM, Mazarati A, Mula M, Smith ML, Omisade A, Tellez-Zenteno J, Hermann BP. The relevance of neuropsychiatric symptoms and cognitive problems in new-onset epilepsy - Current knowledge and understanding. Epilepsy Behav 2015; 51:199-209. [PMID: 26291774 DOI: 10.1016/j.yebeh.2015.07.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/03/2015] [Indexed: 01/11/2023]
Abstract
Neurobehavioral and cognition problems are highly prevalent in epilepsy, but most research studies to date have not adequately addressed the precise nature of the relationship between these comorbidities and seizures. To address this complex issue and to facilitate collaborative, innovative research in the rising field of neurobehavioral comorbidities and cognition disturbances in new-onset epilepsy, international epilepsy experts met at the 3rd Halifax International Epilepsy Conference & Retreat at White Point, South Shore, Nova Scotia, Canada from September 18 to 20, 2014. This Conference Proceedings provides a summary of the conference proceedings. Specifically, the following topics are discussed: (i) role of comorbidities in epilepsy diagnosis and management, (ii) role of antiepileptic medications in understanding the relationship between epilepsy and neurobehavioral and cognition problems, and (iii) animal data and diagnostic approaches. Evidence to date, though limited, strongly suggests a bidirectional relationship between epilepsy and cognitive and psychiatric comorbidities. In fact, it is likely that seizures and neurobehavioral problems represent different symptoms of a common etiology or network-wide disturbance. As a reflection of this shared network, psychiatric comorbidities and/or cognition problems may actually precede the seizure occurrence and likely get often missed if not screened.
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Affiliation(s)
- B Pohlmann-Eden
- Division of Neurology, Dalhousie University of Halifax, Canada; Brain Repair Center, Dalhousie University of Halifax, Canada.
| | - A Aldenkamp
- Epilepsiecentrum Kempenhaeghe, The Netherlands
| | - G A Baker
- Division of Neurosciences, University of Liverpool, United Kingdom
| | - C Brandt
- Bethel Epilepsy Center, Mara Hospital, Bielefeld, Germany
| | - F Cendes
- Department of Neurology, University of Campinas, São Paulo, Brazil
| | - R Coras
- Department of Neuropathology, University of Erlangen, Germany
| | - C E Crocker
- Division of Neurology, Dalhousie University of Halifax, Canada
| | | | - M Jones-Gotman
- McGill University, Montreal Neurological Institute, Montreal, Canada
| | - A M Kanner
- Epilepsy Center, University of Miami, Miller School of Medicine, USA
| | - A Mazarati
- Children's Discovery and Innovation Institute, D. Geffen School of Medicine at UCLA, Los Angeles, USA
| | - M Mula
- Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust and Institute of Medical and Biomedical Sciences St. George's University of London, United Kingdom
| | - M L Smith
- Department of Psychology, University of Toronto, Canada
| | - A Omisade
- Division of Neurology, Dalhousie University of Halifax, Canada
| | | | - B P Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, USA
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25
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Mula M, Sander JW. Suicide and epilepsy: do antiepileptic drugs increase the risk? Expert Opin Drug Saf 2015; 14:553-8. [DOI: 10.1517/14740338.2015.1010506] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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26
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Yang Y, Gao X, Xu Y. The dilemma of treatments for epileptic patients with depression. Int J Neurosci 2014; 125:566-77. [PMID: 25271800 DOI: 10.3109/00207454.2014.959122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Depression is a state of low mood and aversion to activity. It may occur due to existence of other mental or physical diseases or from the medications for those illnesses. It is one of the leading sources of disability. Among these physical diseases, epilepsy is widely recognized as one of the main causes of depression. Patients with epilepsy are at high risk of developing depressive symptoms, and the suicide rates in patients with epilepsy have been reported to be much higher than in the general population. However, due to fears of lowering seizure threshold and adverse drug interactions between antidepressants and antiepileptic drugs, physician are reluctant to place patients with epilepsy on antidepressant medication. As a result, the question has been raised that what the best managements should be used to treat epileptic patients with depression. In this review, the currently used medications for antidepressants and antiepileptic drugs were summarized by their working targets in order to establish appropriate pharmacological management of depression and epilepsy. Despite the complex relationship between epilepsy and depression, coadministration of antidepressants and AEDs can still be done safely and effectively under the conditions of good clinical management. The ideal antidepressants for people with epilepsy should be efficacious but with few adverse effects, which will not antagonize GABAergic mechanisms or interfere with plasma anticonvulsant concentrations.
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Affiliation(s)
- Yang Yang
- 1Department of Clinical Psychology, Subei People Hospital of Jiangsu Province, Yangzhou, 225001, China
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27
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Salpekar JA, Mishra G. Key issues in addressing the comorbidity of attention deficit hyperactivity disorder and pediatric epilepsy. Epilepsy Behav 2014; 37:310-5. [PMID: 24835083 DOI: 10.1016/j.yebeh.2014.04.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/22/2014] [Accepted: 04/23/2014] [Indexed: 11/16/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is a common comorbidity of epilepsy encountered by clinicians. However, relatively little information is available to guide optimal diagnostic and treatment strategies. Differentiating ADHD from effects of epilepsy requires careful history taking and emphasis upon characteristic symptoms and course of illness. Rating scales for ADHD are well validated and may aid clinical management. Use of antiepileptic drugs may cause cognitive or behavioral side effects yet may improve behavior in some cases. Historically, clinicians have been hesitant to treat ADHD comorbidity for fear of lowering the seizure threshold. However, an aggregate of recent evidence now suggests that stimulants may be well tolerated and effective for ADHD comorbid with epilepsy. Studies that further clarify pathophysiology and treatment outcomes are needed in order to enhance clinical efficacy and quality of life for this population.
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Affiliation(s)
- Jay A Salpekar
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA.
| | - Gaurav Mishra
- Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
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28
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Abstract
Topiramate is an antiepileptic drug (AED) with multiple mechanisms of action that has been shown to be effective in a number of neuropsychiatric disorders. However, cognitive dysfunction is frequently observed in such patients, often representing a relevant challenge in their management. Moreover, there is a long-held recognition that AEDs may profoundly affect cognitive functions. This paper reviews available data on cognitive adverse events in patients with neurological disorders treated with topiramate, discussing the role of different contributing factors such as the pharmacological properties of the drug, the specific features of the brain disorder, and other variables pertinent to the discussion. All studies agree that up to 10% of patients may complain of treatment-emergent adverse events on cognition. Such problems occur early during treatment (i.e. within 6 weeks) and emerge in a dose-dependent fashion, suggesting that such prevalence may be significantly reduced using the drug in monotherapy and adopting individualized doses and titration schedules. The magnitude of the problem is generally mild to moderate and the subjective perception of the patient needs to be taken into account. In fact, apart from language problems, data are not conclusive. Comparisons with new AEDs are limited to levetiracetam and lamotrigine, in both cases generally disfavoring topiramate, while data regarding first-generation AEDs show clear differences only for verbal fluency.
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Affiliation(s)
- Marco Mula
- Division of Neurology, University Hospital Maggiore della Carità, C.so Mazzini 18, 28100 Novara, Italy
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29
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Kirilly E, Gonda X, Juhász G, Bagdy G. [Anxiogenic and depressogenic side-effects of non-psychiatric drugs]. Orv Hetil 2013; 154:1327-36. [PMID: 23955968 DOI: 10.1556/oh.2013.29681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although medications such as anticancer, antimicrobial, immunomodulatory, neurological or hormonal therapies may have a negative impact on mood, adequate attention was not paid until the withdrawal of rimonabant in 2008. In the present study the authors review full spectrum of currently available medications discussing anxiety and depression as possible adverse effects of treatment. A relatively high risk of depression should always be considered when pharmacotherapy applied, especially if current depressive episodes, positive family history, or neurotic personality traits increasing susceptibility to depressogenic effects. Prior to start of medical treatment, the potential effectiveness of the given drug should be precisely evaluated, and alternative medical and non-medical treatment options should also be carefully considered. In addition, monitoring patients during treatment for signs of depressive or anxious symptoms is necessary.
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Affiliation(s)
- Eszter Kirilly
- Semmelweis Egyetem, Gyógyszerésztudományi Kar Gyógyszerhatástani Intézet Budapest Nagyvárad tér 4. 1089
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30
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Korczyn AD, Schachter SC, Brodie MJ, Dalal SS, Engel J, Guekht A, Hecimovic H, Jerbi K, Kanner AM, Landmark CJ, Mares P, Marusic P, Meletti S, Mula M, Patsalos PN, Reuber M, Ryvlin P, Štillová K, Tuchman R, Rektor I. Epilepsy, cognition, and neuropsychiatry (Epilepsy, Brain, and Mind, part 2). Epilepsy Behav 2013; 28:283-302. [PMID: 23764496 PMCID: PMC5016028 DOI: 10.1016/j.yebeh.2013.03.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 12/13/2022]
Abstract
Epilepsy is, of course, not one disease but rather a huge number of disorders that can present with seizures. In common, they all reflect brain dysfunction. Moreover, they can affect the mind and, of course, behavior. While animals too may suffer from epilepsy, as far as we know, the electrical discharges are less likely to affect the mind and behavior, which is not surprising. While the epileptic seizures themselves are episodic, the mental and behavioral changes continue, in many cases, interictally. The episodic mental and behavioral manifestations are more dramatic, while the interictal ones are easier to study with anatomical and functional studies. The following extended summaries complement those presented in Part 1.
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Affiliation(s)
- Amos D. Korczyn
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv 69978, Israel
| | - Steven C. Schachter
- Center for Integration of Medicine and Innovative Technology, Harvard Medical School, Boston, MA, USA
| | | | - Sarang S. Dalal
- Zukunftskolleg & Department of Psychology, University of Konstanz, Germany
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | | | - Alla Guekht
- Russian National Research Medical University, Moscow City Hospital No. 8 for Neuropsychiatry, Moscow, Russia
| | - Hrvoje Hecimovic
- Zagreb Epilepsy Center, Department of Neurology, University Hospital, Zagreb, Croatia
| | - Karim Jerbi
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | - Andres M. Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, Miami FL, USA
| | - Cecilie Johannessen Landmark
- Department of Pharmacy and Biomedical Science, Oslo, Norway
- Akershus University College of Applied Sciences, Oslo, Norway
| | - Pavel Mares
- Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Petr Marusic
- Department of Neurology, Charles University in Prague, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Stefano Meletti
- Department of Biomedical Sciences, Metabolism, and Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Mula
- Amedeo Avogadro University, Novara, Italy
| | - Philip N. Patsalos
- Department of Clinical and Experimental Epilepsy, UCL-Institute of Neurology, London and Epilepsy Society, Chalfont St Peter, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Philippe Ryvlin
- Service de neurologie fonctionnelle et d’épileptologie, Hôpital Neurologique, HCL TIGER, CRNL, INSERM U1028, UMR-CNRS 5292, Université Lyon-1, Lyon, France
| | - Klára Štillová
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
| | - Roberto Tuchman
- Autism and Neurodevelopment Program, Miami Children’s Hospital Dan Marino Center, Departments of Neurology and Psychiatry, Herbert Wertheim College of Medicine, Florida International University, FL, USA
| | - Ivan Rektor
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
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Mula M, Sander JW. Suicide risk in people with epilepsy taking antiepileptic drugs. Bipolar Disord 2013; 15:622-7. [PMID: 23755740 DOI: 10.1111/bdi.12091] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 03/10/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The standardized mortality ratio for suicide in people with epilepsy is reported as 5.1 [95% confidence interval (CI): 3.9-6.6], but this is only partially explained by the high rates of psychiatric comorbidity. This issue was revived when, in 2008, the Food and Drug Administration (FDA) issued an alert on an increased risk of suicide in people taking antiepileptic drugs (AEDs). We discuss and elaborate on available evidence on the interplay among epilepsy, suicide, and AEDs, taking into account the phenomenology of mood disorders in people with epilepsy and the psychotropic potential of AEDs. METHODS Articles were identified by searches of Medline/PubMed using the terms epilepsy, antiepileptic drugs, and suicide. Only papers published in English in international peer-reviewed journals were considered. The reference lists of relevant articles were hand-searched for additional publications (e.g., book chapters or review papers) if relevant to the discussion. RESULTS The results of studies supporting or opposing the FDA conclusions have been inconsistent. This may be due to a number of methodological limitations, such as the failure to adjust for past suicidality and the confounding effect of epilepsy. CONCLUSIONS A subgroup of people with epilepsy appears to be at risk of developing treatment-emergent psychiatric adverse effects of AEDs independently of the specific mechanism of action of the drug. Clinicians need to pay attention not only to seizure patterns when choosing the appropriate AED but also to a number of different parameters, not least the mental state of the individual patient.
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Affiliation(s)
- Marco Mula
- Division of Neurology, Trinity Hospital, Borgomanero, Italy
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Longitudinal Associations of Migraine and Depressive Symptoms: A Cohort Analysis. PSYCHOSOMATICS 2013; 54:317-27. [DOI: 10.1016/j.psym.2012.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 10/11/2012] [Accepted: 10/22/2012] [Indexed: 11/23/2022]
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Kanner AM. The treatment of depressive disorders in epilepsy: what all neurologists should know. Epilepsia 2013; 54 Suppl 1:3-12. [PMID: 23458461 DOI: 10.1111/epi.12100] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
One of every three patients with epilepsy (PWE) will experience a depressive disorder in the course of their life, often associated with anxiety symptoms or a full blown anxiety disorder. Clearly, the high prevalence of these psychiatric comorbidities calls for their early identification and management. This article provides practical strategies in the management of depressive episodes in PWE. Contrary to long-held beliefs, the use of antidepressant drugs are safe in PWE when used at therapeutic doses. Antidepressant drugs of the selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) families are the first line of therapy in depressive disorders, and failure to achieve complete symptom remission after a trial of an SSRI or SNRI at optimal doses should be followed by a second trial with a drug from the other antidepressant family. In developing countries, antidepressant drugs of these two antidepressant families are not always available, and tricyclic antidepressants (TCAs) are the drugs of choice. Although there are no differences in efficacy among the three families of antidepressants, TCAs have a lower tolerability and higher toxicity, with greater mortality risk associated with cardiotoxic effects in overdoses. Cognitive behavior therapy is another treatment modality that has been shown to be effective in the treatment of depressive disorders in patients with and without epilepsy. Its use should be considered together with pharmacotherapy or by itself.
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Affiliation(s)
- Andres M Kanner
- Comprehensive Epilepsy Program and Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida 33136, USA.
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Perucca P, Mula M. Antiepileptic drug effects on mood and behavior: molecular targets. Epilepsy Behav 2013; 26:440-9. [PMID: 23092694 DOI: 10.1016/j.yebeh.2012.09.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 09/06/2012] [Indexed: 01/09/2023]
Abstract
With almost 100 years of clinical experience, antiepileptic drugs (AEDs) remain the mainstay of epilepsy treatment. They suppress epileptic seizures by acting on a variety of mechanisms and molecular targets involved in the regulation of neuronal excitability. These include inhibitory-GABAergic and excitatory-glutamatergic neurotransmission, as well as ion (sodium and calcium) conductance through voltage-gated channels. On the other hand, accruing evidence indicates that these mechanisms and targets are also implicated in the regulation of mood and behavior, which may explain why each AED is associated with specific psychotropic effects. These effects, however, cannot be explained solely on the basis of the known mode of action of each AED, and other mechanisms or targets are likely to be implicated. In this article, we review positive and negative effects of AEDs on mood and behavior, discuss putative underlying mechanisms, and highlight knowledge gaps which should be addressed in future studies.
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Affiliation(s)
- Piero Perucca
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada.
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Caplan R. Psychopathology in pediatric epilepsy: role of antiepileptic drugs. Front Neurol 2012; 3:163. [PMID: 23233847 PMCID: PMC3516700 DOI: 10.3389/fneur.2012.00163] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 10/24/2012] [Indexed: 01/17/2023] Open
Abstract
Children with epilepsy are usually treated with antiepileptic drugs (AEDS). Some AEDs adversely affect behavior in susceptible children. Since psychiatric comorbidity is prevalent in pediatric epilepsy, this paper attempts to disentangle these AED side effects from the psychopathology associated with this illness. It first outlines the clinical and methodological problems involved in determining if AEDs contribute to the behavior and emotional problems of children with epilepsy. It then presents research evidence for and against the role AEDs play in the psychopathology of children with epilepsy, and outlines how future studies might investigate this problem. A brief description of how to clinically separate out AED effects from the complex illness-related and psychosocial factors that contribute to the behavior difficulties of children with epilepsy concludes the paper.
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Affiliation(s)
- Rochelle Caplan
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles Los Angeles, CA, USA
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Mula M, Kanner AM, Schmitz B, Schachter S. Antiepileptic drugs and suicidality: an expert consensus statement from the Task Force on Therapeutic Strategies of the ILAE Commission on Neuropsychobiology. Epilepsia 2012; 54:199-203. [PMID: 22994856 DOI: 10.1111/j.1528-1167.2012.03688.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 2008, the U.S. Food and Drug Administration (FDA) issued an alert to health care professionals about an increased risk of suicide ideation and suicide behavior in people treated with antiepileptic drugs (AEDs). Since then, a number of retrospective cohort and case-control studies have been published that are trying to address this issue, but gathered results are contradictory. This report represents an expert consensus statement developed by an ad hoc task force of the Commission on Neuropsychobiology of the International League Against Epilepsy (ILAE). Although some (but not all) AEDs can be associated with treatment-emergent psychiatric problems that can lead to suicidal ideation and behavior, the actual suicidal risk is yet to be established, but it seems to be very low. The risk of stopping AEDs or refusing to start AEDs is significantly worse and can actually result in serious harm including death to the patient. Suicidality in epilepsy is multifactorial, and different variables are operant. Clinicians should investigate the existence of such risk factors and adopt appropriate screening instruments. If necessary, patients should be referred for a psychiatric evaluation, but AED treatment should not be withheld, even in patients with positive suicidal risks. When starting an AED or switching from one to other AEDs, patients should be advised to report to their treating physician any change in mood and suicidal ideation. Data on treatment-emergent psychiatric adverse events need to be collected, in addition to general safety information, during controlled studies in order to have meaningful information for patients and their relatives when a new drug is marketed.
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Affiliation(s)
- Marco Mula
- Amedeo Avogadro University, Novara, Italy.
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Mula M. Treatment-emergent psychiatric adverse events of antiepileptic drugs in epilepsy: how can we avoid them? ACTA ACUST UNITED AC 2011. [DOI: 10.2217/npy.11.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Antiepileptic drugs have a number of mechanisms of action that target brain excitability systems. The potentiation of GABAergic inhibitory neurotransmission represents a classic and well-known antiseizure effect. Currently available GABAergic antiepileptic drugs mainly target GABA(A) receptor-associated complexes, GABA reuptake or GABA catabolism. All these compounds, although generally effective, are limited by their deleterious effects on cognition and behavior. The challenge will be to find GABAergic drugs that exhibit the beneficial effects, without the adverse ones.
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Hoppe C, Elger CE. Depression in epilepsy: a critical review from a clinical perspective. Nat Rev Neurol 2011; 7:462-72. [PMID: 21750525 DOI: 10.1038/nrneurol.2011.104] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mula M, Hesdorffer DC. Suicidal behavior and antiepileptic drugs in epilepsy: analysis of the emerging evidence. DRUG HEALTHCARE AND PATIENT SAFETY 2011; 3:15-20. [PMID: 21753899 PMCID: PMC3132858 DOI: 10.2147/dhps.s13070] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/23/2022]
Abstract
Two years after the warning issued by the Food and Drug Administration on an increased risk of suicide for people taking antiepileptic drugs (AEDs), a number of pharmacoepidemiologic studies have been published but the scientific community is far from definitive answers. The present paper is aimed at reviewing available evidence on the association between AEDs and suicidal behavior, discussing major variables involved such as the relationship between epilepsy, depression, and suicide and the psychotropic potential of AEDs. All studies published so far show a lack of concordance and are constrained by various methodological limitations. What seems to be established is that mood disorders represent a frequent comorbidity in epilepsy and suicide is a serious complication more frequently encountered in epilepsy rather than in the general population. Moreover, a subgroup of patients appears to be at risk of developing treatment-emergent psychiatric adverse effects of AEDs independently of the specific mechanism of action of the drug. The prior history of suicide attempt, especially preceding the onset of the epilepsy, may represent a key element explaining why what is observed is independent of the specific mechanism of the drug. In general terms, risks associated with stopping, or not even starting, AEDs in epilepsy might well be in excess of the risk of suicide in epilepsy, as deaths due to accident and epilepsy itself may predominate. Clinicians need to pay attention not only to seizure patterns when choosing the appropriate AED but also to a number of different parameters (eg, age, gender, working needs, medical comorbidities, history of psychiatric disorders, and suicidality before epilepsy onset) and not the least the mental state of the patient. Missing severe complications such as suicidal behavior or delaying its treatment may worsen the prognosis of epilepsy.
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Affiliation(s)
- Marco Mula
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University and Division of Neurology, University Hospital Maggiore della Carità, Novara, Italy
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Abstract
PURPOSE OF REVIEW The risk of suicide is thought be increased in epilepsy. Antiepileptic drugs (AEDs) remain the primary treatment. An FDA alert in 2008 raised concerns that AEDs may increase the risk of suicidal thoughts and behaviour. The risk profile for suicide in epilepsy is examined in the context of recent reports investigating the risk of suicide and the reported association between AEDs and risk of suicide. RECENT FINDINGS Following a diagnosis of epilepsy the risk of completed suicide is increased (standardized mortality ratio 2-3.5); although the causes remain poorly understood, co-morbid depression and the first 6 months after epilepsy surgery seem to be particular risk factors. The evidence for AEDs increasing risk for suicide remains mixed and is based on retrospective data. SUMMARY The identification of risk factors such as mood or anxiety disorders in patients with epilepsy should not delay AED treatment as the risks associated with seizures far outweigh the current research evidence for increased AED-related suicide risk. A pragmatic approach to clinical assessment and management is suggested. Prospective AED trials should include validated scales to systematically identify neuropsychiatric complications of AEDs.
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Celano CM, Freudenreich O, Fernandez-Robles C, Stern TA, Caro MA, Huffman JC. Depressogenic effects of medications: a review. DIALOGUES IN CLINICAL NEUROSCIENCE 2011. [PMID: 21485751 PMCID: PMC3181967 DOI: 10.31887/dcns.2011.13.1/ccelano] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The literature is filled with reports that link medications with the onset or progression of depression. Because depression is so common in patients with medical illness, assessing whether a medication has in fact caused depression, or whether the relationship is coincidental, can be challenging. In this article, we review the literature on the association between medications and depression. For most agents, there are case reports or small studies linking the medication with the onset of depression, but more rigorous prospective studies are either lacking or found no association between the agent and depression. However, several medications, (eg, barbiturates, vigabatrin, topiramate, flunarizine, corticosteroids, mefloquine, efavirenz, and interferon-α) do appear to cause depression in some patients and should be used with caution in patients at risk for depression.
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Abstract
Selecting an antiepileptic drug (AED) for treatment of seizures is daunting because there are now 20 from which to choose. Following simple principles allows a systematic approach to drug selection. Efficacy studies provide limited information. For initial monotherapy of partial seizures, high-level evidence exists for the efficacy of lamotrigine, carbamazepine, oxcarbazepine, and topiramate. For initial monotherapy of generalized seizures, high-level evidence is available for valproate, lamotrigine, topiramate, and oxcarbazepine. For initial monotherapy of absence seizures, high-level evidence exists for valproate, lamotrigine, and ethosaximide. All second-generation AEDs have efficacy as adjunctive therapy for partial seizures. AEDs are often useful for comorbid conditions or have properties that should be avoided in some groups. Thus, AEDs should usually be selected on the basis of comorbid conditions, including depression, migraine, chronic pain, obesity, and nephrolithiasis, or patient characteristics, especially for women of childbearing potential and older adults.
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Phabphal K, Udomratn P. Topiramate-induced depression in cases using topiramate for migraine prophylaxis. Cephalalgia 2009; 30:747-9. [DOI: 10.1111/j.1468-2982.2009.01946.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- K Phabphal
- Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Pichet Udomratn
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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46
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Kanner AM. Can antiepileptic drugs unmask a susceptibility to psychiatric disorders? Nat Rev Neurol 2009; 5:132-3. [DOI: 10.1038/ncpneuro1051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 01/21/2009] [Indexed: 11/09/2022]
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