Prevalence of interictal psychiatric disorders in patients with refractory temporal and extratemporal lobe epilepsy in Spain. A comparative study

Psychosis and schizophrenia among patients with epilepsy: A systematic review and meta-analysis

BACKGROUND

Prior research has indicated an association between epilepsy and psychosis. This review aimed to estimate the global prevalence rate of psychosis and schizophrenia in epilepsy and assess the odds of psychosis and schizophrenia among patients with epilepsy (PWE).

METHOD

A comprehensive literature search was carried out utilizing relevant keywords in PubMed/MEDLINE and Scopus, covering from January 1, 1990, to November 18, 2023. The meta-analysis was performed using R software employing a random-effect model to establish the overall prevalence and odds ratio (OR), with 95 % confidence intervals (95 % CI), of psychosis and schizophrenia in epilepsy.

RESULT

Eighty-one studies encompassing 970,497 PWE met the inclusion criteria. The meta-analysis revealed that the overall prevalence of psychosis and schizophrenia among PWE was 7.8 % (95 % CI: 6.3-9.2 %, I2 = 100 %) and 3 % (95 % CI: 1.7-4.3 %, I2 = 95 %), respectively. Moreover, epilepsy was associated with a threefold rise in the odds of psychosis (OR = 3.41, 95 % CI: 2.3-5.08, p-value < 0.01, I2 = 99 %, p-heterogeneity < 0.01). Furthermore, epilepsy was found to be significantly correlated with a fivefold increased odds of schizophrenia (OR = 5.22, 95 % CI: 2.99-9.11, p-value < 0.01, I2 = 94 %, p-heterogeneity < 0.01) CONCLUSION: Epilepsy can increase the risk of developing psychosis and schizophrenia. Additional longitudinal research is warranted to elucidate the influence of epilepsy and its treatments on the risk of psychosis and schizophrenia, and also a comprehensive suite of confounding adjustments will be requisite.

Effects of Psychiatric Comorbidities on the Prognosis of New-Onset Pediatric Epilepsy: A Retrospective Nationwide Cohort Study

Background/Objectives: To determine the impact of psychiatric disorders on epilepsy treatment outcomes and healthcare utilization in children with epilepsy (CWE) based on the presence or timing of the onset of psychiatric disorders. Methods: This retrospective controlled study enrolled children (age < 18 years) with newly diagnosed epilepsy into four groups stratified by the presence and timing of the onset of psychiatric disorders (None: no psychiatric disorders; Before: psychiatric disorders only preceding the epilepsy diagnosis; After: new psychiatric disorders diagnosed only after the epilepsy diagnosis; Mixed: different psychiatric disorders diagnosed both before and after epilepsy diagnosis) and compared the intergroup differences in epilepsy treatment outcomes and healthcare utilization. Results: Among the CWE (n = 37,678), 13,285 (35.26%) had comorbid psychiatric disorders. The After (n = 7892), Mixed (n = 3105), and Before (n = 2288) groups had significantly longer treatment periods than those in the None group (p < 0.001). Compared with the None group, the remaining groups had significantly higher frequencies of outpatient visits, emergency room visits, and admissions and higher rates of status epilepticus and drug-resistant epilepsy (p < 0.001, respectively), with higher odds ratios [95% confidence interval] for status epilepticus (2.92 [2.68-3.18]) and drug-resistant epilepsy (3.01 [2.85-3.17]) in the After group. Conclusions: Psychiatric comorbidities, diagnosed before and after epilepsy diagnosis, negatively affected the treatment outcomes. CWE without prior psychiatric disorders that were newly diagnosed during epilepsy treatment had the worst outcomes and the highest healthcare utilization rates.

Psychiatric and psychological assessment of patients with drug-resistant epilepsy and psychogenic nonepileptic seizures (PNES) with no response to previous treatments

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are common imitators of epileptic seizures. Refractoriness to antiseizure medication hinders the differential diagnosis between ES and PNES, carrying deleterious consequences in patients with PNES. Psychiatric and psychological characteristics may assist in the differential diagnosis between drug-resistant epilepsy (DRE) and PNES. Nevertheless, current comprehensive psychiatric and psychological descriptive studies on both patient groups are scarce and with several study limitations. This study provides a comprehensive psychiatric and psychological characterization of Spanish patients with DRE and PNES.

METHOD

A cross-sectional and comparative study was completed with 104 patients with DRE and 21 with PNES. Psychiatric and psychological characteristics were assessed with the HADS, SCL-90-R, NEO-FFI-R, PDQ-4+, COPE, and QOLIE-31 tests. Parametric and non-parametric tests were used, and regression models were fit to further explore factors affecting patients' life quality.

RESULTS

Patients with PNES had greater levels of somatization and extraversion and were associated with benzodiazepine intake. Patients with DRE showed greater narcissistic personality disorder symptoms than those with PNES. In patients with DRE, difficulty in performing basic needs-related tasks and greater psychological distress severity and seizure frequency were associated with poorer life quality. In contrast, being a woman, having a psychiatric disorder history, and greater psychiatric symptoms' intensity were associated with poorer life quality in patients with PNES.

CONCLUSION

Patients with DRE and PNES share similar psychiatric and psychological characteristics, with only very few being significantly different.

Contribution of the μ-opioid receptor system to affective disorders in temporal lobe epilepsy: A bidirectional relationship?

OBJECTIVE

Affective disorders are frequent comorbidities of temporal lobe epilepsy (TLE). The endogenous opioid system has been implicated in both epilepsy and affective disorders, and may play a significant role in their bidirectional relationship. In this cross-sectional study, we investigated the association between μ-opioid receptor binding and affective disorders in patients with TLE.

METHODS

Nine patients with TLE and depression/anxiety underwent ¹¹ C-carfentanil positron emission tomography (CFN PET) and neuropsychiatric assessment, including the Hospital Anxiety and Depression Scale and the Positive and Negative Affect Schedule. The normalized CFN PET scans were compared with those of 26 age-matched healthy controls. Correlation analyses with affective symptoms were performed by region of interest-based analysis focusing on the limbic circuit and orbitofrontal cortex.

RESULTS

We observed widely reduced CFN binding potential (BP) in bilateral frontal lobes and striata in patients with TLE compared to healthy controls. In the TLE group, more severe anxiety and negative affect were associated with decreased CFN BP in the posterior cingulate gyrus.

SIGNIFICANCE

In patients with TLE, interictally reduced binding in the opioid system was associated with higher levels of anxiety and negative affect. We speculate that seizure-related agonist-driven desensitization and downregulation of opioid receptors could be a potential underlying pathomechanism.

Mood Disturbances, Anxiety, and Impact on Quality of Life in Patients Admitted to Epilepsy Monitoring Units

Introduction: The overall combined prevalence of anxiety and depression in patients with epilepsy has been estimated at 20.2 and 22.9%, respectively, and is considered more severe in drug-refractory epilepsy. Patients admitted to epilepsy monitoring units constitute a particular group. Also, patients with psychogenic non-epileptic seizures can reach more than 20% of all admissions. This study aims to characterize these symptoms in a large cohort of patients admitted for evaluation in a tertiary epilepsy center.

Materials and Methods: The study was conducted among 493 consecutive patients (age: 38.78 ± 12.7, 57% females) admitted for long-term video EEG from January 2013 to February 2021. Demographic, clinical, and mood disorder patients' data were collected. Anxiety and depression symptoms were assessed through the Hospital Anxiety Depression Scale (HADS-A and HADS-D), the State Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI-II). Quality of life was determined using the QOLIE-10. Patients were divided into three groups: patients with epilepsy (n = 395), psychogenic non-epileptic seizures (PNES) (n = 56), and combined (n = 33). A univariate and multivariate regression analysis was performed for variables associated with quality of life.

Results: Of 493 patients, 45.0% had structural etiology, and considering epilepsy classification, 43.6% were of temporal lobe origin. In addition, 32.45% of patients had a previous psychiatric history, 49.9% of patients had depressive symptoms in BDI, and 30.9% according to HADS-D; 56.42 and 52.63% of patients presented pathological anxiety scores in STAI-T and STAI-S, respectively; and 44.78% according to HADS-A. PNES and combined groups revealed a higher incidence of pathologic BDI scores (64.29 and 78.79%, p < 0.001) as well as pathologic HADS-A scores (p = 0.001). Anxiety and depression pathologic results are more prevalent in females, HADS-A (females = 50.7%, males = 36.8%; p = 0.0027) and BDI > 13 (females = 56.6%, males = 41.0%; p = 0.0006). QOLIE-10 showed that 71% of the patients had their quality of life affected with significantly higher scores in the combined group than in the epilepsy and PNES groups (p = 0.0015).

Conclusions: Subjective anxiety, depression, and reduced quality of life are highly prevalent in patients with refractory epilepsy. These symptoms are more evident when PNES are associated with epilepsy and more severe among female patients. Most of the cases were not previously diagnosed. These factors should be considered in everyday clinical practice, and specific approaches might be adapted depending on the patient's profile.

Predictive factors of quality of life in temporal and extratemporal lobe epilepsy: association with affective temperament profiles and psychiatric comorbidities

BACKGROUND

Investigating predictive factors of reduced quality of life (QOL) of patients and their association with focal epilepsy can improve management and treatment strategies.

OBJECTIVE

This study aimed to investigate the relationship between affective temperaments, depression, anxiety, disease characteristics, and QOL and to explore the predictors of QOL in patients with temporal lobe epilepsy (TLE) and extratemporal lobe epilepsy (ETLE).

METHODS

A total of 50 patients with TLE, 51 patients with ETLE, and 70 controls were enrolled. Affective temperaments were evaluated using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A). QOL was assessed by the Short-Form Health Survey (SF-36). Beck Depression Inventory and Beck Anxiety Inventory were used to explore depression and anxiety severity, respectively.

RESULTS

Compared with the controls, patients with TLE and ETLE had significantly higher scores on all TEMPS-A scales, except on hyperthymic temperament. All the SF-36 subscale scores were lower in the TLE and ETLE groups. Linear regression analysis revealed that depressive symptoms, anxiety, depressive and irritable temperament, and seizure frequency were significant predictors of QOL in TLE. Patients with ETLE with temperamental disturbances, depressive symptoms, and polytherapy had a poorer QOL.

CONCLUSIONS

Affective temperaments, psychiatric disorders, and clinical factors may predict impaired QOL in patients with TLE and ETLE. Further studies are needed to identify predictors of QOL in various epilepsy subtypes.

The relation of major depression, OCD, personality disorders and affective temperaments with Temporal lobe epilepsy

BACKGROUND

In patients with temporal lobe epilepsy (TLE), studies demonstrate frequent comorbidity with mood disorders, personality disorders (especially obsessive-compulsive disorder) and major depression, but there are conflicting findings. This study aimed to investigate psychiatric comorbidities and affective temperament among TLE patients and to explore the relationships between obsessive compulsive disorder, other personality disorders, major depression and affective temperament in order to clarify the mediator effect of TLE in these relationships.

METHODS

Thirty patients with TLE and 30 healthy volunteers were included. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II), Hamilton Anxiety (HAM-A) scale, Hamilton Depression (HAM-D) scale, Beck Suicidal Ideation Scale (BSSI) and Yale Brown Obsession Compulsion Scale (YBOCS) were applied and evaluated by a psychiatrist. Additionally, all individuals completed The Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A).

RESULTS

Patients with temporal lobe epilepsy had higher scores in TEMPS-A, HAM-A, HAM-D, YBOCS and BSSI. Major depression, obsessive compulsive disorder and dependent and antisocial personality disorders were prevalent in patients. With respect to affective temperaments, depressive, cyclothymic and anxious temperaments were associated with obsessive compulsive disorder comorbidity; whereas, depressive and anxious temperaments were found to be associated with major depression comorbidity in patients with TLE. Furthermore, cluster A and cluster C personality disorders were associated with affective temperaments in patients with TLE. Affective temperaments had no correlation with illness duration, seizure frequency, depression severity and suicidal thoughts, but obsessions and compulsions. Suicidal thoughts were associated with obsessions and compulsions.

CONCLUSION

Affective temperaments are core personality traits with biological background and they may provide a foundation for psychiatric disorders, especially mood disorders. Considering that TLE originates from abnormalities in brain circuitry, it may form a basis for psychiatric disorders. Therefore, psychiatric evaluation to determine comorbidities may be beneficial to increase the quality of life of patients with TLE.

The effects of insular and mesiotemporal lesions on affective information processing: Preliminary evidence from patients with epilepsy surgery

Depressive symptoms and anxiety are common complaints in patients who have had epilepsy surgery. Recent studies have reported disturbances in emotional memory, facial and vocal emotion recognition, and affective learning after temporal lobe and/or insular resection for drug-resistant seizures, suggesting that these regions may be involved in emotional processes underlying psychological symptoms. The insula is a core component of the salience network and is thought to be involved in processing emotions such as disgust, and the role of mesial temporal lobe structures in affective processing is well established. However, to our knowledge, no study has yet investigated whether attentional processing of affective information is altered when these structures are resected as part of an epilepsy surgery. The present study examined the interference control capacity and attentional biases for emotional information in adult patients with epilepsy who underwent temporal lobe resections including the amygdala and hippocampus (n = 15) and/or partial or complete insular resections (n = 16). Patients were tested on an Emotional Stroop test and on a Dot-Probe task using fearful and disgusting pictures and were compared with a healthy control group (n = 30) matched for age, gender, and education. Repeated-measures analyses of variances revealed a significant effect of emotional words on color naming speed in the Emotional Stroop task among insular patients, which was not observed in the other groups. By contrast, the groups did not differ on Dot-Probe task performance. These preliminary findings suggest that insular damage may alter emotional interference control.

Neuropsychiatric Aspects of Epilepsy

This article reviews common and clinically important neuropsychiatric aspects of epilepsy. Comorbidities are common, underdiagnosed, and powerfully impact clinical outcomes. Biological, psychological, and social factors contribute to the associations between epilepsy and neuropsychiatric disorders. Epidemiologic studies point to a bidirectional relationships between epilepsy and neuropsychiatric disorders. People with epilepsy are more likely to develop certain neuropsychiatric disorders, and those with these disorders are more likely to develop epilepsy. This relationship suggests the possibility of shared underlying pathophysiologies. We review the neuropsychiatric impact of antiseizure medications and therapeutic options for treatment. Diagnosis and treatment involve close collaboration among a multidisciplinary team.

Comparison of psychiatric comorbidities and impact on quality of life in patients with epilepsy or psychogenic nonepileptic spells

OBJECTIVES

Psychiatric comorbidity is common in people with epilepsy (PWE) and psychogenic nonepileptic spells (PNES). These comorbidities can be detrimental to quality of life (QOL) and are often underdiagnosed and undertreated. Some types of epilepsy, such as focal temporal lobe epilepsy (TLE), have been associated with higher rates of psychiatric comorbidity. This study examined the impact of psychiatric comorbidity on QOL in patients admitted to two level 4 epilepsy monitoring units (EMUs).

METHODS

In this prospective observational study, 200 patients admitted to two level 4 EMUs completed standardized surveys including the Quality of Life in Epilepsy (QOLIE-31-P), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory-II (BDI-II). Hierarchal multiple regression was performed to assess impact on QOL.

RESULTS

Of the 200 participants, 113 had a diagnosis of epilepsy, 36 had a diagnosis of PNES, and 51 were excluded for nondiagnostic evaluation or dual diagnosis. Of those with epilepsy, 65 had TLE, 28 had focal extratemporal lobe epilepsy (ETLE), and 20 had nonfocal epilepsy. Patients with PNES had higher self-reported anxiety and depression levels (GAD-7: p = 0.04, PHQ-9: p < 0.01; BDI-II: p < 0.01) but similar QOL to PWE (p = 0.78). Using hierarchal multiple regression, symptoms of anxiety and depression were significant predictors of lower QOL in PWE but not in patients with PNES. There was no difference in QOL in those with ETLE and TLE.

CONCLUSIONS

Our findings suggest that self-reported anxiety and depression symptoms are common in patients admitted to level 4 EMUs regardless of diagnosis and play an important role in predicting QOL in PWE. Our findings emphasize the importance of routinely screening all EMU patients for psychiatric comorbidity.

Mechanisms of Psychiatric Comorbidities in Epilepsy

Psychiatric illnesses, including depression and anxiety, are highly comorbid with epilepsy (for review see Josephson and Jetté (Int Rev Psychiatry 29:409-424, 2017), Salpekar and Mula (Epilepsy Behav 98:293-297, 2019)). Psychiatric comorbidities negatively impact the quality of life of patients (Johnson et al., Epilepsia 45:544-550, 2004; Cramer et al., Epilepsy Behav 4:515-521, 2003) and present a significant challenge to treating patients with epilepsy (Hitiris et al., Epilepsy Res 75:192-196, 2007; Petrovski et al., Neurology 75:1015-1021, 2010; Fazel et al., Lancet 382:1646-1654, 2013) (for review see Kanner (Seizure 49:79-82, 2017)). It has long been acknowledged that there is an association between psychiatric illnesses and epilepsy. Hippocrates, in the fourth-fifth century B.C., considered epilepsy and melancholia to be closely related in which he writes that "melancholics ordinarily become epileptics, and epileptics, melancholics" (Lewis, J Ment Sci 80:1-42, 1934). The Babylonians also recognized the frequency of psychosis in patients with epilepsy (Reynolds and Kinnier Wilson, Epilepsia 49:1488-1490, 2008). Despite the fact that the relationship between psychiatric comorbidities and epilepsy has been recognized for thousands of years, psychiatric illnesses in people with epilepsy still commonly go undiagnosed and untreated (Hermann et al., Epilepsia 41(Suppl 2):S31-S41, 2000) and systematic research in this area is still lacking (Devinsky, Epilepsy Behav 4(Suppl 4):S2-S10, 2003). Thus, although it is clear that these are not new issues, there is a need for improvements in the screening and management of patients with psychiatric comorbidities in epilepsy (Lopez et al., Epilepsy Behav 98:302-305, 2019) and progress is needed to understand the underlying neurobiology contributing to these comorbid conditions. To that end, this chapter will raise awareness regarding the scope of the problem as it relates to comorbid psychiatric illnesses and epilepsy and review our current understanding of the potential mechanisms contributing to these comorbidities, focusing on both basic science and clinical research findings.

Anxiety disorders in predominantly African American and Caribbean American adults with intractable epilepsy: The role of perceived epilepsy stigma

INTRODUCTION

Anxiety disproportionately affects people with epilepsy (PWE) and leads to poor outcomes. Yet, risk factors are not well understood especially among underserved groups. This cross-sectional study aimed to identify epilepsy-specific predictors of anxiety disorders in predominantly African American and Caribbean American PWE.

MATERIALS AND METHODS

The prevalence of anxiety disorders was established via diagnostic interview (Mini-International Neuropsychiatric Interview (MINI)). We identified the extent to which aspects of seizure burden (seizure frequency, seizure severity, convulsive vs. nonconvulsive seizures), seizure worry, and perceived epilepsy stigma were associated with anxiety disorder diagnosis. Finally, logistic regression assessed the overall and independent contributions of significant risk factors.

RESULTS

There were 60 participants (62% women, 52% African American, 27% Caribbean American, 20% Hispanic/Latino) with an average of 2 seizures per month. Nearly half of the sample (43%) had ≥1 anxiety disorder, with 62% of affected individuals qualifying for agoraphobia. Those with anxiety disorders tended to have convulsive seizures (p = 0.037) and endorsed greater seizure worry (p = 0.012), more general symptoms of anxiety (p = 0.005), and worse perceived epilepsy stigma (p = 0.003). Logistic regression accounted for 28% to 37.6% of the variance in anxiety disorder diagnostic status and correctly classified 73% of cases; however, only perceived epilepsy stigma made a unique contribution.

CONCLUSIONS

Anxiety disorders were prevalent in these predominantly African American and Caribbean American PWE. Epilepsy-specific risk factors included convulsive seizures, seizure worry, and perceived epilepsy stigma. Interventions aimed at treating anxiety disorders in diverse PWE may especially benefit from targeting stigma beliefs.

Association between seizure freedom and default mode network reorganization in patients with unilateral temporal lobe epilepsy

RATIONALE

The spontaneous synchronized activity and intrinsic organization of the Default Mode Network (DMN) has been found to be altered because of epileptic activity of temporal lobe origin. Thus, the aim of the present study was to compare DMN's topological properties in patients with seizure-free (SF) and not seizure-free (NSF) temporal lobe epilepsy (TLE).

METHODS

Functional connectivity within the DMN was determined from an 8-minute resting state functional magnetic resonance imaging (fMRI) in 27 patients with TLE (12 SF, 15 NSF) and 15 healthy controls (HC). The DMN regions of interest were extracted according to the automated anatomical labeling (AAL) atlas. Network properties were assessed using standard graph-theoretical measures.

RESULTS

Analyses revealed, irrespectively of focus lateralization, borderline significance for longer paths (p = 0.049) and in trend reduced local efficiency within the DMN of SF when compared with that of NSF (p = 0.075). The SF and NSF patients did not differ in global network topology from HC (p > 0.05). At the nodal network level, the degree of central hubs was significantly reduced in SF when compared with that in NSF (0.002 ≤ p ≤ 0.080) and HC (0.001 ≤ p ≤ 0.066) while simultaneously, right anterior superior temporal gyrus revealed significantly higher degree in SF than in NSF (p = 0.005) and HC (p = 0.016).

CONCLUSION

Seizure freedom seems to be associated with hub redistributions that may underlie longer paths and (in trend) reduced local efficiency of the network. An associated slower system response might reduce the probability of a rapid spread of epileptic discharges over the whole network and may help to prevent hypersynchronous neuronal activity in brain networks that may result in epileptic seizures.

Depressive disorders in patients with pharmaco-resistant mesial temporal lobe epilepsy

Objectives To assess depressive disorders in patients with mesial temporal lobe epilepsy (MTLE) refractory to medical treatment. Methods Adult patients with refractory MTLE completed two questionnaires (Mini International Neuropsychiatric Interview (MINI) and the Beck Depression Inventory (BDI) had a semi-structured psychiatric interview and a high resolution MRI scan. For complete neuropsychiatric diagnosis, as per International Classification of Diseases (ICD-10), the results were combined with clinical history and additional information from the patients' family. Results Of the 40 patients identified for this case series study which took place from 2008-2012, 31 (77.5%) had a depressive disorder: 14 had dysthymia, 11 had recurrent depressive disorder and 6 had bipolar disorder. Of the nine patients without a firm diagnosis of mood disorder, seven had isolated symptoms of depression or anxiety and two presented with mixed depression/anxiety symptoms. Only 8/31 (25.8%) patients were receiving antidepressant treatment. There was no association between BDI scores and seizure frequency. No significant difference was found between patients with and without depression and the presence or laterality of HA. Conclusions Depressive disorders are common, underdiagnosed and undertreated in patients with refractory MTLE.

Anxiety and depressive disorders in people with epilepsy: A meta-analysis

OBJECTIVE

Comorbid anxiety and depressive disorders in people with epilepsy (PWE) are highly prevalent and associated with various adverse outcomes. However, the prevalence of anxiety disorders in PWE across studies is highly variable. Our aim was to estimate the prevalence and moderating factors of anxiety and depressive disorders in PWE.

METHODS

Following prospective registration (PROSPERO; CRD42015027101), electronic databases were searched for studies that reported the prevalence of both anxiety and depressive disorders in samples of PWE up until July 2016. Data extracted included the prevalence of anxiety and depressive disorders, and moderators of interest (e.g., method of diagnosis, prevalence of drug-resistant epilepsy). Meta-analysis of the overall pooled prevalence of anxiety and depressive disorders was conducted.

RESULTS

The search yielded 8,636 unique articles, with 27 studies meeting final inclusion criteria (3,221 PWE). The pooled prevalence of anxiety and depressive disorders was 20.2% (95% confidence interval [CI] 15.3-26.0%) and 22.9% (95% CI 18.2-28.4%), respectively. Method of diagnosis significantly moderated anxiety disorder prevalence (Q statistic with one degree of freedom [Q₁ ] = 36.29, p < 0.0001); the prevalence of anxiety disorders based on unstructured clinician assessment was 8.1% (95% CI 5.7-11.4%), compared to a prevalence of 27.3% (95% CI 22.1-33.3%) based on a structured clinical interview. There were no significant moderators of depressive disorder diagnosis.

SIGNIFICANCE

Findings suggest the prevalence of anxiety and depressive disorders in PWE are equivalent, and variability in prevalence of anxiety disorders across studies can be attributed partly to the method of diagnosis. These findings also challenge widely held assumptions that psychiatric comorbidity is more common in people with drug-resistant epilepsy. Future research should aim to improve the detection and management of these comorbidities in PWE, particularly anxiety disorders, which have remained relatively neglected.

Psychiatric symptoms after temporal epilepsy surgery. A one-year follow-up study

Psychiatric symptoms must be considered in patients with refractory temporal lobe epilepsy after epilepsy surgery. The main objectives of our study were to describe clinical and socio-demographical characteristics of a cohort of patients with pharmacoresistant temporal lobe epilepsy who underwent temporal lobe epilepsy surgery, and moreover, to evaluate possible risk factors for developing psychiatric symptoms. In order to achieve those goals, we conducted a prospective evaluation of psychopathology throughout the first year after surgery in a clinical sample of 72 patients, by means of three clinical rated measures; the Hamilton Anxiety Rating Scale (HARS), the Hamilton Depression Rating Scale (HDRS), and the Brief Psychiatric Rating Scale (BPRS). The psychopathological evaluations were performed by an experienced psychiatrist. A presurgical evaluation was done by a multidisciplinary team (that includes neurologist, psychiatrist, neurosurgeon, neurophysiologist, radiologists, and nuclear medicine specialist) in all patients. The decision to proceed to surgery was taken after a surgical meeting of all members of the Multidisciplinary Epilepsy Unit team. The psychiatrist conducted two postoperative assessments at 6months and 12months after surgery. The main finding was that past history of mental illness (patients who were receiving psychiatric treatment prior to the baseline evaluation) was a risk factor for anxiety, depression, and psychosis after temporal lobe epilepsy surgery.

The Diathesis-Epilepsy Model: How Past Events Impact the Development of Epilepsy and Comorbidities

In epilepsy, seizures and comorbidities (e.g., cognitive deficits and depression) occur when specific thresholds are crossed. These thresholds depend on the diathesis (or vulnerability) of a given individual. The diathesis is controlled by multiple genetic and environmental factors. Diathesis changes over multiple timescales: on a daily basis, and as part of the development/aging processes, etc. The diathesis-epilepsy model introduced here provides a conceptual framework to understand how past events (e.g., a very stressful event) can directly influence the occurrence of epilepsy and comorbidities later in life. Experimental evidence supports this model, and the existence of biomarkers predictive of a vulnerability state have led to the development of preventive therapeutic strategies. Epigenetic modifications could be a key determinant of diathesis. Their role is discussed.

Familial epilepsy in Algeria: Clinical features and inheritance profiles

PURPOSE

To document the clinical characteristics and inheritance pattern of epilepsy in multigeneration Algerian families.

METHODS

Affected members from extended families with familial epilepsy were assessed at the University Hospital of Oran in Algeria. Available medical records, neurological examination, electroencephalography and imaging data were reviewed. The epilepsy type was classified according to the criteria of the International League Against Epilepsy and modes of inheritance were deduced from pedigree analysis.

RESULTS

The study population included 40 probands; 23 male (57.5%) and 17 female subjects (42.5%). The mean age of seizure onset was 9.5 ± 6.1 years. According to seizure onset, 16 patients (40%) had focal seizures and 20 (50%) had generalized seizures. Seizure control was achieved for two patients (5%) for 10 years, while 28 (70%) were seizure-free for 3 months. Eleven patients (27.5%) had prior febrile seizures, 12 were diagnosed with psychiatric disorders and four families had syndromic epilepsy. The consanguinity rate among parents of affected was 50% with phenotypic concordance observed in 25 families (62.5%). Pedigree analysis suggested autosomal dominant (AD) inheritance with or without reduced penetrance in 18 families (45%), probable autosomal recessive (AR) inheritance in 14 families (35%), and an X-linked recessive inheritance in one family.

CONCLUSION

This study reveals large Algerian families with multigenerational inheritance of epilepsy. Molecular testing such as exome sequencing would clarify the genetic basis of epilepsy in some of our families.

Predicting and treating stress-induced vulnerability to epilepsy and depression

Accumulation of stressful events can render individuals susceptible to develop epilepsy and comorbidities. Whether such vulnerability can be predicted and reversed is not known. Here we show that social defeat, although not producing depression by itself, produced in 50% of rats reduced threshold for status epilepticus (SE), accelerated epileptogenesis, and once epilepsy was induced, depression-like profile and cognitive deficits. Low serum brain-derived neurotrophic factor (BDNF) levels measured before SE identified this vulnerable population. Treatment with a BDNF analog before SE prevented the occurrence of comorbidities. Thus, vulnerability to comorbidities after epilepsy onset due to unresolved past stressful events may be predicted and reversed.

Measurement Invariance of the Experiences in Close Relationships Questionnaire across Different Populations

The measurement invariance of the Experiences in Close Relationships (ECR) questionnaire was investigated across four samples of non-clinical subjects (N = 222), dermatological patients (N = 458), psychiatric inpatients (N = 156), and patients with drug-resistant epilepsy (N = 101). The results provided evidence of configural, metric, and scalar invariance across groups. Overall, our findings provide further support to the reliability and validity of the ECR.

The prevalence of psychosis in epilepsy; a systematic review and meta-analysis

BACKGROUND

Epilepsy has long been considered to be a risk factor for psychosis. However there is a lack of consistency in findings across studies on the effect size of this risk which reflects methodological differences in studies and changing diagnostic classifications within neurology and psychiatry. The aim of this study was to assess the prevalence of psychosis in epilepsy and to estimate the risk of psychosis among individuals with epilepsy compared with controls.

METHODS

A systematic review and meta-analysis was conducted of all published literature pertaining to prevalence rates of psychosis in epilepsy using electronic databases PUBMED, OVIDMEDLINE, PsychINFO and Embase from their inception until September 2010 with the following search terms: prevalence, incidence, rate, rates, psychosis, schizophrenia, schizophreniform illness, epilepsy, seizures, temporal lobe epilepsy.

RESULTS

The literature search and search of reference lists yielded 215 papers. Of these, 58 (27%) had data relevant to the review and 157 were excluded following a more detailed assessment. 10% of the included studies were population based studies. The pooled odds ratio for risk of psychosis among people with epilepsy compared with controls was 7.8. The pooled estimate of prevalence of psychosis in epilepsy was found to be 5.6% (95% CI: 4.8-6.4). There was a high level of heterogeneity. The prevalence of psychosis in temporal lobe epilepsy was 7% (95% CI: 4.9-9.1). The prevalence of interictal psychosis in epilepsy was 5.2% (95% CI: 3.3-7.2). The prevalence of postictal psychosis in epilepsy was 2% (95% CI: 1.2-2.8).

CONCLUSIONS

Our systematic review found that up to 6% of individuals with epilepsy have a co-morbid psychotic illness and that patients have an almost eight fold increased risk of psychosis. The prevalence rate of psychosis is higher in temporal lobe epilepsy (7%). We suggest that further investigation of this association could give clues to the aetiology of psychosis.

Psychiatric symptoms in children prior to epilepsy surgery differ according to suspected seizure focus

PURPOSE

Children and adolescents with epilepsy have an overrepresentation of psychiatric illness. However, few studies in pediatrics have characterized specific psychiatric conditions associated with seizure localization. In addition, degree to which psychiatric illness may be more prominent in children refractory to standard medical treatment for epilepsy is not known. The aim of this study was to assess psychiatric symptoms in children with medically refractory epilepsy and ascertain whether symptoms were associated with specific localization.

METHODS

Case records were reviewed for 40 children with medically refractory epilepsy at the time of their referral for presurgical evaluation. Patients received a clinical psychiatric evaluation and parents completed the Child Behavioral Checklist (CBCL). Seizure localization was verified by pediatric epileptologists, and suitability for surgical procedures was verified by neurosurgical specialists. Groups were compared based on localization of seizure foci, either in the temporal lobe or predominantly extratemporal.

KEY FINDINGS

The majority of the sample had psychiatric diagnoses and behavior problems, well beyond the level reported in chronic epilepsy populations. In addition, children with temporal lobe seizure foci had more CBCL behavioral problem categories rated in the clinically significant range, and also were more likely to have clinical diagnoses of depression.

SIGNIFICANCE

Routine psychiatric evaluation prior to epilepsy surgery may be important for pediatric patients with medically refractory epilepsy. Psychiatric illness, particularly depression, may be especially prominent for those with temporal lobe seizure foci.

Rates of DSM-IV mood, anxiety disorders, and suicidality in Australian adult epilepsy outpatients: a comparison of well-controlled versus refractory epilepsy

Despite recent research into the impact of seizure control on mood disorders in epilepsy, it is often assumed that rates of psychiatric disorders are higher in people with refractory rather than well-controlled epilepsy. We assessed the point prevalence of mood and anxiety disorders and suicide risk using the Mini International Neuropsychiatric Interview (MINI) in a consecutive sample of epilepsy outpatients from a tertiary referral center. One hundred and thirty patients, whose epilepsy was categorized as well-controlled versus drug-treatment-refractory epilepsy (69; 53% well-controlled epilepsy) were recruited. High rates of mood disorders (n = 34; 26%), anxiety disorders (n = 37; 29%) and suicide risk (n = 43; 33%) were found. However, there was no difference in rates of disorders or suicide risk for those with refractory versus well-controlled epilepsy. These results underscore the importance of assessment and management of psychopathology in all people with epilepsy, regardless of their seizure control.

Depression in patients with refractory temporal lobe epilepsy

OBJECTIVE

To evaluate the comorbidity of depressive disorders in patients with refractory temporal lobe epilepsy (TLE).

METHOD

We evaluated 25 consecutive patients with refractory TLE (16 women and 9 men), using semi-structured psychiatric interviews, according to the International Classification of Diseases (ICD-10), and the Beck Depression Inventory.

RESULTS

Seventeen of 25 patients (68%) had depressive disorder: 6 with dysthymia, three with major depressive episodes and 8 with recurrent depressive disorders. Two (8%) were diagnosed with mixed anxiety and depression. Only 5 of 17 patients (29.4%) were previously diagnosed with depressive disorder and received prior antidepressant treatment. Duration of epilepsy was significantly higher in patients with depressive disorder (p=0.016), but there was no relationship between depression and seizure frequency.

CONCLUSION

This study confirmed that depressive disorders are common and underdiagnosed in patients with TLE refractory to AEDs. Patients with longer duration of epilepsy are at higher risk of having depression.

Is major depressive disorder specifically associated with mesial temporal sclerosis?

PURPOSE

Whether a specific lesion such as mesial temporal sclerosis (MTS) increases the risk for a mood disorder in epilepsy remains subject to debate. Despite evidence of limbic system involvement in the genesis of emotional symptoms, recent studies fail to support an association between depression and MTS. We aimed to clarify this controversial issue by overcoming prior methodologic limitations, hypothesizing that rates of major depressive disorder (MDD) would be higher in patients with MTS.

METHODS

Three hundred eight patients with focal epilepsy (International League Against Epilepsy [ILAE] criteria), were classified into three groups on the basis of neuroimaging findings: MTS, a lesion different from MTS, or absence of lesion. Patients were assessed using the Structured Interview for DSM-IV axis I psychiatric disorders (SCID-I), by a psychiatrist blinded to epilepsy subtype. The Spanish version of the Hospital Anxiety and Depression Scale (HADS) was also administered. A complete logistic regression analysis was performed to investigate the association between MTS and MDD.

KEY FINDINGS

MTS increased the likelihood of a lifetime MDD by nearly 2.5. No other current or "postseizure onset" lifetime Axis I DSM-IV psychiatric disorder was associated with MTS. Female gender, primary education, comorbid anxiety disorders, and antidepressant treatment were also associated with an increased risk of MDD. Marriage was found to be a protective factor for MDD.

SIGNIFICANCE

Our results support a specific association between MTS and lifetime "postseizure onset," MDD. The lack of association with current depression is in line with the hypothesis that the link between MTS and depression is more of a chronic than a state-dependent condition.

Cognitive-behavioral therapy for depression in patients with temporal lobe epilepsy: a pilot study

Depression has a high prevalence among patients with temporal lobe epilepsy (TLE). A pilot study was carried out to evaluate group cognitive-behavioral therapy (CBT) as a treatment for depression in patients with TLE. Twenty-three outpatients with TLE and major depressive disorder, according to DSM-IV criteria, were enrolled and divided into two groups to receive 16 weekly sessions of CBT. The primary outcome measures were depression severity (assessed with the Beck Depression Inventory) and quality of life (measured with the Quality of Life in Epilepsy-31). Sixteen patients (70%) completed at least 80% of the sessions. From week 8, CBT had a significant positive effect on severity of depression that lasted until the end of treatment. A significant improvement in quality of life was also observed. CBT seems to be a useful intervention for treating depression and improving quality of life in patients with TLE.

Depression in temporal lobe epilepsy: a review of prevalence, clinical features, and management considerations

Depression in temporal lobe epilepsy has been established as a frequent occurrence, and various possible mechanisms for this significant comorbidity have been posited. However, there is still little to guide a clinician in the recognition and management of depression in patients with temporal lobe epilepsy. This is in part due to the lack of consistent findings in earlier studies, which was likely partly due to variabilities in methodology, sampling, and diagnosis of both temporal lobe epilepsy and depression. However, in recent years, significant effort has been made to address these issues and provide a framework for diagnosis and management of depression in this population. The following is a review of the literature, with special emphasis on clinical phenomenology of depressive symptoms, described bidirectional risk between depression and temporal lobe epilepsy, and treatment strategies in the context of potential drug interactions with antiepileptic drugs.

Inventário de Depressão de Beck (BDI) e Escala de Avaliação de Depressão de Hamilton (HAM-D) em pacientes com epilepsia

OBJETIVO: Determinar os pontos de melhor sensibilidade e especificidade do Inventário de Depressão de Beck (BDI) e da Escala de Avaliação de Depressão de Hamilton (HAM-D) no diagnóstico de depressão associada à epilepsia. MÉTODOS: Setenta e três pacientes de um centro de referência no tratamento da epilepsia foram submetidos à avaliação neuropsiquiátrica. Foram colhidos dados clínicos e sociodemográficos, sendo utilizados os seguintes instrumentos: entrevista clínica estruturada (MINI-PLUS) para diagnóstico psiquiátrico conforme o DSM-IV, HAM-D e BDI. RESULTADOS: No momento da entrevista, 27,4% dos pacientes estavam deprimidos e 37% preenchiam critérios para diagnóstico de depressão maior ao longo da vida. A análise da curva ROC indicou que o ponto de corte em 16 (> 16) para o BDI (sensibilidade de 94,4%, especificidade de 90,6%) e em 16 (> 16) para a HAM-D (sensibilidade de 95%, especificidade de 75,5%) representou dicotomização ótima entre deprimidos e não deprimidos. Ambos os instrumentos apresentaram um valor preditivo negativo superior a 95%. CONCLUSÃO: A frequência de depressão maior é elevada em pacientes com epilepsia. BDI e a HAM-D podem auxiliar o clínico na identificação da depressão associada à epilepsia, diminuindo seu subdiagnóstico.