Prevalence of bipolar symptoms in epilepsy vs other chronic health disorders

Psychiatric implications of anti-seizure medications in epileptic population

BACKGROUND AND OBJECTIVE

Epilepsy is a prevalent neurological disorder that affects a significant number of individuals globally. This condition is associated with a high occurrence of psychiatric comorbidities, which can significantly affect the quality of life of individuals affected. The aim of this study was to investigate the association between antiseizure therapies and the likelihood of psychiatric comorbidities in individuals with epilepsy.

METHODOLOGY

Data for this study was gathered from the Neurology referral center in Islamabad, Pakistan. A standardized questionnaire was utilized to gather data from 120 individuals diagnosed with epilepsy. The survey consisted of inquiries regarding the management of seizures, the utilization of anti-seizure medications, and the presence of psychiatric comorbidities. The data was analyzed using the Statistical Package for the Social Sciences (SPSS).

RESULTS

The findings indicated that individuals who were using multiple antiseizure medications had a notably higher likelihood of having psychiatric comorbidities in comparison to those who were on mono therapy (p = 0.010). suggests that patients with unsuccessful seizure control are more probable to have psychiatric comorbidities as compared to those with good seizure control (p = 0.029).

CONCLUSION

To conclude poor seizure control and poly therapy are associated with increased risk of psychiatric comorbidities.

The metabolic overdrive hypothesis: hyperglycolysis and glutaminolysis in bipolar mania

Evidence from diverse areas of research including chronobiology, metabolomics and magnetic resonance spectroscopy indicate that energy dysregulation is a central feature of bipolar disorder pathophysiology. In this paper, we propose that mania represents a condition of heightened cerebral energy metabolism facilitated by hyperglycolysis and glutaminolysis. When oxidative glucose metabolism becomes impaired in the brain, neurons can utilize glutamate as an alternative substrate to generate energy through oxidative phosphorylation. Glycolysis in astrocytes fuels the formation of denovo glutamate, which can be used as a mitochondrial fuel source in neurons via transamination to alpha-ketoglutarate and subsequent reductive carboxylation to replenish tricarboxylic acid cycle intermediates. Upregulation of glycolysis and glutaminolysis in this manner causes the brain to enter a state of heightened metabolism and excitatory activity which we propose to underlie the subjective experience of mania. Under normal conditions, this mechanism serves an adaptive function to transiently upregulate brain metabolism in response to acute energy demand. However, when recruited in the long term to counteract impaired oxidative metabolism it may become a pathological process. In this article, we develop these ideas in detail, present supporting evidence and propose this as a novel avenue of investigation to understand the biological basis for mania.

The neuropsychological presentation of women with epilepsy: clinical considerations and future directions

Objective: Cognitive, mood, and behavioral changes are common among persons with epilepsy (PWE), resulting in a complex neuropsychological presentation. Women with epilepsy (WWE) represent a distinct cohort within the broader epilepsy population due to sex and gender-specific factors impacting epilepsy semiology and treatment. However, unique neuropsychological profiles among WWE have not been established. This narrative review aims to further define neuropsychological correlates in WWE and promote meaningful discussion related to enhancing the provision of neuropsychological care within this clinical population. Method: Current literature in PWE examining differences in cognitive function, mental health, and quality of life (QoL) between women and men was critically reviewed, emphasizing considerations for neuropsychological practice. Results: WWE demonstrate a preservation of verbal learning and memory compared to men both pre- and post-surgically, with sex-based, neurobiological mechanisms likely contributing to this association. WWE also have elevated risk for affective disorder psychopathology, suicidality, and traumatic experiences. Epidemiology related to psychotic and bipolar spectrum disorders is less clear, and findings are mixed regarding sex-specific behavioral side effects of antiseizure and psychotropic medication. Finally, hormonal and obstetric factors are highlighted as important contributors to neuropsychological symptoms in WWE, with elevated risk for low QoL and increased stigma associated with greater medical and psychiatric comorbidities compared to men. Conclusions: While emerging literature has begun to characterize the neuropsychological presentation of WWE, future research is needed to define sex and gender differences in neuropsychological sequalae among PWE to ensure consistency and quality of care for WWE.

Mania Following Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Mania is an uncommon, but debilitating, psychiatric occurrence following TBI. The literature on mania following TBI is largely limited to case reports and case series. In the present review, the investigators describe the clinical, diagnostic, and treatment characteristics of mania following TBI.

METHODS

A systematic search of MEDLINE, EMBASE, and PsycINFO was conducted for English-language studies published from 1980 to July 15, 2021. The included studies provided the required individual primary data and sufficient information on clinical presentation or treatment of manic symptoms. Studies with patients who reported a history of mania or bipolar disorder prior to TBI and studies with patients who sustained TBI before adulthood were excluded.

RESULTS

Forty-one studies were included, which reported information for 50 patients (the mean±SD age at mania onset was 39.1±14.3 years). Patients were more frequently male, aged <50 years, and without a personal or family history of psychiatric disorders. Although 74% of patients reported mania developing within 1 year following TBI, latencies of up to 31 years were observed. Illness trajectory varied from a single manic episode to recurrent mood episodes. Rapid cycling was reported in six patients. Mood stabilizers and antipsychotics were most frequently used to improve symptoms.

CONCLUSIONS

Heterogeneity of lesion locations and coexisting vulnerabilities make causality difficult to establish. Valproate or a second-generation antipsychotic, such as olanzapine or quetiapine, may be considered first-line therapy in the absence of high-level evidence for a more preferred treatment. Early escalation to combined therapy (mood stabilizer and second-generation antipsychotic) is recommended to control symptoms and prevent recurrence. Larger prospective studies and randomized controlled trials are needed to refine diagnostic criteria and provide definitive treatment recommendations.

Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity

BACKGROUND AND OBJECTIVES

Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts.

METHODS

The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses.

RESULTS

A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts.

DISCUSSION

In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.

Prevalence of Bipolar Symptoms or Disorder in Epilepsy: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

This systematic review with meta-analysis (PROSPERO: CRD42021249336) was performed to estimate the pooled lifetime prevalence of bipolar symptoms (BS) and bipolar disorder (BD) in people with epilepsy (PWE).

METHODS

A search was performed on June 5^th, 2021, in four databases (MEDLINE/PubMed, Ovid EMBASE, Ovid APA PsycInfo, and Web of Science) for original research reporting on BS/BD in PWE, with no restriction on language or time of publication. Inclusion criteria were as follows: 1) original research, 2) cross-sectional study design component, 3) reported a lifetime prevalence of BS/BD or enough information to calculate an estimate, and 4) reported the method by which participants were deemed bipolar. Studies based on an exclusively pediatric population were excluded. To calculate pooled lifetime prevalence of BS/BD, two meta-analytic random-effects models were fitted, one for BS, and the other for BD. Risk of bias was assessed using a standardized appraisal tool for studies reporting prevalence. Certainty of evidence was evaluated using the GRADE approach.

RESULTS

A total of 750 records were screened, and 17 studies were included for analysis: seven provided prevalence estimates for only BS, eight for only BD, and two for both BS and BD. After outlier exclusion and subgroup analysis using screening method as a moderator, the pooled prevalence of BS in PWE was 12.3% [95% CI; 10.6-14.1%] (7,506 PWE). The pooled prevalence of BD in PWE was 4.5% [95% CI; 2.2-7.4%] (48,334 PWE). Considerable heterogeneity was present - more so for BD than for BS - and could be explained through differences in population demographics and study methodology.

DISCUSSION

This study's main limitation was regarding the certainty of evidence. Notwithstanding, our estimates of prevalence should prompt further research on BS/BD in PWE. Given the significant morbidity associated to BD, clinicians should carefully screen PWE for BS.

Bipolar spectrum disorders in neurologic disorders

Psychiatric symptoms frequently predate or complicate neurological disorders, such as neurodegenerative diseases. Symptoms of bipolar spectrum disorders (BSD), like mood, behavioral, and psychotic alterations, are known to occur - individually or as a syndromic cluster - in Parkinson's disease and in the behavioral variant of frontotemporal dementia (FTD). Nonetheless, due to shared pathophysiological mechanisms, or genetic predisposition, several other neurological disorders show significant, yet neglected, clinical and biological overlaps with BSD like neuroinflammation, ion channel dysfunctions, neurotransmission imbalance, or neurodegeneration. BSD pathophysiology is still largely unclear, but large-scale network dysfunctions are known to participate in the onset of mood disorders and psychotic symptoms. Thus, functional alterations can unleash BSD symptoms years before the evidence of an organic disease of the central nervous system. The aim of our narrative review was to illustrate the numerous intersections between BSD and neurological disorders from a clinical-biological point of view and the underlying predisposing factors, to guide future diagnostic and therapeutical research in the field.

Insomnia moderates the association between recurrent seizures and emotional instability in persons with epilepsy

PURPOSE

We investigated the moderating effect of sleep disturbance on the association between seizure recurrence and emotional instability in patients with epilepsy, independent of psychological distress.

METHODS

This was a cross-sectional study. Patients completed the short form of the Affective Lability Scale (ALS-18), Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). A stepwise linear regression analysis and an analysis of covariance with an interaction term were performed.

RESULTS

A total of 171 subjects (63.2% men) were included. The mean ALS-18 score was 15.6 ± 11.3. An ISI ≥ 15, PHQ-9 ≥ 10, and GAD-7 ≥ 7 were noted in 20.5%, 18.1%, and 23.4% of subjects, respectively. A stepwise linear regression analysis found that recurrent seizures in the last year, an ISI ≥ 15, a GAD-7 ≥ 7, and use of levetiracetam were significant and independent factors that were positively associated with higher ALS-18 scores. The coefficient of determination for the model was 0.331. The interaction between recurrent seizures and an ISI ≥ 15 had a significant effect on the ALS-18 scores (F = 6.812, p = 0.010, partial eta² = 0.040). An ISI ≥ 15 was associated with ALS-18 scores in patients without seizure recurrence (p < 0.001). This association almost reached significance (p = 0.084) in those with recurrent seizures. In contrast, the presence of recurrent seizures was associated with ALS-18 scores in patients with an ISI < 15 (p < 0.001), but not in those with an ISI ≥ 15 (p = 0.360).

CONCLUSIONS

The significant interaction between insomnia and seizure status may have an effect on emotional instability. These findings have clinical implications in the development of potential interventions for emotional instability in patients with epilepsy.

Emotion and mood disorders associated with epilepsy

Epilepsy is a disorder characterized by recurrent seizures. Epilepsy can alter mood and emotions. Treatments for epilepsy can also alter mood and emotions. This chapter reviews the emotional changes that can occur before, during, and after a seizure, such as fear and anger, the interictal mood disorders associated with epilepsy, such as depression and anxiety, as well as alterations of emotional processing including comprehending and expressing emotional prosody and faces. The possible treatments of these emotional and mood disorders are also reviewed.

Effect of seizure viewing on psychological outcome in persons with epilepsy

PURPOSE

Psychiatric disease is the most common co-morbidity seen in persons with epilepsy (PWE), often secondary to psychosocial disturbances due to poor adaptation to the disease. Optimizing epilepsy treatment by targeting both seizure control and addressing psychological issues go a long way in improving psychological outcome among PWE. This study aims to assess the psychological status among PWE using validated questionnaires and to assess the effect of viewing their own seizures on their psychological milieu post-viewing.

METHODS

A prospective interventional study was conducted enrolling 52 PWE. Their baseline psychological scores were assessed using Hospital Anxiety Depression Scale (HADS), Self Esteem Inventory (SEI), Locus of Control (LOC) and Quality of Life in Epilepsy (QOLIE-31). The scores were reassessed 3 months post seizure viewing and compared with the baseline scores.

RESULTS

Among the 52 patients analyzed, anxiety was present in 20 (38.4%) and depression in 8 (15.3%). The mean HADS-A (anxiety) scores for study population was 9.56 ± 4.12. Gender, income status, risk factors antedating index seizure, type of seizure, temporal semiology, seizure frequency, MRI or EEG characteristics did not have any significant association with baseline psychological scores. There was statistically significant reduction in HADS-A scores from 9.56 ± 4.12 to 8.35 ± 3.85 in the study population after seizure viewing (p = 0.049). We identified patient characteristics that benefit seizure viewing with respect to each of the psychological batteries mentioned earlier.

CONCLUSION

This study emphasizes that viewing one's own seizures improves the psychological milieu of PWE and improves their quality of life by helping them cope up with their illness more judiciously.

Valproate, sexual health, and men: A narrative review

OBJECTIVE

This article explores current evidence about the effects of valproate (VPA) medicines on sexual health in men, how to monitor symptoms, communicate with patients, and improve clinical outcomes. There has been a lot of focus on VPA use in women of childbearing age following recent changes to prescribing regulations owing to the well-established and significant teratogenic risk. Concerns have been raised by patients and clinicians as to the risk of adverse sexual effects of VPA use in men.

RESULTS

The evidence base for the effect of VPA on sexual function compared with other antiepileptic drugs (AEDs) in men is limited with no randomized controlled trials. Sexual function in men with epilepsy is complex, and there is no direct relationship between objective measures of sexual function and sexual satisfaction. Epilepsy, comorbidities, psychosocial factors, and most AEDs including VPA may cause sexual dysfunction in men, including reduced sexual desire, erectile dysfunction, and fertility problems. Sexual and reproductive function should be discussed with men prior to treatment with AEDs including VPA.

CONCLUSION

Early and proactive discussion of sexual and reproductive functioning mitigates, rather than increases, the risk of sexual problems and potentially improves adherence. Sexual dysfunction in men with cognitive impairment [such as intellectual disability (ID) and dementia] may present with behavioral disturbance. Identification of sexual adverse effects of medication could significantly change treatment plans which is of particular importance for individuals with treatment resistance. We provide an information fact sheet for men to help guide prescribing discussions.

Exploring the genetic overlap between psychiatric illness and epilepsy: A review

There is a long-documented epidemiological link between epilepsy and psychiatric disorders. People with epilepsy are at an increased risk for a variety of psychiatric illnesses, as are their family members, and people with epilepsy may experience psychiatric side effects because of their antiepileptic drugs (AEDs). In recent years, large-scale, collaborative international studies have begun to shed light on the role of genetic variation in both epilepsy and psychiatric illnesses, such as schizophrenia, depression, and anxiety. But so far, finding shared genetic links between epilepsy and psychiatric illness has proven surprisingly difficult. This review will discuss the prevalence of psychiatric comorbidities in epilepsy, recent advances in genetic research into both epilepsy and psychiatric illness, and the extent of our current knowledge of the genetic overlap between these two important neurobiological conditions.

Treatment of psychiatric comorbidities in patients with epilepsy and intellectual disabilities: Is there a role for the neurologist?

This paper will explore the nature of psychiatric co-morbidities in people with an intellectual disability (ID) who have epilepsy. The complexity of clinical presentations and associated co-morbidities require thorough assessment utilising both neurological and psychiatric skills. The neurologist plays a central role in the management of epilepsy in people with ID and therefore requires basic competencies in the assessment of neuropsychiatric co-morbidities. This is key to liaison with other specialist services to ensure individuals receive holistic person-centred care. This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

Depressive Symptom Severity in Individuals With Epilepsy and Recent Health Complications

Identifying relationships between depression severity and clinical factors may help with appropriate recognition and management of neuropsychiatric conditions in persons with epilepsy (PWE). Demographic characteristics, epilepsy variables, and medical and psychiatric comorbidities were examined from a baseline randomized controlled trial sample of 120 PWE. Among demographic characteristics, only inability to work was significantly associated with depression severity (p = 0.05). Higher 30-day seizure frequency (p < 0.01) and lower quality of life (p < 0.0001) were associated with greater depression severity. Comorbid bipolar disorder (p = 0.02), panic disorder (p < 0.01), and obsessive-compulsive disorder (p < 0.01) were correlated with worse depression severity. The literature supports our findings of correlations between worse depression, seizure frequency, and lower quality of life. Less well studied is our finding of greater depression severity and selected psychiatric comorbidities in PWE.

High risk of anxiety and depression in caregivers of adult patients with epilepsy and its negative impact on patients' quality of life

OBJECTIVE

The objective of this study was to assess the anxiety and depression of caregivers of adult patients with epilepsy (PWE) and evaluate its effect on patient quality of life (QOL).

METHOD

One hundred sixty pairs of adult PWE and their caregivers were enrolled in our study. Quality of life in adult PWE was evaluated with the Quality of Life in Epilepsy Inventory-31 scale (QOLIE-31). Symptoms of anxiety and depression in caregivers were assessed with the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D) respectively. Correlation and stepwise multiple liner regression analyses were used as statistical analysis.

RESULTS

Of the caregivers, 41 (31.30%) had anxiety symptoms (HAM-A scores > 6) and 44 (33.59%) had depression symptoms (HAM-D scores > 6). Caregiver anxiety was significantly associated with poorer adult PWE QOL scores in four of the seven subscales and the QOLIE-31 total score. Caregiver depression was significantly associated with poorer adult PWE QOL in all seven subscales as well as the QOLIE-31 total score. Caregiver depression was an independent predictor of the QOLIE-31 total score and five subscales: seizure worry, emotional wellbeing, energy/fatigue, cognitive, and medication effects.

CONCLUSION

Caregivers of adult PWE are at high risk of experiencing anxiety and depression. Caregiver psychological status, especially depression, was an independent predictor of poorer QOL for adult PWE.

Chronic Medical Conditions and Peripartum Mental Illness: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to examine the association between maternal chronic medical conditions (CMCs) and peripartum mental illness. MEDLINE, Embase, CINAHL, and PsycINFO were searched to September 2017. Data were extracted and quality was assessed using standardized instruments. We generated unadjusted and adjusted pooled odds ratios and 95% confidence intervals using DerSimonian and Laird random effects models. The review included 16 papers representing 12 studies and 1,626,260 women. CMCs overall were associated with peripartum mental illness overall (adjusted pooled odds ratios (aPOR) = 1.43, 95% confidence interval (CI): 1.25, 1.63). CMCs overall were associated with antepartum (aPOR = 1.41, 95% CI: 1.10, 1.81) and postpartum mental illness separately (aPOR = 1.44, 95% CI: 1.13, 1.85) and with peripartum depression (aPOR = 1.45, 95% CI: 1.25, 1.67) and anxiety separately (aPOR = 1.63, 95% CI: 1.35, 1.95). No studies examined bipolar or psychotic disorders. Diabetes (aPOR = 1.34, 95% CI: 1.07, 1.69), hypertension/heart disease (aPOR = 1.60, 95% CI: 1.05, 2.45), migraine (aPOR = 1.75, 95% CI: 1.20, 2.54), and other neurological disorders (aPOR = 1.45, 95% CI: 1.19, 1.77), but not asthma, were each associated with peripartum mental illness. Findings suggest that mental health resources should be integrated in medical settings where pregnant and postpartum women with CMCs are treated.

Increased risk of hospital admission for mood disorders following admission for epilepsy

OBJECTIVE

To determine if epilepsy admissions, compared to admissions for other medical causes, are associated with a higher readmission risk for mood disorders.

METHODS

The Nationwide Readmissions Database is a nationally representative dataset comprising 49% of US hospitalizations in 2013. In this retrospective cohort study, we used ICD-9-CM codes to identify medical conditions. Index admissions for epilepsy (n = 58,278) were compared against index admissions for stroke (n = 215,821) and common medical causes (n = 973,078). Readmission rates (per 100,000 index admissions) for depression or bipolar disorders within 90 days from discharge for index hospitalization were calculated. Cox regression was used to test for associations between admission type (defined in 3 categories as above) and readmission for depression or bipolar disorder up to 1 year after index admission, in univariate models and adjusted for age, sex, psychiatric history, drug abuse, income quartile of patient's zip code, and index hospitalization characteristics.

RESULTS

The adjusted hazard ratio (HR) for readmission for depression in the epilepsy group was elevated at 2.80 compared to the stroke group (95% confidence interval [CI] 2.39-3.27, p < 2 × 10^-16), and 2.09 compared to the medical group (95% CI 1.88-2.32, p < 2 × 10^-16). The adjusted HR for readmission for bipolar disorder in the epilepsy group was elevated at 5.84 compared to the stroke group (95% CI 4.56-7.48, p < 2 × 10^-16), and 2.46 compared to the medical group (95% CI 2.16-2.81, p < 2 × 10^-16).

CONCLUSION

Admission for epilepsy was independently associated with subsequent hospital readmission for mood disorders. The magnitude of elevated risk in this population suggests that patients admitted with epilepsy may warrant targeted psychiatric screening during their hospital admission.

Hippocampal Pathophysiology: Commonality Shared by Temporal Lobe Epilepsy and Psychiatric Disorders

Accumulating evidence points to the association of epilepsy, particularly, temporal lobe epilepsy (TLE), with psychiatric disorders, such as schizophrenia. Among these illnesses, the hippocampus is considered the regional focal point of the brain, playing an important role in cognition, psychosis, and seizure activity and potentially suggesting common etiologies and pathophysiology of TLE and schizophrenia. In the present review, we overview abnormal network connectivity between the dentate gyrus (DG) and the Cornus Ammonis area 3 (CA3) subregions of the hippocampus relative to the induction of epilepsy and schizophrenia. In light of our recent finding on the misguidance of hippocampal mossy fiber projection in the rodent model of schizophrenia, we discuss whether ectopic mossy fiber projection is a commonality in order to evoke TLE as well as symptoms related to schizophrenia.

Epilepsy and neuropsychiatric comorbidities

Epilepsy is a common neurological condition with wide-ranging neuropsychiatric manifestations. The relationship between epilepsy and psychiatry has been recognised for centuries. However, the wide range of neuropsychiatric comorbidities and their extent is only now beginning to be appreciated. The impact of these comorbidities on patients' help-seeking behaviour, seizure control and quality of life suggests that early detection and treatment are of paramount importance. Clinical issues in relation to accurate recognition and appropriate management of neuropsychiatric conditions in epilepsy are discussed.

Psychiatric comorbidities in epilepsy

Psychiatric comorbidities, including mood, anxiety, and psychotic disorders, are common in epilepsy, often occurring at rates 2-3-fold or higher than in the general population without epilepsy. This article discusses the epidemiology of psychiatric disorders in epilepsy, hypotheses regarding the pathogenesis of these comorbidities, and treatment implications. More specifically, it addresses: (1) How common are major depressive disorder, anxiety disorders, and psychotic disorders in epilepsy? (2) How does one screen for these psychiatric disorders in persons with epilepsy? (3) Why do psychiatric conditions occur in epilepsy? (4) Is the treatment of psychiatric comorbidity in epilepsy associated with seizures? The important topic of suicide and suicidal ideation in epilepsy, risk factors for their occurrence, and how to screen for these co-existent conditions is also discussed. Finally, gaps in knowledge regarding psychiatric conditions in epilepsy are briefly discussed.

Barriers and facilitators to epilepsy self-management for patients with physical and psychological co-morbidity

Objectives This exploratory study identifies barriers and facilitators to self-management to inform future epilepsy self-management interventions for persons who have epilepsy complicated by co-morbid mental health conditions and serious medical events. Methods Focus group methods were used in a series of community advisory board meetings. Analysis was conducted using a thematic, constant comparative approach aiming to describe the range of barriers and facilitators salient to participants. There were a total of 22 participants, including 8 health professionals, 9 patients with epilepsy, and 5 care partners. Mean age was 49.1 (SD = 11.0, range 32-69), 11 (50%) were female, and 11 (50%) were male. For those with epilepsy, mean years having epilepsy was 24.7 (SD = 19.9, range 1-58 years). Results Individual psychological barriers (mental illness, fatigue, and psychological distress) prominently interfered with health behaviors. Community and family barriers included stigma, lack of epilepsy knowledge, and poor social support. Facilitators included planning for seizures, learning about medications, stress management, socializing with others, and talking with other epilepsy patients. Discussion Qualitative evidence in this study suggests a linkage between social integration and positive health behaviors. Future efforts to embed patients with epilepsy and their caregivers into clinical care processes could offset barriers and enhance facilitators.

Clinical stabilisation with lacosamide of mood disorder comorbid with PTSD and fronto-temporal epilepsy

Background and aim of the work:

Mood disorders are often complicated by comorbidity with epilepsy. Anxiety and personality disorders may worsen prognosis and treatment outcome. Lacosamide has been recently introduced as adjunctive treatment for partial epilepsy. Its mechanism consists of selective slow inactivation of voltage-gated sodium channels, thus promoting an extended stabilisation of cell membranes. Antiepileptic drugs have been largely used since the 1950s in psychiatry as mood stabilisers due to their membrane stabilising and anti-kindling effects. Like lithium, antiepileptic drugs are first choice treatment for Bipolar and Cyclothymic Disorders.

Methods:

We tested the efficacy of the most recent antiepileptic medication, lacosamide, in a patient with simultaneously occurring cyclothymic disorder, severe post-traumatic stress disorder, and fronto-temporal epilepsy. Lacosamide was titrated up to 200 mg/day, added to ongoing 750 mg/day lithium, 15 mg/day oral aripiprazole then switched to 400 mg/month long-acting aripiprazole, and 2 mg/day A-desmethyldiazepam.

Results:

We observed EEG normalisation one month later, along with reduced anxiety and an additive effect to lithium-induced stabilisation of mood fluctuations since the second week of lacosamide addition.

Conclusions:

Further studies with this drug in the bipolar spectrum are warranted. (www.actabiomedica.it)

Targeted Self-Management of Epilepsy and Mental Illness for individuals with epilepsy and psychiatric comorbidity

OBJECTIVES

Serious mental illness is disproportionately common in people with epilepsy and contributes to complications and mortality. Few care approaches specifically target individuals who have epilepsy and severe mental illness. We used an iterative process to refine an existing intervention and tested the novel intervention, Targeted Self-Management for Epilepsy and Mental Illness (TIME) in individuals with epilepsy and comorbid mental illness (E-MI).

METHODS

The TIME intervention was developed with input from a community advisory board and then tested for feasibility, acceptability, and preliminary efficacy in people with E-MI, using a 16-week prospective, randomized controlled design comparing TIME (N=22) vs. treatment as usual (TAU, N=22). Primary outcome was change in depressive symptoms, assessed by the Montgomery Asberg Depression Rating Scale (MADRS). Secondary assessments included global psychiatric symptom severity, seizure frequency, sleep patterns, quality of life, stigma, social support, and self-efficacy.

RESULTS

There were 44 individuals enrolled, mean age 48.25 (SD=11.82) with 25 (56.8%) African-Americans. The majority (N=31, 70.5%) were unemployed, and most (N=41, 95.5%) had annual income <U.S. $25,000. With respect to study retention, there were 36 individuals (18 in TIME, 18 in TAU) assessed at 12weeks and 35 individuals (19 in TIME, 16 in TAU) assessed at 16weeks. There was a significant effect for MADRS (p=0.036; effect size of 0.70), with lower MADRS at 16weeks in TIME, while TAU MADRS did not change. Differences between most secondary measures were not statistically significant.

SIGNIFICANCE

The TIME intervention engages individuals to actively participate in self-management and can reduce depression in E-MI. Given the high morbidity and mortality associated with epilepsy complicated by serious mental illness, additional research is needed to better identify how TIME might be implemented in routine care settings.

Major depressive disorder, suicidal behaviour, bipolar disorder, and generalised anxiety disorder among emerging adults with and without chronic health conditions

BACKGROUND

Despite the considerable physical, emotional and social change that occurs during emerging adulthood, there is little research that examines the association between having a chronic health condition and mental disorder during this developmental period. The aims of this study were to examine the sex-specific prevalence of lifetime mental disorder in an epidemiological sample of emerging adults aged 15-30 years with and without chronic health conditions; quantify the association between chronic health conditions and mental disorder, adjusting for sociodemographic and health factors; and, examine potential moderating and mediating effects of sex, level of disability and pain.

METHOD

Data come from the Canadian Community Health Survey-Mental Health. Respondents were 15-30 years of age (n = 5947) and self-reported whether they had a chronic health condition. Chronic health conditions were classified as: respiratory, musculoskeletal/connective tissue, cardiovascular, neurological and endocrine/digestive. The World Health Organization Composite International Diagnostic Interview 3.0 was used to assess the presence of mental disorder (major depressive disorder, suicidal behaviour, bipolar disorder and generalised anxiety disorder).

RESULTS

Lifetime prevalence of mental disorder was significantly higher for individuals with chronic health conditions compared with healthy controls. Substantial heterogeneity in the prevalence of mental disorder was found in males, but not in females. Logistic regression models adjusting for several sociodemographic and health factors showed that the individuals with chronic health conditions were at elevated risk for mental disorder. There was no evidence that the level of disability or pain moderated the associations between chronic health conditions and mental disorder. Sex was found to moderate the association between musculoskeletal/connective tissue conditions and bipolar disorder (β = 1.71, p = 0.002). Exploratory analyses suggest that the levels of disability and pain mediate the association between chronic health conditions and mental disorder.

CONCLUSIONS

Physical and mental comorbidity is prevalent among emerging adults and this relationship is not augmented, but may be mediated, by the level of disability or pain. Findings point to the integration and coordination of public sectors - health, education and social services - to facilitate the prevention and reduction of mental disorder among emerging adults with chronic health conditions.

Depression and anxiety in people with epilepsy: Why should we identify?

Introduction. People with epilepsy (PWE) have a higher risk of developing depression and anxiety than people without epilepsy. However, understanding and management of that issue remain under-recognized.

Aim. To emphesize: a) the relationship between depression, anxiety, and epilepsy, and b) to suggest practical strategies for their identification by clinicians.

Methods. The current literatures was reviewed investigating the impact of depression and anxiety in PWE and those examining the validity of simple screening tools for the detection of depression and anxiety.

Review. Approximately one quarter of PWE have been known to be suffered from depression. The frequency of depression and anxiety was closely related to poor seizure control. Depression and anxiety have been reported to have a bidirectional relationship with epilepsy. The higher degree of depression and anxiety was more likely to elicit the suicidal ideation and attempt, adverse events and poor compliance of antiepileptic drugs, poor surgical outcome, and eventually, poor quality of life. Furthermore, depression and anxiety were closely associated with perceived stigma, obsessive-compulsive symptom, aggression, fatigue, and perceived stress.

Conclusions. Clinicians who take care of PWE in a busy clinical setting should identify their psychiatric problems by brief screening tools and treat them instantly to minimize their negative impacts.

Gene Prioritization by Integrated Analysis of Protein Structural and Network Topological Properties for the Protein-Protein Interaction Network of Neurological Disorders

Neurological disorders are known to show similar phenotypic manifestations like anxiety, depression, and cognitive impairment. There is a need to identify shared genetic markers and molecular pathways in these diseases, which lead to such comorbid conditions. Our study aims to prioritize novel genetic markers that might increase the susceptibility of patients affected with one neurological disorder to other diseases with similar manifestations. Identification of pathways involving common candidate markers will help in the development of improved diagnosis and treatments strategies for patients affected with neurological disorders. This systems biology study for the first time integratively uses 3D-structural protein interface descriptors and network topological properties that characterize proteins in a neurological protein interaction network, to aid the identification of genes that are previously not known to be shared between these diseases. Results of protein prioritization by machine learning have identified known as well as new genetic markers which might have direct or indirect involvement in several neurological disorders. Important gene hubs have also been identified that provide an evidence for shared molecular pathways in the neurological disease network.

Psychiatric Comorbidity, Social Aspects and Quality of Life in a Population-Based Cohort of Expecting Fathers with Epilepsy

OBJECTIVES

To investigate psychiatric disorders, adverse social aspects and quality of life in men with epilepsy during partner's pregnancy.

METHOD

We used data from the Norwegian Mother and Child Cohort Study, including 76,335 men with pregnant partners. Men with epilepsy were compared to men without epilepsy, and to men with non-neurological chronic diseases.

RESULTS

Expecting fathers in 658 pregnancies (mean age 31.8 years) reported a history of epilepsy, 36.9% using antiepileptic drugs (AEDs) at the onset of pregnancy. Symptoms of anxiety or depression were increased in epilepsy (7.0% and 3.9%, respectively) vs. non-epilepsy (4.6% and 2.5%, respectively, p = 0.004 and 0.023), and so were new onset symptoms of depression (2.0% vs. 1.0%, p < 0.031) and anxiety (4.3% vs. 2.3%, p = 0.023). Low self-esteem (2.5%) and low satisfaction with life (1.7%) were more frequent among fathers with epilepsy compared to fathers without epilepsy (1.3% and 0.7%, respectively, p = 0.01 and 0.010). Adverse social aspects and life events were associated with epilepsy vs. both reference groups. Self-reported diagnoses of ADHD (2.2%) and bipolar disorder (1.8%) were more common in epilepsy vs. non-epilepsy (0.4% and 0.3%, respectively, p = 0.002 and 0.003) and non-neurological chronic disorders (0.5% and 0.5%, respectively, p = 0.004 and 0.018). A screening tool for ADHD symptoms revealed a higher rate compared to self-reported ADHD (9.5% vs. 2.2%, p < 0.001).

CONCLUSION

Expecting fathers with epilepsy are at high risk of depression and anxiety, adverse socioeconomic aspects, low self-esteem, and low satisfaction with life. Focus on mental health in fathers with epilepsy during and after pregnancy is important. The use of screening tools can be particularly useful to identify those at risk.

Parental and comorbid epilepsy in persons with bipolar disorder

BACKGROUND

Population-based studies have demonstrated an overrepresentation of bipolar disorder (BPD) in individuals with epilepsy. However, few studies have examined the reverse association, i.e. comorbid epilepsy in individuals selected based on BPD diagnosis. No previous population-based study having examined the co-occurrence of BPD and epilepsy has adjusted for parental psychopathology. Such an adjustment is motivated by population-based studies reporting an overrepresentation of various types of parental psychiatric disorders in both BPD and epilepsy. Furthermore, an association between epilepsy in first-degree relatives and BPD has previously only been examined and demonstrated in a small clinical sample. The objective of this study is to examine the associations between parental and comorbid epilepsy and BPD, adjusting for parental psychopathology.

METHODS

This nested case-control study identified 1861 cases with BPD, age up to 25 years, 3643 matched controls, and their parents from Finnish national registers. Conditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) and two-sided significance limits of p<0.05.

RESULTS

BPD was associated with comorbid epilepsy (adjusted OR 2.53, 95% CI: 1.73-3.70) but not with parental epilepsy. Epilepsy was found in 3.33% of cases versus 1.29% of controls, 2.69% of cases' parents versus 2.53% of controls' parents.

LIMITATIONS

The diagnoses were register-based, not based on standardized procedures with direct ascertainment.

CONCLUSIONS

An association between BPD and comorbid epilepsy persists even after adjusting for parental psychopathology. Lack of familial clustering of BPD and epilepsy would suggest that the elevated co-occurrence of these disorders is influenced by non-genetic factors.

Depression and hypomania symptoms are associated with high dose corticosteroids treatment for MS relapses

BACKGROUND

Psychiatric side effects are known to occur with low dose corticosteroids. Standard of care for Multiple Sclerosis (MS) relapses is high dose corticosteroids (HDC), at least 1g/day for 3-5 days, and yet the relationship between this treatment and mood is not known. We sought to determine the frequency and potential predictors of (hypo)manic and depressive symptoms with HDC treatment for MS relapses.

METHODS

Consecutive MS subjects requiring HDC treatment were identified. The Mood Disorders Questionnaire (MDQ) and the Beck Depression Inventory-Fast Screen (BDIFS) were administered for (hypo)manic and depressive symptoms, respectively, prior to HDC, 3 days and one month post-HDC.

RESULTS

Eighty eight subjects completed the study. At relapse diagnosis, the mean BDIFS score was 4.2 (SD 3.1); the mean number of (hypo)manic symptoms endorsed on the MDQ was 4.3 (SD 3.5). Three days after completing HDC, 22.5% had an increase on the BDIFS and 38.2% endorsed more symptoms on the MDQ. A history of depression (p=0.006) and low reported quality of life (p=0.029) predicted an increase on the MDQ; the odds of an increase in (hypo)manic symptoms was 5.6 times higher with a history of any psychiatric disease/substance abuse (p=0.005). No predictors for worsening on the BDIFS were found.

LIMITATIONS

Self-reported measures were used, anxiety was not evaluated and 17 subjects were lost to follow up.

CONCLUSION

Depressive and hypo(manic) symptoms are commonly associated with HDC for MS relapses. It is important for clinicians and MS patients to be aware of this risk.

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

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

Epilepsy and bipolar disorder

It is well recognized that mood disorders and epilepsy commonly co-occur. Despite this, our knowledge regarding the relationship between epilepsy and bipolar disorder is limited. Several shared features between the two disorders, such as their episodic nature and potential to run a chronic course, and the efficacy of some antiepileptic medications in the prophylaxis of both disorders, are often cited as evidence of possible shared underlying pathophysiology. The present paper aims to review the bidirectional associations between epilepsy and bipolar disorder, with a focus on epidemiological links, evidence for shared etiology, and the impact of these disorders on both the individual and wider society. Better recognition and understanding of these two complex disorders, along with an integrated clinical approach, are crucial for improved evaluation and management of comorbid epilepsy and mood disorders.

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

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

Third International Congress on Epilepsy, Brain, and Mind: Part 2

Epilepsy is both a disease of the brain and the mind. Here, we present the second of two papers with extended summaries of selected presentations of the Third International Congress on Epilepsy, Brain and Mind (April 3-5, 2014; Brno, Czech Republic). Humanistic, biologic, and therapeutic aspects of epilepsy, particularly those related to the mind, were discussed. The extended summaries provide current overviews of epilepsy, cognitive impairment, and treatment, including brain functional connectivity and functional organization; juvenile myoclonic epilepsy; cognitive problems in newly diagnosed epilepsy; SUDEP including studies on prevention and involvement of the serotoninergic system; aggression and antiepileptic drugs; body, mind, and brain, including pain, orientation, the "self-location", Gourmand syndrome, and obesity; euphoria, obsessions, and compulsions; and circumstantiality and psychiatric comorbidities.

Electronic medical record analysis of emergency room visits and hospitalizations in individuals with epilepsy and mental illness comorbidity

OBJECTIVE

Epilepsy is a chronic neurological condition that significantly increases risk of injury and premature death. Rates of mental illness are also disproportionately high in those with epilepsy, which can be attributed in part to the stress and stigma associated with epilepsy. Psychiatric conditions generally complicate the management of epilepsy, and understanding how psychiatric comorbidity affects use of crisis-based health resources could inform care approaches that help improve epilepsy care. To better understand effects of psychiatric comorbidity on epilepsy burden, we conducted a 5-year retrospective analysis of data from a large safety-net healthcare network and compared the occurrence of negative health events (NHEs), defined as emergency department (ED) visits and hospitalizations, among individuals with epilepsy and mental illness (E-MI) vs. those with epilepsy alone (E).

METHODS

Electronic health record (EHR) data from a large Midwestern U.S. safety-net healthcare system were queried to identify a study population of adults ≥18years with a diagnosis of epilepsy, with or without mental illness. We assessed demographic and clinical characteristics for each of the 5years and compared NHEs between subgroups with E-MI vs. E. An additional analysis focused on those individuals who remained in the healthcare system over the entire 5-year study time frame (January, 2010 to December, 2014). Annual and cumulative NHE counts and hospital length of stay for individuals with E-MI and E were assessed, as were hospital discharge diagnoses.

RESULTS

The number (approximately 2000) and demographic characteristics of individuals with epilepsy who received care each year of the study period was relatively consistent. In 2014, mean age of individuals with epilepsy was 48 (range: 18-95), 48.2% were women, 51.5% were White, 37.9% were African-American, and 8.6% were Hispanic. In 2014, there were 1616 (78.6%) individuals in the subgroup with E and 439 (21.4%) in the subgroup with E-MI. Most clinical and demographic variables between the subgroups with E-MI and E were similar, except that individuals with E-MI were less likely to be employed or commercially insured. Overall, NHEs were common, with over 1/4 (27.5%) of all individuals with epilepsy having an ED visit during the year, 13.7% having hospitalization, and 34.2% having either an ED visit or hospitalization. Individuals with E-MI had significantly more NHEs compared to individuals with epilepsy only, as evidenced by higher rates of any NHE (p<.001), ED visits (p<.001), and hospitalizations (p<.001). The cumulative differential in ED and hospital use between subgroups with E-MI and E was substantial over a 5-year time period. While most NHEs were directly related to seizures for the overall group, substance-use complications appeared as a top reason for hospitalization only in the group with E-MI.

CONCLUSIONS

Individuals with E-MI made up just over 20% of all people with epilepsy in a safety-net system and had higher rates of NHEs than those without mental illness. Better and earlier identification of individuals with E-MI, assistance with self-management including helping individuals to optimize ambulatory care settings as opposed to the ED, and treatment for substance use disorders could eventually reduce NHEs in this vulnerable subgroup of individuals with epilepsy.

Comparison of precipitating factors for mania and partial seizures: Indicative of shared pathophysiology?

OBJECTIVES

Mania in bipolar disorder (BD) and partial (focal) seizures (PS) arising from the temporal lobes, have a number of similarities. Typically, a chronic course of the disorders is punctuated by acute illness episodes. Common features of episodes may include sensory, perceptual, cognitive and affective changes. Both respond to anticonvulsant treatment. Common mechanisms imputed include neurotransmitters and kindling processes. Further investigation may improve understanding of the occurrence of both mania and PS, casting light on the relevance of temporal lobe mediated processes and pathology. One avenue of investigation is to compare aetiological factors and determine the extent of overlap which may indicate shared brain localization or pathophysiology. Aetiology includes predisposing, precipitating or perpetuating factors. This paper examines the literature on precipitating factors of mania, first or subsequent episode, and of PS in diagnosed epilepsy, which is the second or subsequent seizure, to identify the extent and nature of their overlap.

METHOD

Narrative review based on a literature search of PubMed and Google Scholar.

RESULTS

Precipitating factors for both mania and PS were stress, sleep deprivation, antidepressant medication and, tentatively, emotion. For mania alone, goal-attainment events, spring and summer season, postpartum, and drugs include steroids and stimulants. For PS alone, winter season, menstruation and specific triggers in complex reflex epilepsies. Those not substantiated include lunar phase and menopause. A wide range of chemicals may provoke isolated seizures but by definition epilepsy requires at least two seizures.

CONCLUSIONS

The overlap of precipitating factors in mania and PS imply that common brain processes may contribute to both, consistent with findings from neuroscience research.

Suicidal risk, affective dysphoric disorders, and quality-of-life perception in patients with focal refractory epilepsy

OBJECTIVES

We aim to study the frequency of (suicidal ideation) in patients with focal refractory epilepsy and its possible association with factors such as perceived QOL (quality of life) and ASDD (affective somatoform dysphoric disorder) using the 2007 ILAE proposal to classify affective disorders of epilepsy.

METHODS

A total sample of 82 patients was divided into two groups depending on the presence of suicidal risk: (A) study group - with suicidal risk and (B) control group - without suicidal risk. Questionnaires, scales, interviews, and clinical charts were evaluated by professionals with expertise in neurology and epileptology (RAM and AGA), psychiatry (AGE), and neuropsychology (FGR). Suicidal risk was evaluated with the M.I.N.I. (Mini-International Neuropsychiatric Interview) suicidal module that specifies the current suicidal risk based on scores. Quality of life was evaluated with the Quality of Life in Epilepsy Inventory - 31 (QOLIE-31) survey. Logistic regression was conducted to ascertain if ASDD and QOL significantly predicted suicidal risk. The results were considered statistically significant when the p-value was <0.05.

RESULTS

Suicidal risk was present in 33 (40.3%) patients. It was classified as severe in 31.7% of the patients, and it was only present in cases with temporal lobe epilepsy (p=0.002). More than half (52%) of patients with ASDD had risk of suicide (p=0.006). The presence of ASDD was found to be a risk factor for suicidal risk (OR=3.86; IC=1.3-12.2). Patients with suicidal risk had a lower QOL score compared with patients without suicidal risk (57.8±16.9 vs. 46.0±18.2; p<0.05), and an affected QOL significantly increased suicidal risk (OR=2.9; CI=1.3-7.8). Multivariate analysis demonstrated that an impaired QOL (OR=2.2) and the presence of ASDD (OR=4.1) significantly increased the probability of having suicidal risk (x(2)=13.6; OR=5.2; p=0.009).

SIGNIFICANCE

Affective somatoform dysphoric disorder and low QOL perception increase, independently, the risk of suicide.

Prevalence of Mental Disorders in a Canadian Household Population with Dementia

Background:

Medical and mental health comorbidity in Alzheimer's disease and other dementias presents difficult challenges for health service delivery. However, existing studies have been conducted in clinical samples and may not be informative for planning community services. The Canadian Community Health Survey (CCHS) provides an opportunity to characterize associations between dementias and mental and physical comorbidity in a household population aged 55 and over.

Methods:

Data were obtained from the 2005 CCHS-cycle 3.1. Weighted estimates for mood and anxiety disorders and other characteristics in Canadian population with dementia were calculated and were compared to those in people without the condition.

Results:

According to the CCHS, the prevalence of Alzheimer's disease and other dementia increases with age, more or less doubling every decade. The increase among women is monotonic, whereas among men in the household population the rate of dementia peaks at age 85-89 and falls thereafter. Mood and anxiety disorders were found to be substantially more frequent among people with Alzheimer's disease and other forms of dementia compared to those without the disease (mood disorders: 19.5% vs. 5.3% and anxiety disorders: 16.3% vs. 4.0%). Heart disease, stroke and obesity were associated with dementia as was a lower level of education. Furthermore, people with dementia were more likely than those without the disease to report activity restrictions.

Conclusions:

The high prevalence of mood and anxiety disorders in household population with Alzheimer's disease and other dementia demonstrates the burden of disease that is likely to worsen quality of life over time.

Bipolar disorder and comorbidity: increased prevalence and increased relevance of comorbidity for hospital-based mortality during a 12.5-year observation period in general hospital admissions

BACKGROUND

Bipolar disorder (BD) is associated with an increase of psychiatric and physical comorbidities, but the effects of these disorders on general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on hospital-based mortality differed between individuals with and without BD during a 12.5-year observation period in general hospital admissions.

METHODS

During 1 January 2000 and 30 June 2012, 621 individuals with BD were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 6210 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses. Comorbidities that increased the risk for hospital-based mortality (but not mortality outside of the hospitals) were identified using multivariate logistic regression analyses.

RESULTS

Individuals with BD had a more severe course of disease than controls that was associated with a higher total number of in-hospital deaths. Individuals with BD compared to controls had a substantial higher burden of comorbidities, the most frequent comorbidities included asthma, type-2 diabetes mellitus (T2DM), and alcohol dependence. 18 other diseases with a surplus of diabetes related complications were also increased. Fourteen comorbidities contributed to the prediction of hospital-based mortality in univariate analyses. Risk factors for hospital-based mortality in multivariate analyses were ischemic stroke, pneumonia, bronchitis, chronic obstructive pulmonary disease, T2DM, and hypertension. The impact of T2DM on hospital-based mortality was higher in individuals with BD than in controls.

LIMITATIONS

The study design was not assigned to assess the type of BD, the current bipolar status, and if individuals with BD were treated with medication. It was neither possible to compare drug effects, nor to compare the adherence to treatment between samples.

CONCLUSION

In one of the largest samples of individuals with BD in general hospitals, the excess comorbity in individuals with BD compared to controls is in particular caused by asthma and T2DM. T2DM and its complications cause significant excess hospital-based mortality in individuals with BD.

Record-linkage studies of the coexistence of epilepsy and bipolar disorder

PURPOSE

Interest is growing in a possible link between epilepsy and bipolar disorder (BPD). We used two large datasets of hospital admission data to determine whether epilepsy and BPD occur together in the same individuals more commonly than expected.

METHODS

We undertook retrospective cohort studies using the Oxford Record Linkage Study (ORLS) and English national linked Hospital Episode Statistics. We constructed a cohort of people in each dataset admitted with epilepsy (without prior admission for BPD), and a control cohort (without prior admission for BPD), and compared their subsequent admission rates for BPD. Conversely, we constructed a cohort of people in each dataset admitted with BPD and a control cohort (both without prior admission for epilepsy), and compared their subsequent admission rates for epilepsy.

RESULTS

In the epilepsy cohort, compared with the control cohort, the rate ratio (RR) for BPD was significantly high at 3.0 (95 % confidence interval 1.7-5.1) in the ORLS and 3.6 (3.3-3.9) in the all-England dataset. In the BPD cohort, the RR for epilepsy was 2.2 (1.2-3.7) in the ORLS and 4.2 (4.0-4.4) in the all-England cohort. We found no significant differences between RRs for males and females.

CONCLUSIONS

Epilepsy and BPD occur together in individuals more frequently than expected by chance.

Self-harm in people with epilepsy: a retrospective cohort study

OBJECTIVES

Little is known about self-harm in people with epilepsy, despite suicide being recognized as a leading cause of mortality in this population. This study aimed to investigate the characteristics of self-harm in people with epilepsy, and associated demographic and psychosocial factors.

METHODS

Patients presenting to hospital following self-harm between 1994 and 2008 were identified from the Oxford Monitoring System for Self-Harm. Epilepsy diagnosis was confirmed through review of medical records. Demographic features, patient, and self-harm characteristics of 132 people with epilepsy and 9,778 self-harm patients without epilepsy were compared using a regression model, adjusting for age, sex, and repetition. Patients presenting between 1998 and 2008 were followed up for all-cause mortality to the end of 2011.

RESULTS

The rate of self-harm per individual with epilepsy was 2.04 (95% confidence interval [CI] 1.85-2.25) times that of the comparison group, and time between first and second self-harm events was shorter (hazard ratio 1.86; 1.46-2.38). People with epilepsy were significantly more likely to use antiepileptic medication in overdose, although overall methods of self-harm were similar in the two groups. No significant differences in suicide intent scores or the proportion of patients who died by suicide were found. Previous outpatient psychiatric treatment, longer duration of unemployment, experience of violence, and housing problems were associated with self-harm in people with epilepsy.

SIGNIFICANCE

People with epilepsy who self-harm do so more frequently than other self-harm patients. Clinicians should be aware of this and pay attention to contributory factors as these may enhance risk in this population. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

An investigation into the relationship between first-degree relatives of bipolar affective disorder and (idiopathic) epilepsy in a sub-Saharan African population

OBJECTIVE

Phenomenological, neuro-biological and pharmacological investigations linked bipolar affective disorders with epilepsy. Similarly, a large community-based epidemiological study of epileptic patients reported that 12% of the participants had bipolar symptoms, a rate 7× higher than in control. Bipolar and epileptic disorders are epiphenomena of an underlying genetic susceptibility. This study aimed to determine the relationship between first-degree relatives of bipolar and epileptic patients in a sub-Saharan African population.

METHOD

In this case-control study, we used a socio-demographic and clinical variables questionnaire to assess random convenient samples of 50 control, 40 and 60 first-degree relatives of bipolar and epileptic patients, respectively at Federal Neuro-psychiatric Hospital (FNPH), Maiduguri. Relatives of epileptic patients and the control completed the mood disorder questionnaire (MDQ). Two consultant psychiatrists made the diagnosis of epilepsy using the ILAE criteria, in relatives of bipolar patients and the control. Participants in both groups had no EEG. We analysed the data obtained, using EPI-info 7 to report averages and associations between categorical variables with Chi-square test, and analysis of variance (ANOVA) for parametric data(statistical significance set at p=0.5, two-tailed).

RESULTS

The rate of epilepsy among relatives of bipolar disorder compared with control was 15.2% vs. 2.0% (χ(2)=46.08, p<0.001), and that of bipolar among relatives of epileptics compared with control was 14.5% vs. 2.1% (χ(2)=31.2, p<0.001). Educational status showed significant relationship across two groups (χ(2)=24.19, p=0.0001). Using ANOVA, age showed significant relationship among relatives of bipolar and epileptic patients (F=5.769, p=0.0039).

CONCLUSION

Despite its limitations, this preliminary study contributes to literature on the relationship between epilepsy and bipolar affective disorder in sub-Saharan Africa.

[Coexistent depressive and anxiety disorders in epilepsy and multiple sclerosis: a challenge to neuropsychiatric practice]

The high rate of co-existent emotional disorders in major neurological disorders, such as epilepsy and multiple sclerosis is challenging. As a rule, this co-existence comprises a more dramatic subjective suffering, a reduced psychological coping, possible negative interferences with somatic treatments and rehabilitations, an impaired quality of life and higher grades of psychosocial disability. It may also lead to an overall increased risk of somatic morbidity and even mortality in the further course of illness. These complex interrelations may be favourably integrated within a biopsychosocial model. Psychological and psychosocial stressors can be appreciated on their own discrete levels, have to be reflected, however, in their neurobiological correlates. Both neurological and emotional disorders frequently share decisive pathogenetic mechanisms, i.e. the underlying process of neurological disease may contribute to major affective problems also in a somato-psychic direction. In addition, mutual interactions of both neurological and psychiatric treatments in their impact on the emotional and neurological risks have to be appreciated.

Limbic networks: clinical perspective

Limbic epilepsy refers to a condition that consists of epileptic seizures that originate in or preferentially involve the limbic system. The majority of cases are medically refractory, necessitating surgical resection when possible. However, even resection of structures thought to be responsible for seizure generation may not leave a patient seizure free. While mesial temporal lobe limbic structures are centrally involved, there is growing evidence that the epileptogenic network consists of a broader area, involving structures outside of the temporal lobe and the limbic system. Information on structural, functional, and metabolic connectivity in patients with limbic epilepsy is available from a large body of studies employing methods such as MRI, EEG, MEG, fMRI, PET, and SPECT scanning, implicating the involvement of various brain regions in the epileptogenic network. To date, there are no consistent and conclusive findings to define the exact boundaries of this network, but it is possible that in the future studies of network connectivity in the individual patient may allow more tailored treatment and prognosis in terms of surgical resection.