Depression in epilepsy: etiology, phenomenology, and treatment

Depression and suicide in epileptic victims: a population-based study of suicide victims during the years 1988-2002 in northern Finland

Patients with epilepsy are known to have comorbid affective disorders and a higher risk for suicide compared with the general population. Epilepsy, depression, and suicidal behavior have been shown to have common pathogenic mechanisms in their etiology. We evaluated the association between epilepsy, suicidal behavior, and depression by using the comprehensive database of all suicides (n=1877) committed in northern Finland during the years 1988-2002 with information on all hospital-treated somatic and psychiatric disorders. Hospital-treated epilepsy occurred in 1.3% of the victims. Compared with other suicide victims, those with epilepsy were more often female, were older, and had significantly more often suffered from depression. Epilepsy was first diagnosed 8.8 (3.9-11.6) years before suicide, and depression, about 1 year after epilepsy diagnosis. Interictal depression among patients with chronic epilepsy is often classified as atypical or chronic depression, or it can mimic a dysthymic disorder. Therefore, diagnosis and treatment of depression among patients with epilepsy constitute a great challenge in clinical practice.

Depression and anxiety in epilepsy: the association with demographic and seizure-related variables

BACKGROUND

Depression and anxiety are common psychiatric symptoms in patients with epilepsy, exerting a profound negative effect on health-related quality of life. Several issues, however, pertaining to their association with psychosocial, seizure-related and medication factors, remain controversial. Accordingly, the present study was designed to investigate the association of interictal mood disorders with various demographic and seizure-related variables in patients with newly-diagnosed and chronic epilepsy.

METHODS

We investigated 201 patients with epilepsy (51.2% males, mean age 33.2 +/- 10.0 years, range 16-60) with a mean disease duration of 13.9 +/- 9.5 years. Depression and anxiety were assessed in the interictal state with the Beck Depression Inventory, 21-item version (BDI-21) and the state and trait subscales of the State-Trait Anxiety Inventory (STAI-S and STAI-T), respectively. The association of mood disorders with various variables was investigated with simple and multiple linear regression analyses.

RESULTS

High seizure frequency and symptomatic focal epilepsy (SFE) were independent determinants of depression, together accounting for 12.4% of the variation of the BDI-21. The STAI-S index was significantly associated with the type of epilepsy syndrome (SFE). Finally, high seizure frequency, SFE and female gender were independent determinants of trait anxiety accounting for 14.7% of the variation of the STAI-T.

CONCLUSION

Our results confirm the prevailing view that depression and anxiety are common psychological disorders in epileptics. It is additionally concluded that female gender, high seizure frequency and a symptomatic epilepsy syndrome are independent risk factors for the development of anxiety and/or depression.

Psychiatric events in epilepsy

Psychiatric events are thought to be more frequent in people with epileptic seizures than in the general population. However, inter-ictal psychiatric events attributable to epilepsy remain controversial. The aim of the present study was to evaluate the occurrence of psychiatric events in a population of fairly unselected patients with epilepsy and in the general population, and the correlation between psychiatric complaints and selected demographic and disease characteristics. The survey was part of a multicentre prospective cohort study of everyday life risks conducted in eight European countries and comparing referral children and adults with epilepsy referred to secondary/tertiary centers to age- and sex-matched non-epileptic controls. Nine hundred and fifty-one patients with epilepsy and 909 controls were studied. Each patient and his/her control received a diary to record any accident or illness, with severity, circumstances, causes, consequences, and (for the cases) the possible relation to a seizure. The follow-up period ranged between 1 and 2 years. Fifty-eight psychiatric events occurred in 25 patients (2.6%) and 88 in 19 controls (2.1%). Housewives (9.3%) and unemployed persons (4.1%) were mostly affected. No correlation was found between psychiatric events, demographic and disease characteristics. Our results suggest that people with epilepsy if unselected are not at higher risk for psychiatric disorders than the general population.

Increased rate of treatment with antidepressants in patients with epilepsy

The risk of depressive and anxiety disorders is increased among patients with epilepsy, but it is not known whether patients are treated with antidepressants in clinical practice. In a nationwide case register linkage study, all patients who received a main diagnosis of epilepsy or osteoarthritis on first admission or outpatient contact during the period 1995 to 2000 in Denmark were identified, and rates of subsequent purchases of antidepressants were calculated. Comparisons were also made with a gender-, age-, and calendar-matched sample of the general population. Patients diagnosed with epilepsy had a 1.73 (95% CI: 1.45-2.06) times increased rate of subsequently purchasing antidepressants, compared with patients diagnosed with osteoarthritis and a 2.44 times (95% CI: 2.12-2.81) increased rate compared with the rate among the general population. It is concluded that patients with epilepsy have a moderately increased probability of being prescribed antidepressants in clinical practice.

The acceleration of amygdala kindling epileptogenesis by chronic low-dose corticosterone involves both mineralocorticoid and glucocorticoid receptors

We have previously demonstrated that low-dose corticosterone (CS) administration, used as a model of the effect of chronic stress, accelerates epileptogenesis in the electrical amygdala kindling rat model of temporal lobe epilepsy (TLE). This current study examined the relative contributions to this effect of mineralocorticoid (MR) and glucocorticoid (GR) subtypes of glucocorticoid receptors. Female non-epileptic wistar rats 10-13 weeks of age were implanted with a bipolar electrode into the left amygdala. Five treatment groups were subjected to rapid amygdala kindling: water-control (n=9), CS treated (6 mg/100 ml added to drinking water; n=9), CS+spironolactone (MR antagonist, 50 mg/kg sc; n=9), CS+mifepristone (GR antagonist, 25 mg/kg sc; n=9), and CS+both antagonists (n=7). Rats were injected with vehicle or the relevant antagonist twice daily for the entire kindling period. Experimental groups differed significantly in the number of stimulations required to reach the 'fully kindled state' (Racine, 1972) ANOVA, F(4,38)=2.73, p=0.04). Amygdala kindling was accelerated in the CS-treated group compared with water controls (mean stimulations for full kindling: 45.2 vs. 86.5, p<0.01). This acceleration was inhibited by both the MR and GR antagonist treatments (mean stimulations: 69.6 and 70.4, p=0.04 and 0.04 vs. CS group, respectively), with the kindling rates in these groups not significantly different from water-treated subjects (p=0.26 and 0.29, respectively). The kindling rates in the MR and GR antagonist treatment groups did not significantly differ from each other (p=0.93), nor from the combined treatment group (mean stimulations: 62.8, p=0.59 and 0.54, respectively). This study demonstrates that activation of both high-affinity (MR) and low-affinity (GR) glucocorticoid receptors are involved in mediating CS-induced acceleration of amygdala kindling epileptogenesis.

Oxcarbazepine improves mood in patients with epilepsy

This study prospectively examined whether continued add-on treatment with oxcarbazepine (OXC) is associated with quantitative improvement in mood and anxiety symptoms in adult patients with partial epilepsy. Depressive symptoms and anxiety were assessed by clinical interview using the Hamilton Depression Rating Scale (HDRS), the Cornell Dysthymia Rating Scale (CDRS), the Beck Depression Inventory (BDI), and the Hamilton Anxiety Rating Scale (HARS). Forty controls (patients with epilepsy treated with antiepileptic drugs other than OXC) and 40 OXC-treated patients were enrolled and completed the study. In our study, a significant improvement in affect, as measured by the CDRS, was demonstrated during the course of OXC treatment for 3 months. HDRS and BDI scores also declined in the OXC-treated group, but these decreases did not reach statistical significance. In addition, 28 of 40 OXC-treated subjects who were dysthymic by CDRS criteria on study entry (score > or =20) demonstrated affective improvement consistent with a treatment-related antidepressant effect (score <20). Although our results do not provide conclusive evidence supporting the specific use of OXC as an antidepressant, the significant decline in dysthymic symptoms in OXC-treated subjects compared with controls lends support to the hypothesis that OXC improves mood.

Sertraline and fluoxetine: safe treatments for children and adolescents with epilepsy and depression

OBJECTIVE

Depression is frequent, underdiagnosed, and untreated in people with epilepsy. The lack of treatment is partially explained by the concerns over the proconvulsive effects of psychoactive drugs. There are few studies on the effects of selective serotonin reuptake inhibitors (SSRIs) in adults with epilepsy and none in children. The main purpose of the present study was to analyze the impact of SSRIs on the severity and frequency of seizures in children and adolescents with epilepsy and major depressive disorders. In addition, we also evaluated the efficacy of SSRIs in the treatment of depressive symptoms and side effects other than seizure aggravation.

METHODS

Monthly frequency of seizures was recorded in the 3-6 months preceding the introduction of SSRIs. According to the criteria proposed by A.M. Kanner, A.M. Kozak and M. Frey (Epilepsy Behav 2000;1:100-5), a positive correlation between introduction of SSRIs and seizure worsening should be considered in the following circumstances: (1) occurrence of de novo generalized tonic-clonic (GTC) seizures; (2) recurrence of GTC seizures following a period of at least 1 year without such episodes; and (3) increase in monthly seizure frequency compared with that reported before introduction of SSRIs. Seizure worsening was considered as probably caused by an SSRI when the increase in monthly frequency occurred in a period up to 3 months after the beginning of SSRI use.

RESULTS

Thirty-six children with epilepsy had a depressive disorder. Seizures worsened in two patients. Among this group of patients with depression, all had an improvement in their depressive symptoms. One patient taking fluoxetine had a facial rash and one patient taking sertraline had gastrointestinal disorders. These conditions improved, with total remission, when fluoxetine was replaced with sertraline and vice versa.

CONCLUSION

In this sample of children and adolescents with epilepsy and depressive disorders, we observed that SSRIs are a good therapeutic option, considering their efficacy in remission of depressive symptoms, their few adverse effects, and their maintenance of satisfactory seizure control. Treatment of depression should be considered relevant in the treatment of patients with epilepsy.

The psychological impact of a newly diagnosed seizure: losing and restoring perceived control

This study aimed to characterize the process of psychosocial adjustment following a newly diagnosed seizure. Eighty-five adult patients were assessed 1 and 3 months after a first seizure presentation with a purpose-developed semistructured interview, the NEWQOL, and the COPE. Among a broad range of patient concerns, psychological issues were paramount, representing a process of losing and restoring perceived control. Two psychological adjustment trajectories were identified, which hinged on the experience of a limited (n=37) or pervasive (n=48) loss of control. These adjustment trajectories were predicted by demographic and clinical factors. The pervasive group described a more extensive process of reevaluation, leading to an improved sense of self at 3 months. Pervasive loss of control, anxiety, and depression predicted subsequent seizure recurrence. Overall, a first seizure can trigger a complex adjustment process, which might require therapeutic management in some patients.

Epileptiformic activity induced by antidepressants in amygdala-kindled rats

The present study was undertaken to investigate the spontaneous epileptiformic activity induced by antidepressants using amygdala-kindled rats. The intraperitoneal injection of imipramine and amitriptyline resulted in potent behavioral and electroencephalogram (EEG)-detected seizures in amygdala-kindled rats compared with those seen in sham rats (non-kindled rats). Almost the same findings were observed with clomipramine and maprotiline. On the other hand, paroxetine caused no or little behavioral or EEG seizures in either amygdala-kindled or sham rats, even at a dose of 50 mg/kg. In conclusion, our results indicate that epileptiformic activity induced by kindling increases the susceptibility to cyclic antidepressant-induced seizures.

Effect of lamotrigine on depressive symptoms in adult patients with epilepsy

In this investigation, the effects of lamotrigine versus placebo on depressive symptoms in patients with epilepsy were prospectively assessed. This investigation was a secondary analysis of a randomized, double-blind, placebo-controlled, parallel-group study in which adult patients received adjunctive lamotrigine (n=32) or placebo (n=38) for a 7-week dose escalation phase, followed by a 12-week maintenance phase, for primary generalized tonic-clonic (PGTC) seizures. Mood symptoms were assessed with the Beck Depression Inventory, second edition (BDI-II), the Profile of Mood States (POMS), and the Cornell Dysthymia Rating Scale-Self-Report (CDRS). Mean (SD) BDI-II scores at screening reflected mild depressive symptoms and were similar between groups (lamotrigine 18.3 (12.1), placebo 16.8 (12.0)). At the end of the maintenance phase, mean (SD) improvement from baseline was greater with lamotrigine than placebo with respect to BDI-II score (lamotrigine 8.9 (7.6), placebo 1.7 (8.5), P=0.01) and POMS total score (lamotrigine 32.0 (30.4), placebo 6.5 (32.3), P=0.03) and numerically greater with lamotrigine than placebo for CDRS score (lamotrigine 7.3 (7.8), placebo 4.1 (13.9), P=0.50). Among the subset of patients with at least mild depression (BDI-II score10), mean improvement from baseline was numerically, but not statistically significantly, greater with lamotrigine (11.5, n=13) than placebo (3.1, n=18) (P=0.054). Median percentage reductions in seizure frequency were significantly greater with lamotrigine than placebo during the escalation phase, the maintenance phase, and the escalation and maintenance phases combined for PGTC seizures and all generalized seizures. However, improvement in seizure frequency was not correlated with improvement in mood (r=0.1, P=ns). Compared with placebo, lamotrigine improved mood symptoms independently of seizure reduction in patients with generalized seizures. Lamotrigine may be useful in treating patients with epilepsy and comorbid depressive symptoms.

Health habits, attitudes and behavior towards oral health of children with epilepsy

Introduction: Children suffering from epilepsy are high at risk of oral diseases primarily due to their underlying medical condition which can have an impact on the maintenance level of oral hygiene, but also due to adverse effects of antiepileptic drugs. Objective. The aim of this paper was to identify habits, attitudes and behavior of children with epilepsy and parents in respect to oral health. Method. The experimental group consisted of 50 children with epilepsy, 24 boys and 26 girls, 7-14 years old, mean age 11.2?2.2 years. The control group consisted of healthy children, matched by age and gender. The instruments of investigation consisted of the structured interview of children and parents concerning oral health habits, attitudes and behavior. We used medical records of children with epilepsy as a source of information on their diagnosis, duration of the illness and current therapy. Statistical analysis was performed by chi-squared test, nonparametric correlation, Wilcoxon?s signed rank test and logistic regression. Results. Results showed that more children with epilepsy and their parents had inappropriate habits and attitudes towards oral health, as well as nutrition habits (p<0.001). Compared to healthy controls, children with epilepsy washed their teeth less often and shorter, they had less knowledge about causes of oral diseases and about influence of oral diseases on general health, and they had worse self-rating of teeth and gum condition. In addition, significantly more children with epilepsy used an incorrect technique of teeth brushing (p<0.001). Characteristics of children?s epilepsy and educational degree of parents had no influence on these differences. Conclusion. Study results showed that children with epilepsy and their parents had worse habits, attitudes and behavior towards oral health than healthy controls and their parents. This difference can be explained primarily by worse parental estimation of oral health and behavior towards oral health in comparison to parents of healthy controls. .

Depression in Temporal Lobe Epilepsy Surgery Patients: An FDG-PET Study

PURPOSE

Depression is common in temporal lobe epilepsy (TLE) and after temporal lobectomy, and its etiology is obscure. In nonepileptic depression (including depression associated with other neurologic disorders), a consistent PET imaging finding is frontal lobe hypometabolism. Many TLE patients have hypometabolism involving frontal regions. Thus in data available from routine clinical assessments in an epilepsy surgery unit, we tested the hypothesis that the pattern of hypometabolism, particularly in the frontal lobe, may be associated with the depression seen in patients with TLE and TLE surgery.

METHODS

We studied 23 medically refractory TLE patients who underwent anterior temporal lobectomy and who had preoperative FDG-PET scanning. All patients had pre- and postoperative psychiatric assessment. By using statistical parametric mapping (SPM-99), patterns of hypometabolism were compared between patients who had a preoperative history of depression (n=9) versus those who did not (n=14) and between those in whom postoperative depression developed (n=13) versus those in whom it did not (n=10). A significant region of hypometabolism was set at p<0.001 for a cluster of >or=20 contiguous voxels.

RESULTS

Patients with a history of depression at any time preoperatively showed focal hypometabolism in ipsilateral orbitofrontal cortex compared with those who did not (t=4.64; p<0.001). Patients in whom depression developed postoperatively also showed hypometabolism in the ipsilateral orbitofrontal region (t=5.10; p<0.001).

CONCLUSIONS

Although this study is methodologically limited, and other explanations merit consideration, orbitofrontal cortex dysfunction, already implicated in the pathophysiology of nonepileptic depression, may also be relevant to the depression of TLE and temporal lobectomy.

Correlation between Cognition and Behavior in Epilepsy

Cognitive function is more frequently impaired in people with epilepsy than in the general population, and the degree of cognitive impairment varies according to the epilepsy syndrome. Behavioral disorders are also more frequent in people with epilepsy than in individuals who do not have epilepsy. Behavioral disturbance is observed more frequently in people with drug-resistant epilepsy, frequent seizures, and/or associated neurological or mental abnormalities. In children and adolescents, many data suggest a close link between behavior/cognition and some specific epilepsy syndromes. For example, aspects of mood, behavior, personality, and cognition may be related to temporal lobe epilepsy or juvenile myoclonic epilepsy. Behavioral disorders may precede, occur with, or follow a diagnosis of epilepsy; they differ between children and adults. Predictors of behavioral disorders in children with epilepsy are the epilepsy itself, treatment, the underlying lesion, and personal reactions to epilepsy. More specifically, conditions in which behavioral disorders may be associated with epilepsy include depression, psychosis, particular personality traits, aggression, anxiety, and attention deficit and hyperactivity disorder.

Mechanism of imipramine-induced seizures in amygdala-kindled rats

The present study was undertaken to get insight in the possible mechanisms of imipramine-induced seizures in amygdala-kindled rats. The intraperitoneal (i.p.) injection of imipramine produced potent behavioral and electroencephalogram (EEG) seizures in amygdala-kindled rats. Histidine (1500 mg/kg, i.p.) and histamine (10 and 20 microg, i.c.v.) significantly attenuated the seizures induced by imipramine (50 mg/kg, i.p.) in kindled rats. In addition, the inhibition of imipramine-induced seizures by histamine (20 microg, i.c.v.) was antagonized by an H1 antagonist, pyrilamine. An H3 antagonist, thioperamide (50 microg, i.c.v.), also significantly attenuated the imipramine-induced seizures in kindled rats. The i.p. injection of alpha-methyl-p-tyrosine at a dose of 250 mg/kg significantly diminished the seizures induced by imipramine. However, p-chlorophenylalanine and physostigmine did not affect the imipramine-induced seizures to any extent. These data give strong hints that the H1 receptor antagonistic properties and the brain noradrenaline activating effects of imipramine are centrally involved in imipramine-induced seizures, and central serotonergic and cholinergic neurotransmissions are not involved in the seizures induced by imipramine in amygdala-kindled rats.

[Clinical features, diagnosis, and treatment of dysphoric states and psychoses associated with epilepsy]

Although dysphoric states and psychoses represent clinically relevant psychiatric complications in patients with epilepsy, their symptomatologies are complex and therefore frequently underrecognized and undertreated in daily psychiatric routine. Detecting dysphoric states and psychoses secondary to the psychotropic effects of various antiepileptic drugs is often challenging, even for the most experienced psychiatrists. This article gives an overview of epidemiology, clinical features, diagnosis, and therapy of interictal, peri-ictal, and alternative dysphoric states and psychoses in patients with epilepsy. Further, potential drug interactions between antiepileptic and psychiatric medications are discussed.

Postpartum depression in women with epilepsy versus women without epilepsy

The goal of this study was to determine if there is a significant difference in the rate of postpartum depression among patients with epilepsy and healthy controls. All patients were recruited from the Epilepsy Center and the Department of Obstetrics and Gynecology, University of Milan, St. Paolo Hospital (Milan, Italy). Thirty-five pregnant women with epilepsy and an equal number of pregnant women without epilepsy were assessed with the Edinburgh Postnatal Depression Scale (EPDS), a clinical interview used to screen for postpartum depression (PPD), and a sociodemographic questionnaire. The rate of PPD in patients with epilepsy was statistically significantly higher than that of the controls (P<0.05). PPD was present in 29% of the patients with epilepsy and 11% of the controls. In conclusion, it is very important to point out that in our pilot study, the rate of PPD was higher among women with epilepsy than among women without epilepsy. In this regard, women at higher PPD risk can be identified earlier and treated as soon as possible to alleviate their symptoms and improve their quality of life.

Rapid detection of major depression in epilepsy: a multicentre study

BACKGROUND

Depression is a common comorbid disorder in epilepsy but is not routinely assessed in neurology clinics. We aimed to create a rapid yet accurate screening instrument for major depression in people with epilepsy.

METHODS

We developed a set of 46 items to identify symptoms of depression that do not overlap with common comorbid cognitive deficits or adverse effects of antiepileptic drugs. This preliminary instrument and several reliable and valid instruments for diagnosis of depression on the basis of criteria from the Diagnostic and Statistical Manual IV, depression symptom severity, health status, and toxic effects of medication were applied to 205 adult outpatients with epilepsy. We used discriminant function analysis to identify the most efficient set of items for classification of major depression, which we termed the neurological disorders depression inventory for epilepsy (NDDI-E). Baseline data for 229 demographically similar patients enrolled in two other clinical studies were used for verification of the original observations.

FINDINGS

The discriminant function model for the NDDI-E included six items. Internal consistency reliability of the NDDI-E was 0.85 and test-retest reliability was 0.78. An NDDI-E score of more than 15 had a specificity of 90%, sensitivity of 81%, and positive predictive value of 0.62 for a diagnosis of major depression. Logistic regression showed that the model of association of major depression and the NDDI-E was not affected by adverse effects of antiepileptic medication, whereas models for depression and generic screening instruments were. The severity of depression symptoms and toxic effects of drugs independently correlated with subjective health status, explaining 72% of variance. Results from a separate verification sample also showed optimum sensitivity, specificity, and predictive power at a cut score of more than 15.

INTERPRETATION

Major depression in people with epilepsy can be identified by a brief set of symptoms that can be differentiated from common adverse effects of antiepileptic drugs. The NDDI-E could enable rapid detection and improve management of depression in epilepsy in accordance with internationally recognised guidelines.

Factors associated with generic and disease-specific quality of life in temporal lobe epilepsy

PURPOSE

We aimed at further elucidating the association between quality of life (QOL) and sociodemographic factors, clinical seizure factors, depression and anxiety in drug-resistant temporal lobe epilepsy (TLE).

METHODS

We studied 106 consecutive adult right-handed patients (mean age 35.4 +/- 9.7; 50% males; IQ> or = 70) with drug-resistant unilateral (59% right) TLE (70% hippocampal sclerosis, 30% tumors or other lesions), who underwent a comprehensive non-invasive pre-surgical protocol. They completed the Beck Depression Inventory (BDI) and the State Form of the Spielberger State-Trait Anxiety Inventory (STAI). To measure QOL, we used both a generic instrument, the WHOQOL-100, and a disease-specific instrument, the 31-item quality of life in epilepsy (QOLIE-31). Multiple linear regression analysis was used to examine the relationship between each QOL domain and age, gender, education, side of TLE, duration of epilepsy, seizure frequency, and level of depression and anxiety.

RESULTS

Severity of depressive symptoms was significantly associated with lower scores across most QOL domains. Depression was consistently the strongest predictor of lower scores on almost all QOL domains. Also, severity of anxiety symptoms was significantly associated with lower scores across many QOL domains. Independent significant relationships between QOL and sociodemographic or clinical epilepsy variables were limited in number and strength.

CONCLUSIONS

Our findings suggest that QOL in TLE might be substantially affected by the presence and severity of depressive symptoms and, to a lesser degree, of anxiety symptoms. While clinical seizure variables had a weaker association with QOL, the absence of seizure-free patients might have obscured a relation between seizure frequency and QOL. Healthcare professionals should be aware of the significance of patients' emotional state and of the role it plays for their QOL. Adopting a biopsychosocial approach might be useful to address patients' needs.

The relationship between fatigue and depression, and event-related potentials in epileptics

The aim of the present study was to establish the rate of fatigue and the relationship between fatigue, depression, and P300 in people with epilepsy. We compared Fatigue Severity Scale (FSS) and Beck Depression Inventory (BDI) scores and event-related potentials (ERPs) of people with epilepsy (n=73) with those of controls (n=31). The rate of fatigue was found to be 42.4%, and fatigue and depression were positively correlated. There was an interaction between fatigue and ERPs, but the effect of ERPs on fatigue was greater. While polytherapy was a major factor affecting ERPs, depression had no effect on ERPs in people with epilepsy. The data suggest that fatigue is an important finding and is strongly correlated with cognitive processes and depression. Polytherapy contributed to cognitive disturbances and, hence, fatigue, whereas depression had no effect on cognitive processes in people with epilepsy.

Cognitive dysfunction in epilepsy: case reports

Cognitive dysfunction in people with epilepsy is a frequently encountered but also easily overlooked problem. In this article three patients with epilepsy are presented with cognitive problems due to a relapse of seizures, due to continuing absence seizures or as a consequence of deteriorating mental functions resulting from frequent complex partial seizures. In the last patient the decline in mental functioning was also demonstrated in a disseminated activation pattern on her fMRI, which contrasts with the localised activity as seen in controls on fMRI. Suggestions how to handle these problems in daily practice are given.

Risk factors for depression in patients with epilepsy

PURPOSE

Symptoms of depression are present in 40 to 60 percent of patients with epilepsy. Prior research indicated significant correlation between the incidence and frequency of focal seizures and clinical depression, especially in patients with temporal lobe epilepsy. Anticonvulsive drugs and psychosocial factors contribute to the occurrence of depression as well. The aim of the study was to determine the major depression risk factors in patients with epilepsy.

METHODS

The research was conducted on 203 patients with epilepsy (117 females and 86 males), aged 18 to 50 years, with total time of illness ranging from 60 to 580 months. All subjects underwent the same research protocol, which was applied interictally. Interictal depression was diagnosed according to ICD-10 diagnostic criteria for affective and delusional disorders. The diagnosis was supported by Beck Depression Inventory (BDI), Hamilton Depression Rating Scale (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS). Statistical analysis included chi2 test, Fisher's exact test and stepwise logical regression model analysis.

RESULTS

In our study 100 patients with epilepsy out of 203 suffered from concurrent depression (49.2%); 76 of them had severe depression (37.4%) and 24 patients had mild depression (11.8%). Complex partial seizures and absence of secondary generalized tonic-clonic seizures were found to be the risk factors for depression. Treatment with clonazepam, frequent hospitalizations (drug-resistancy) and lack of occupational activity were revealed to be additional significant contributing factors.

CONCLUSIONS

Depression in patients with epilepsy is a serious medical and social problem since it afflicts almost one half of all patients treated in epilepsy referral centers. It seems to be correlated with certain types of epileptic seizures, with high frequency of seizures, sub-optimal pharmacologic treatment and lack of occupational and social activity.

Epidemiological and medical aspects of epilepsy in the elderly

Both the incidence and prevalence of epilepsy are high among the elderly. Cerebrovascular disease is the most common underlying cause, although as many as 25-40% of new epilepsy cases in the elderly have no obvious underlying etiology. Status epilepticus appears to occur more frequently in individuals greater than 60 years, and the morbidity and mortality of status epilepticus are significantly greater in this age group. Elderly patients with seizures, particularly complex partial seizures, present differently than younger adults, which can lead to misdiagnosis. Post-ictal confusion may last as long as 1-2 weeks in an elderly patient, as opposed to minutes in younger individuals. Adverse events are similar in symptomatology, but are more common in elderly patients and occur at lower doses and plasma drug concentrations. Neuropsychiatric disorders, such as depression and anxiety, are common in elderly patients with epilepsy, although often under-diagnosed and inadequately treated. The risk of osteoporosis is high among elderly women taking antiepileptic drugs, which underscores the importance of assessing bone health and treatment in this group. Management of the older patient with epilepsy requires an understanding of the etiologies and the medical and psychological aspects unique to this age group.

Epilepsy - success in clinical practice: translating trials to practice

Success in clinical practice results from the combination of a clinician's experience, an understanding of patient preferences and factors that influence patient perceptions, and careful interpretation of data from clinical trials. However, successful clinical trials fulfil rigid methodological requirements in order to provide a basis from which to evaluate the place of a drug within a therapeutic strategy. Their translation into practice is therefore complicated by an intrinsic tension between the requirements for scientific methods that minimize error, and the need for clinically relevant data. In practice, the clinician has the flexibility to individualize epilepsy management to maximize benefits and minimize adverse effects of antiepileptic drug (AED) therapy. AED adverse effects and psychiatric comorbidity, in particular depression, have a profound impact on subjective health status; systematic screening for these confounding variables can guide clinical management and optimize quality of life. In addition, patient preferences can be acknowledged in any management plan. To achieve success in clinical practice, we need to remember that the information gleaned from clinical trials provides only part of the picture and needs to be augmented by our clinical experience, patient assessment (including routine screening for adverse effects and depression) and patient preference.

Chronic low-dose corticosterone supplementation enhances acquired epileptogenesis in the rat amygdala kindling model of TLE

Mesial temporal lobe epilepsy (MTLE) is associated with high rates of depression and anxiety. A bidirectional causal relationship has been suggested, with these psychiatric comorbidities themselves enhancing epileptogenesis, possibly via hypercortisolemia. We examined the effects on epileptogenesis of chronic supplementation with low-dose corticosterone (CS) in the electrical amygdala kindling rat model. Adult Wistar rats were ovariectomized and implanted with bipolar electrodes into the left amygdala. After 1 week recovery, one group (n=7) had CS (3 mg/100 ml--approx. 4.5 mg/kg/day) and a control group saline (n=7) added to their drinking water, and both groups underwent twice daily electrical stimulations. Rats were culled 2 weeks after reaching the fully kindled state. A stereological optical fractionator technique was used to estimate the number of CA1 pyramidal cells in the hippocampus ipsilateral to the stimulations. Fewer stimulations were required in the CS-supplemented rats than in controls to reach the fully kindled state (32 vs 81, p<0.03, Student's t-test) and the first Class V seizure (14 vs 57, p<0.05). The mean after-discharge length was greater in the CS group (p=0.03, repeated measures analysis of variance). There was no difference in the mean number of CA1 neurons (1.05 x 10(5) vs 1.04 x 10(5), p=0.98). These data demonstrate that low-dose CS enhances epileptogenesis in this model of MTLE. This provides support for the hypothesis that chronic hypercortisolemia, as a result of stress, anxiety, and/or depression, may facilitate the development and progression of epilepsy in patients with MTLE. The lack of difference in hippocampal CA1 neurons indicates that the mechanism does not primarily involve pyramidal cell loss.

Diagnosis and treatment of mood disorders in persons with epilepsy

PURPOSE OF REVIEW

Epilepsy is a common, disabling neurological disorder associated with increased rates of comorbid psychiatric disorders as compared with the general population.

RECENT FINDINGS

Mood disorders, especially major depression, appear to be more prevalent in persons with epilepsy than in those with the other chronic disorders and the general population. Depression may have more influence on quality of life than do cognitive and seizure factors. Although psychological, social, and vocational disabilities contribute to mood dysfunction in epilepsy, functional neuroimaging studies have consistently shown correlation of presence of cerebral abnormalities with increased severity of symptoms of depression. Most persons with epilepsy are not routinely screened for depression, and depression is subsequently treated in only a minority of patients. Although serotonin receptor density is greatest in brain regions commonly associated with epilepsy, such as the mesial temporal and prefrontal areas, no controlled trials have investigated the efficacy of serotonin reuptake inhibitors in persons with epilepsy. Optimal methods to identify and treat depression in epilepsy require substantial further research.

SUMMARY

Depression is a common comorbid condition with significant negative effects on health status in persons with epilepsy, but additional understanding of the disorder is needed to improve diagnosis and treatment.

Differentiating anxiety and depression symptoms in patients with partial epilepsy

Anxiety and depression are separate psychiatric conditions that are often interrelated. This study examines whether they exist independently in this population of patients with partial epilepsy and if they affect all quality-of-life domains. Adult epilepsy patients taking two or more antiepileptic drugs completed a health status survey including demographic items, the Hospital Anxiety and Depression Scale, and the Quality of Life in Epilepsy-10 (QOLIE-10). The questionnaire was completed by 201 epilepsy patients. Symptom prevalences of anxiety (52% none, 25% mild, 16% moderate, 7% severe) and depression (62% none, 20% mild, 14% moderate, 4% severe) were high. All health-related quality-of-life (HRQOL) domains worsened significantly with increasing levels of anxiety and depression: Total QOLIE-10 scores decreased from 72+/-18 in patients with no anxiety to 54+/-13 in those with mild, 48+/-18 in those with moderate, and 40+/-23 in those with severe anxiety (P<0.0001). Total QOLIE-10 scores decreased from 70+/-16 in patients with no depression to 50+/-16 in those with mild, 45+/-16 in those with moderate, and 24+/-21 in those with severe depression (P<0.0001). No significant difference in anxiety scores was observed controlling for seizure frequency or epilepsy duration. Regression analyses showed that anxiety and depression account for different proportions of variance as predictors of HRQOL (R2=0.337 (anxiety) and 0.511 (depression)). The data suggest that patients may benefit from increased attention to the role of anxiety separately from depression.

Recurrent postictal depression with Cotard delusion

Depression is a common occurrence among epileptic patients and constitutes, along with anxiety disorders, the most frequent psychiatric condition in these patients. However, little work is done in the area of post-ictal depression especially in children with epilepsy. Here, the authors report an adolescent boy who developed recurrent depression associated with Cotard's delusion following complex partial seizure at the age of 7 years. Trial of antidepressant drug and lithium worsened the clinical picture but ultimately he responded well to carbamazepine. This case is unique in its presentation due to recurrent depression itself is rare at this age and secondly rarity of onset of Cotard delusion in prepubertal phase. This case also showed that post-ictal depression is biological process rather than psychological and social reaction. Prompt identification and management of underlying cause would definitely prevent further complication and would also prevent the child from exposing unnecessary with various pharmacological treatments.

Postictal mania associated with frontal lobe epilepsy

A 38-year-old man, possibly with frontal lobe epilepsy, developed postictal mania. The changes in psychiatric symptoms and laboratory examinations over time were investigated in two episodes of postictal mania, using long-term electroencephalography with closed circuit television (EEG/CCTV) monitoring, magnetoencephalography (MEG), and single-photon emission computed tomography (SPECT) to elucidate the underlying mechanism of postictal mania. According to the clinical symptoms, the postictal manic episodes of this case had four phases: a lucid interval, manic phase, hypomanic phase, and recovery phase. EEG showed forced normalization during the florid manic phase. The serial findings of EEG, MEG, and SPECT during the postictal manic episodes suggest that functional changes in bilateral frontal lobes, especially the right frontal lobe, right temporal lobe, and right paralimbic area, are crucial in the development of postictal mania, and that these functional changes are dynamic.

Depressed mood and memory impairment in temporal lobe epilepsy as a function of focus lateralization and localization

OBJECTIVE

Memory disorders and depressed mood are prominent psychological symptoms of temporal lobe epilepsies (TLEs). We examined the interaction of depressive mood and memory as a function of focus localization.

METHODS

One hundred fifty-two TLE patients with right mesial (n=37, RTLE-AHS), right lateral (n=31, RTLE-LAT), left mesial (n=42, LTLE-AHS), and left lateral (n=42, LTLE-LAT) lesions and epilepsies underwent comprehensive presurgical evaluation and neuropsychological assessment of mood and memory. Univariate and multivariate analyses of covariance (ANCOVAs) and partial correlation analyses were performed to reveal interactions of depression and memory as a function of focus localization.

RESULTS

No differences between the study groups were revealed for depression, indicating a general risk of 30% for depressed mood (BDI>12) in patients with TLE. ANCOVAs revealed significant main effects of focus side (left: verbal learning deficits; right: figural learning deficits) and site (mesial at disadvantage) on learning and memory scores. Correlation analyses revealed interactions between memory and mood only in LTLE-LAT patients.

CONCLUSIONS

Although the data provide evidence that side and site of the epileptogenic region differentially affect material specific memory performance, there was no evidence of a specific temporal target region for depressive mood. In the majority of the patients, depressed mood and memory impairment appeared as independent rather than as related symptoms of TLE. In LTLE-LAT, however, mood was significantly related to verbal and figural memory performance. Epilepsy-driven pathological left temporofrontal circuits are discussed as a prerequisite for the coupling of mood disorders and memory impairment in this specific patient subgroup which is also known from the psychiatric major depression syndrome.

Effects of antiepileptic medications on psychiatric and behavioral comorbidities in children and adolescents with epilepsy

The three goals of this article are (1) to delineate the limitations in determining the actual incidence of antiepileptic drug (AED) psychiatric and behavioral side effects; (2) to summarize existing data on the direct effects of AEDs on psychiatric and behavioral comorbidities and examine the relationship between these direct effects and specific AED mechanisms of action; and (3) to recognize the indirect effects of AEDs on psychiatric and behavioral medications that can result in aggravation of these comorbidities through drug-drug interactions. All of these data are then combined and formatted into a practical algorithm useful in many clinical situations.

Defining the problem: psychiatric and behavioral comorbidity in children and adolescents with epilepsy

A variety of comorbid psychiatric conditions are frequently identified in children and adolescents with epilepsy, including depression, anxiety, psychosis, and attention-deficit hyperactivity disorder. Data regarding the epidemiology and precise prevalence of comorbid disorders in childhood epilepsy are incomplete and just now beginning to be compiled. Psychiatric and behavioral comorbidities are believed to affect approximately 40-50% of children and adolescents with epilepsy. Optimal diagnosis, clinical evaluation, and choice of treatment are predicated on the proper identification of coexisting psychiatric and behavioral disorders. Comorbid conditions in children and adolescents with epilepsy should be evaluated and treated as soon as they are recognized.

Psychosocial issues in people with epilepsy in Togo and Benin (West Africa) I. Anxiety and depression measured using Goldberg's scale

PURPOSE

This study in Togo and Benin, West Africa, was aimed at measuring depression and anxiety among people with epilepsy (PWE).

METHODS

This cross-sectional study of 281 adult PWE in Togo and 215 in Benin matched with the same number of controls without epilepsy used Goldberg's anxiety and depression scale. The statistical tests used for comparisons were chi(2) tests, Fisher's exact test, analysis of variance, and Fisher's PLSD test when necessary.

RESULTS

PWE in Togo and Benin had significantly higher (P<0.0001) average depression scores (4.4+/-2.1, 4.7+/-2.7) than controls (0.5+/-0.9, 1.4+/-2.4). They also had significantly higher (P<0.0001) average anxiety scores (5.3+/-2.0, 6.2+/-2.1) than controls (2.5+/-1.6, 1.6+/-2.0). In consideration of the thresholds of the scale, the prevalence of possible major anxiety and depression among PWE was also very high compared with controls (P<0.0001). High anxiety and depression scores were, in general, positively correlated with a higher frequency of seizures and lack of treatment.

CONCLUSION

Results confirmed the existence of anxiety and depression among PWE in Togo and Benin.

The psychiatric comorbidity of epilepsy

Several studies have assessed the prevalence of psychiatric disorders in epilepsy. They are characterized by considerable heterogeneity, because of differences in the population setting and type of study. A non-systematic review of the literature allows us to draw some useful, although not definite, conclusions. Six per cent of people with epilepsy in the general population appear to suffer from a psychiatric disorder, while this rises to 10-20% in populations with temporal lobe and/or refractory epilepsy. Mood disorders are the most common culprit (24-74%), particularly depression (30%), followed by anxiety disorders (10-25%), psychoses (2-7%) and personality disorders (1-2%). This comorbidity appears to be related to endogenous and exogenous (including iatrogenic) factors and to the severity and chronicity of epilepsy. Conditions such as schizophrenia-like psychosis of epilepsy and interictal dysphoric disorder are represented only in epilepsy. Adequate recognition and treatment of psychiatric conditions in epilepsy is essential for patient management because of their considerable burden in morbidity and quality of life.

[Anxiety and depression among the epileptics in general population in Benin (Western Africa)]

In order to assess prevalence of depression and anxiety among epileptic patients and to compare it to a control population, a matched case-control survey was performed in 196 persons above 18 Year old (98 epileptics and 98 controls matched according to sex, age 10 and social environment) in Republic of Benin (West Africa), using Goldberg's Depression and Anxiety scale. Two main investigators helped by 5 sociology students were trained on a questionnaire by a psychiatrist skilled with public health matters. People taking part in the survey are epileptic patients who already used health services. Inclusions took place within 17 communes of four departments (Mono, Zou, Ouémé, Atlantique) located in Southern part of Benin. The questionnaire used an Identity sheet and the Goldberg Depression Scale. Results are shown as mean standard deviations, for quantitative values, and percents for qualitative ones. Comparisons of proportions in qualitative variables are carried out using c2 test or Fisher's exact test. Comparisons of means rates between subject's groups are carried out with a Student t test or variance analysis. The correlations between two quantitative variables were assessed by linear correlation coefficient. Significance threshold chosen for the whole set of statistics analysis is 0.05. The majority of interviewed epileptic patients is young (average 32.6 11.5 Years old). A male predominance exists (sex ratio 1.28). 93% of interviewed persons live within their family, are married or cohabit (controls: 98.2%; cases: 87.9%); 57.4% are married (controls: 70%; cases: 44%). The most represented professional categories are craftsmen and shopkeepers (29.2%) as well as farmers (19.5%). Most of recruited patients live in an urban setting (55.4%) and 63.6% of interviewed persons had been living in the area of survey for over 10 Years. The most represented religion within the sample is Christian religion (67.7%), Animists (23.3%) and Muslims (5.8%). 97% of epileptic patients reported they had one fit during the two Years before the survey; roughly one half (48%) had 2 to 5 fits and 41.5% of them had more than 10 fits; only 14% say they have had an EEG. Presence of an Anti Epileptic Drug (77.5%) reduces anxiety and depression. Considering a severity threshold of 5 for anxiety and 2 for depression (8), proportions of epileptic patients displaying a severe anxiety (79.8%) or a severe depression (89.6%) are significantly higher (p<0.0001) than in control subjects (12.3% and 46.9%). Comparison of average scores confirms the difference (p<0.0001) between cases (5.8 2.0 and 2.3 1.9) and controls (4.7 2.4 and 2.0 2.1) regarding anxiety and depression. Neither the sex, nor age, nor life environment (urban/rural), nor frequency of fits hold significant influence over an-xiety and depression. However, results in this survey include higher average rates of anxiety and depression for women (6.3 1.8) than men (5.5 1.8), though such statement is only nearly significant (p=0.06). Results of the survey confirm the other works on this topic about characteristics of depression for epileptic patients, though results here are higher than usual. Anxiety and depression are common troubles found in epileptic patient, both often occurring at the same time. Two distinct theories about this fact are opposed, first explain the connection of anxiety and depression with epilepsy because of the social and cultural burden upon an epileptic patient in those countries, the second theory is about depression and epilepsy sharing some neuroaminergical dysfunctions; these facts were not considered in this survey. When taking into account the thresholds of seriousness on Goldberg's scale, proportion of controls displaying a probably deeper depression is high (46.9%) compared to usual hospital prevalence rates (4 to 25%) found in Western Africa where survey in general population are scarce. It could either be a bias in the selection or the confirmation that family and relatives of an epileptic patient are enduring a great psychic pain too; finally, this high rate o, this high rate of severe depression within controls may suggest a need to adapt thresholds of Goldberg's scale to match African populations. This hypothesis is interesting regarding the results of some Authors who validated this scale in population of aged people; they highlighted the fewer precision of two items (lost of interest, focus difficulties) and also a slight discriminatory weight for other few items. However the psychometric characteristics of Goldberg's scale are accurate (for depression subscale, a sensitivity of 88% and a specificity of 68%; for the whole scale, a sensitivity of 84% and a specificity of 68%). It would be pertinent to carry out a study to validate Goldberg's scale within some African populations. This study also highlights the importance of psychological factors in epilepsy and suggests a specific global care of the disease.

Therapy for neurobehavioral disorders in epilepsy

Neurobehavioral disorders commonly affect patients with epilepsy. In addition to the behavioral changes during and immediately after seizures, the epileptogenic disorder of function often extends further into the postictal and interictal period. Cognitive impairments commonly affect attention, memory, mental speed, and language, as well as executive and social functions. Reducing seizure frequency and the antiepileptic drug burden can reduce these problems. Attentional deficits may respond to therapies for attention-deficit/hyperactivity disorder, but apart from patients with this comorbid disorder, their efficacy is unproven in other epilepsy patients. No effective therapies are established for other cognitive problems, but pragmatic, compensatory strategies can be helpful. Behavioral disorders include fatigue, depression, anxiety, and psychosis. Many of these disorders usually respond well to pharmacotherapy, which can be supplemented by psychotherapy. Cognitive and behavioral disorders can be the greatest cause of morbidity and impaired quality of life, often overshadowing seizures. Yet these problems often go unrecognized and, even when identified, are often undertreated or untreated.

Depression in Epilepsy: Ignoring Clinical Expression of Neuronal Network Dysfunction?

Epilepsy is a chronic disorder that adversely affects social, vocational, and psychological functioning. Despite the variety and complexity of the negative clinical associations with epilepsy, depression is remarkable in prevalence and related adverse effects on health status. An estimated 30-50% of persons with refractory epilepsy have major depression, and depression has a stronger correlation than seizure rate with quality of life. Suicide is one of the leading causes of death in epilepsy. Available data indicate that depression may result from underlying brain dysfunction rather than social and vocational disability. Most patients with depression are not screened systematically for the diagnosis, and are subsequently not treated. Although the density of serotonin receptors is greatest in limbic brain regions commonly involved in human epilepsy, such as the mesial temporal and prefrontal areas, no prior randomized controlled trials have evaluated the efficacy of serotonin reuptake inhibitors for depression in epilepsy.

Evidence of the antiepileptic potential of amiloride with neuropharmacological benefits in rodent models of epilepsy and behavior

Sodium-hydrogen exchangers (NHEs) in the brain play a key role in regulating neuronal pH and, hence, modulate bioelectric and seizure activity. In this study, we investigated the anticonvulsant effect of amiloride (a NHE inhibitor) on increasing current electroshock (ICES) and pentylenetetrazole (PTZ)-induced seizures in mice. Further, the effect of amiloride on mood, memory, grip strength, and rotarod performance was also evaluated. The forced swimming test (FST) and spontaneous alternation behavior (SAB) models were employed to assess the effects on mood and memory, respectively. Amiloride produced a dose-dependent increase in seizure threshold in both rodent models of epilepsy. It was observed that amiloride reduced behavioral depression in the FST in mice. In addition, it resulted in memory improvement in the SAB model. Amiloride did not affect grip strength and rotarod performance, suggesting it is devoid of behavioral impairment. The results indicate the potential antiseizure activity of amiloride along with additional neurological advantages.

Mood disturbance before and after seizure surgery: a comparison of temporal and extratemporal resections

PURPOSE

Mood disturbance is a common comorbid condition of temporal lobe epilepsy before and after seizure surgery. Few studies have examined mood disturbance in patients undergoing resections outside the temporal lobe (extratemporal resections). This study aimed to compare the early, postoperative evolution of mood disturbance in temporal and extratemporal lobe epilepsy patients to examine the effect of site of surgical resection on mood outcome.

METHODS

The study used a longitudinal design and was qualitative in nature. Sixty seizure surgery patients (43 temporal resections, 17 extratemporal resections) were assessed before surgery and at discharge, 1 month, and 3 months after surgery, by using the Austin CEP Interview. Psychosocial adjustment, psychiatric difficulties, including depression and anxiety, and seizure frequency were assessed.

RESULTS

Before surgery, both temporal and extratemporal patients had significant psychiatric histories with similarly high rates of depression (33 and 53%, respectively) and anxiety (23 and 18%, respectively). After surgery, significantly more temporal patients were seizure free at each of the reviews compared with extratemporal patients. Temporal patients also reported significantly higher levels of depression (26%), anxiety (42%), and psychosocial adjustment difficulties (64%) at the 1-month review than did extratemporal patients. Mood disturbance was significantly associated with adjustment difficulties in both groups, but was not related to seizure outcome at any review period.

CONCLUSIONS

A general increase in mood disturbance was evident after surgery, particularly in temporal resection patients at the 1-month review. Site of surgery and psychosocial adjustment showed significant associations with postoperative mood disturbance, supporting the role of both neurobiological and psychosocial factors in mood outcome.

Patterns of lamotrigine use in daily clinical practice during the first 5 years after introduction in the Netherlands

OBJECTIVE

Follow-up data on the long-term effectiveness (efficacy and tolerability) of lamotrigine are limited. A useful though crude measure for effectiveness in daily clinical practice is the treatment retention rate determined from drug dispensing data. This study describes the baseline characteristics, the usage patterns and the retention rate of this antiepileptic drug (AED) in a population-based cohort of lamotrigine users in the Netherlands during the first 5 years after its registration in 1995. Data from this cohort are compared with those from the initial randomized clinical trials (RCTs) in patients with refractory epilepsy.

METHODS

This retrospective cohort study used dispensing data from community pharmacies. Baseline characteristics and usage patterns were evaluated for first time users of lamotrigine in this study. Usage patterns were characterized as continued, add-on or discontinued use during the patient observation time window. Cox regression analysis was used to explore possible relationships between baseline characteristics and specific usage patterns defined. The baseline characteristics and discontinuation rates in this cohort study were compared with RCT data reported in medical literature.

RESULTS

A total of 3598 lamotrigine users were identified. The mean age of the population was 39 years and 54% were female. On average, patients used two other AEDs at the start of lamotrigine therapy and approximately 6% of the patients had no history of prior AED use. The discontinuation rate was 25% after 1 year, and approximately 32% at the end of the 5-year study. Addition of another drug or discontinuation was seen in more than half of the population 3 years after the start of therapy. Concurrent use of valproic acid was associated with a better retention rate. Absence of AED history, use of antidepressants, or use of migraine abortive drugs resulted in an increased likelihood of discontinuing lamotrigine. The population from RCTs differed from the study cohort with respect to age, concurrent use of AEDs and length of follow-up.

CONCLUSION

Data from RCTs cannot easily be extrapolated to daily clinical practice. In this large, observational study, lamotrigine therapy failed in a considerable number of patients, although the mean retention rate was better than previously reported by others. Population-based linkage of health care records can be used to further clarify the effectiveness of lamotrigine.

Depression and anxiety before and after temporal lobe epilepsy surgery

PURPOSE

To examine the course of depression and anxiety in patients with temporal lobe epilepsy (TLE) treated with epilepsy surgery (and anticonvulsant drugs) or medical means alone.

METHODS

Of 94 TLE patients evaluated for epilepsy surgery, 76 underwent a resective procedure, 18 continued on medical treatment alone. Depression (Beck Depression Inventory (BDI)) and anxiety scores (Self-Rating Anxiety Scale (SRAS)) were examined during presurgical evaluation (T1) and after a mean of 16 months (T2), or 12 months after surgery. Depression and anxiety scores were related to type of intervention, underlying epileptogenic lesion, change of seizure control and anticonvulsant therapy.

RESULTS

At T1, depression and anxiety scores were higher in patients with TLE than scores in published normal populations. At T2, depression but not anxiety scores were significantly lower than at T1. Change of depression scores interacted with improvements of seizure control.

CONCLUSIONS

Evidence of depression and anxiety is commonly found in patients with TLE. Depression improves not because of epilepsy surgery per se, but because of improved seizure control. This is more commonly achieved by surgery than medical treatment. The results are consistent with the hypothesis that depression in TLE is caused by pathological epileptic activity rather than a fixed structural defect.

Paradoxical results in the cure of chronic illness: the "burden of normality" as exemplified following seizure surgery

Little has been written about processes of recovery following life-changing medical interventions for chronic illness. This article reviews our research with chronic epilepsy patients undergoing neurosurgery for the relief of intractable partial seizures. This research has given rise to a new conceptualization of adjustment and outcome following effective treatment of chronic illness, representing the first, detailed characterization of this process from a psychological and psychosocial perspective. Crucial to outcome are patient and family expectations prior to treatment, and learning to discard roles associated with chronic illness after treatment. These and the posttreatment affective functioning of the patient temper the view of medical outcome, and can account for paradoxical clinical effects, such as worsening patient psychosocial functioning in the context of medical treatment success. Our results have clear implications for the clinical management of chronically ill patients and their families to optimize treatment outcome.

Troubles dépressifs chez les patients épileptiques suivis au sein d’une unité de consultation spécialisée

The overall prevalence of psychiatric disorders in epileptic patients is estimated between 19 and 62%. Depressive disorders may be the most common psychiatric disorders and the main reason for psychiatric hospitalisation and taking psychotropic drugs. The underdiagnosis and undertreatment of depressive disorders among epileptic patients represent a problem of considerable magnitude. The aim of the present study was to evaluate the prevalence of depressive disorders among patients with primary epilepsy and to determine the risk factors of the occurrence of the depressive illness. The survey was conducted in a outpatient epilepsy clinic in the Ibn Rochd University Hospital Centre in Casablanca. All patients with idiopathic or cryptogenic epilepsy aged 15 Years and above, were eligible, except for patients with severe physical and mental disabilities. Neurologists diagnosed the epilepsy based on clinical criteria with electroencephalograms data. The depressive disorders met a psychiatrist's evaluation of an ICD-10 criterion. Ninety-two subjects participated in the survey, 57.6% were men and the mean age was 30.3 +/- 10.8 Years. The epilepsy age of onset was 16.3 +/- 11.4 Years with an average duration of 14.1 +/- 9.2 Years. The prevalence of depressive disorders among epileptic patients in our survey was 18.5%. According to sex, the prevalence was 23.1% in women and 15.1% in men. The depressed patients were compared with the remaining patients without depression with regard to seizure variables and sociodemographic characteristics. The epilepsy-depression and epilepsy-control groups did not differ significantly in the duration of epilepsy or in the type of anticonvulsant therapy (mono versus polytherapy). Three variables were significantly different between the two groups. The mean age in the epilepsy-depression group was significantly higher (34.4 +/- 9.6 Years versus 29.4 +/- 10.9, p<0.03), the mean age of epilepsy age of onset was also higher in the epilepsy-depression group than in the epilepsy-control group (21.8 +/- 11.9 Years versus 15.04 +/- 11.0, p<0.03) and the seizure frequency per week was more important among depressed epileptic patients (2.4 + 5.2 seizures versus 0.4 + 1.5, p<0.007). The present survey confirms the findings of previous studies that the prevalence of the comorbidity between epilepsy and depression is common in specialised outpatient units. The detection and the treatment of depressive disorders among the epileptic patients remains a very great challenge in the management of the epileptic illness. It will improve the quality of life of these patients. A closer involvement of psychiatric and psychological treatment in patient management is necessary.

Depression and Altered Quality of Life in Women with Epilepsy of Childbearing Age

PURPOSE

To calculate the prevalence of depression in a referral population of women of childbearing age, to define the factors associated with depression, and to assess health-related quality of life (HRQOL) in the same population.

METHODS

The 642 consecutive women with epilepsy aged 18-55 years were enrolled by 40 neurologists over an 8-month period and asked to give details on selected demographic and clinical features regarding the disease, any associated clinical condition, and any drug treatment. Depression was diagnosed by using the Hamilton depression scale and HRQOL was measured through the SF-36 form. Demographic, clinical, and therapeutic risk factors for depression were searched for within the study population.

RESULTS

Depression (any severity) was present at interview in 242 women, giving a prevalence rate of 37.7%[95% confidence interval (CI), 33.9-41.6]. Mild depression was reported by 18.5% of women, moderate depression by 8.6%, major depression by 10.3%, and severe depression by 0.3%. Factors found to be independently associated with depression (any severity) included treatment of associated conditions [relative risk (RR), 1.5; 95% CI, 1.2-1.8), concurrent disability (RR, 1.3; 95% CI, 1.0-1.6), seizures in the preceding 6 months (RR, 1.4; 95% CI, 1.1-1.7), and being unemployed or a housewife (RR, 1.3; 95% CI, 1.0-1.5). Factors associated with moderate to severe depression included treatment for associated conditions (RR, 2.0; 95% CI, 1.4-2.7), seizures in the preceding 6 months (RR, 1.7; 95% CI, 1.2-2.5), and being unemployed or a housewife (RR, 1.6; 95% CI, 1.1-2.2). Compared with normal women of similar age, patients with epilepsy tended to present lower scores for each HRQOL domain (mostly Role Physical, General Health, Social Functioning, and Role Emotional). However, when the analysis was limited to nondepressed women with epilepsy, any difference disappeared.

CONCLUSIONS

Women with epilepsy of childbearing age are at high risk of depression. Factors associated with depression include lack of occupation, the presence of an underlying disabling condition (with treatment), and the severity of epilepsy. Compared with the general population, depressed women have greater impairment of HRQOL with epilepsy, which reflects the physical, social, and emotional implications of the disease.

Antidepressive treatment in patients with temporal lobe epilepsy and major depression: a prospective study with three different antidepressants

Major depression (MD) is underdiagnosed and undertreated in patients with temporal lobe epilepsy (TLE). Side effects of some antidepressants, like increased risk of seizures and drug-drug interactions with anticonvulsants, contribute to undertreatment of MD in patients with TLE. We analyzed post hoc the data from 2 years of treatment of inpatients with MD and TLE. Seventy-five patients received standard treatment with citalopram, mirtazapine, or reboxetine, respectively, at recommended dosage. Examinations were done with the Hamilton Rating Scale for Depression at admission and after 4 and 20-30 weeks. Plasma levels of anticonvulsants were examined at admission and discharge. Seizures were documented. The antidepressive treatment was efficacious in all antidepressant groups. No case of serious adverse event or drug interaction occurred. There was no increase in frequency or severity of seizures. At endpoint the dropout rate for mirtazapine was significantly higher than that for reboxetine or citalopram. Reboxetine showed a trend to be more efficacious than citalopram but not mirtazapine at Week 4.

Psychiatric comorbidity, health, and function in epilepsy

Epilepsy is a chronic condition that has complex effects on social, vocational, and psychological function. Several psychiatric disorders have been shown to have increased prevalence in persons with epilepsy compared to the general population. Depression appears to be the most common psychiatric comorbidity, but anxiety and other diagnoses have not been extensively investigated. Several studies have found that depression or psychological distress may be the strongest predictors of health-related quality of life, even including seizure frequency and severity, employment, or driving status. Despite the high prevalence and adverse effects of comorbid psychiatric disorders in epilepsy, very little is known about optimal treatment strategies, or even the efficacy of standard treatments. Further research is needed to increase understanding of the mechanisms of psychiatric illness in epilepsy, the effects of depression and anxiety on long-term clinical outcomes, and the most effective treatments.