Depression in Individuals with Epilepsy

Effectiveness of Shugan Jieyu capsules for psychiatric symptoms of epilepsy: a systematic review and meta-analysis

BACKGROUND

The relationship between epilepsy and depression is bidirectional. One condition exacerbates the other. However, there are no current guidelines for treating depression in epilepsy patients. In some cases, seizures worsen when antidepressants (AD) are prescribed or when they are discontinued due to adverse events. The Shugan Jieyu capsule, composed of Acanthopanax senticosus and Hypericum perforatum, is a widely used herbal medicine for treating depression. This study aimed to explore the effectiveness and safety of Shugan Jieyu capsules (SJC) in relieving depression in patients with epilepsy.

METHODS

We searched English, Korean, Japanese, and Chinese databases in October 2023 to collect all relevant randomized clinical trials (RCTs). The primary outcomes were the depression scale scores and seizure frequency. The secondary outcomes were quality of life (QoL) and adverse events.

RESULTS

Nine RCTs were included in this meta-analysis. Compared with AD, SJC showed significant differences in the improvement of depression (SMD: 3.82, 95% CI: 3.25, 4.39) and reduction in seizure frequency (MD: 0.39 times/month, 95% CI: 0.28, 0.50). SJC showed more beneficial results than antiepileptic drugs (AED) in terms of antidepressant effects (SMD: 1.10, 95% CI: 0.69, 1.51) and QoL (MD: 11.75, 95% CI: 10.55, 12.95). When patients were prescribed AED, the additional administration of SJC improved depression symptoms (SMD: 0.96, 95% CI: 0.28, 1.63). The SJC treatment group had a lower incidence of side effects than the control group. However, the difference was not statistically significant.

CONCLUSIONS

Our results suggest that SJC may be effective in treating depression in patients with epilepsy. Additionally, SJC has the potential to help reduce seizure frequency in epilepsy patients with depression.

Concurrent mood and anxiety disorders are associated with pharmacoresistant seizures in patients with MTLE

OBJECTIVE

To investigate whether mood disorders (MD) and anxiety disorders (AD) are associated with seizure control in patients with mesial temporal lobe epilepsy (MTLE). We compared patients without any current psychiatric disorder, patients with current MD and/or AD, patients with subsyndromic depression episodes (SSDE) and anxiety episodes (SSAE), and patients with family psychiatric history.

METHODS

In a cross-sectional study, we included 144 consecutive patients with MTLE (82 pharmacoresistant and 62 treatment-responsive patients). Every patient underwent a psychiatric evaluation including the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) Axis I (SCID-I), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), and Interictal Dysphoric Disorder Inventory (IDDI). Patients were divided into four groups: PsychNeg (G1, n = 61), current SSDE and SSAE (G2, n = 26), Current MD or AD (G3, n = 25), and current mixed MD/AD (G4, n = 32).

RESULTS

Among patients with pharmacoresistant MTLE, 68.3% (56/82) experienced symptoms of depression and/or anxiety (G2, G3, and G4) (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.41-5.53, p < 0.01). Patients with mixed MD/AD (G4, n = 24/32) were more likely to have pharmacoresistant MTLE (OR 4.04, 95% CI 1.57-10.42, p < 0.01) than psychiatric asymptomatic patients (G1, n = 26/61), and their seizure frequency was significantly higher (p < 0.01). Positive family psychiatric history was more frequent in pharmacoresistant patients (n = 27/82, OR 2.28, 95% CI 1.02-5.05, p = 0.04). Finally, 31.6% of patients with MD and or AD were not receiving psychiatric treatment.

SIGNIFICANCE

Identification of comorbid MD/AD and of family psychiatric history is of the essence in patients with MTLE, as they appear to be associated with worse seizure control.

Determinants of depression among patients with epilepsy in Athens, Greece

OBJECTIVE

Depression is common among patients with epilepsy. The aim of our study was twofold: to estimate the prevalence of a major depressive episode and to identify its determinants among patients with epilepsy treated in the largest Greek hospital in Athens.

METHODS

All consecutive patients with epilepsy that visited the epilepsy outpatient clinic of Evangelismos General Hospital were invited to participate in the study. Ninety-four patients met our inclusion criteria.

RESULTS

A diagnosis of a current major depressive episode was established in 21 out of 94 eligible to participate (22.3%) patients. Being a female was associated with a 19.68-fold increase in the odds of having a major depressive episode (95% CI 3.39-114.14, p=0.001); being unemployed was associated with a 6.46-fold increase in the odds of having a major depressive episode (95% CI 1.23-34.07, p=0.028), and each extra seizure experienced per month was associated with a 1.38-fold increase in the odds of having a major depressive episode (95% CI 1.03-1.85, p=0.031).

CONCLUSION

Unemployment, female gender, and seizure control are important determinants of a major depression episode among patients with epilepsy.

Association between leisure time, physical activity, and mood disorder levels in individuals with epilepsy

The aim of this study was to investigate the association between physical activity levels (occupational, sports, and leisure time activities), depression, anxiety, and epilepsy. The behavioral outcomes of individuals with epilepsy (E) were also compared with healthy control subjects (C). The sample included 31 individuals with epilepsy (12 with idiopathic generalized epilepsy and 19 with partial epilepsy) and 31 control subjects. Self-rating questionnaires were used to assess mood (State-Trait Anxiety Inventory and Beck Depression Inventory), anxiety, and depression as well as habitual physical activity. Patients with epilepsy were more severely impaired compared to control subjects in both mood questionnaires and presented higher levels of depression (35%), state anxiety (18%), and trait anxiety (12.6%) when compared to the C group. Although physical activity level did not differ significantly between groups, linear regression analyses showed that the physical activity leisure level predicted 31% of depression levels and 26% of anxiety levels in the E group. These data suggest that low levels of physical activity may be considered a risk factor for the development of depression and anxiety and can play an important role in the quality of life of individuals with epilepsy.

Effect of saponin fraction from Ficus religiosa on memory deficit, and behavioral and biochemical impairments in pentylenetetrazol kindled mice

In our previous study, the saponin-rich fraction (SRF) of adventitious root extract of Ficus religiosa L. (Moraceae) was shown to have an anticonvulsant effect in acute animal models of convulsions. The present study was envisaged to study the effect of SRF in the pentylenetetrazol (PTZ) kindling mouse model and its associated depression and cognition deficit. Treatment with the SRF (1, 2 and 4 mg/kg; i.p.) for 15 days in kindled mice significantly decreased seizure severity on days 5, 10 and 15 when challenged with PTZ (35 mg/kg; i.p.). Marked protection against kindling-associated depression was also observed on days 10 and 15 in the SRF-treated groups when tested using the tail-suspension test. However, the SRF treatment failed to protect kindling-associated learning and memory impairments in the passive shock avoidance paradigm. The observed behavioral effects were corroborated with modulation in the levels of noradrenaline, dopamine, serotonin, GABA and glutamate in discrete brain regions.

Dual protective effect of Passiflora incarnata in epilepsy and associated post-ictal depression

ETHNOPHARMACOLOGICAL RELEVANCE

Passiflora incarnata L. (Passifloraceae) has been used for the treatment of epilepsy in several traditional systems of medicine.

AIM OF THE STUDY

The aerial parts of Passiflora incarnata contain multiple bioactive metabolites such as, flavonoids (like, chrysin that show CNS depressant activity by agonizing GABA-benzodiazepine receptor), amino acids (like, GABA), harmala alkaloids (reversible monoamine oxidase-A inhibitor), etc. In view of this, the present study was designed to investigate dual protective effect of the hydroethanolic extract of Passiflora incarnata in pentylenetetrazol (PTZ)-induced seizure and associated post-ictal depression.

MATERIALS AND METHODS

Different groups of mice were administered with repeated subconvulsive doses of PTZ (50mg/kg; i.p.) at an interval of 5 days for 15 days. From 5th to 15th day the animals in different groups were administered daily with varying doses of hydroethanolic extract of Passiflora incarnata (150, 300, and 600mg/kg; i.p.), diazepam (2mg/kg; i.p.) and vehicle. On every 5th day, after PTZ treatment, seizure severity (score) was noted. Following convulsive episodes the locomotor activity (using actophotometer) and immobility period (using forced swim test) were also determined. On 15th day after behavioral assessment, the brain serotonin and noradrenaline levels were determined using spectrofluorometric methods.

RESULTS

Treatment with the extract significantly (p<0.05) reduced the seizure severity and immobility period as compared to vehicle control, in a dose and time-dependent manner. Moreover, the extract treatment retained the serotonin and noradrenaline levels of the brain.

CONCLUSIONS

The results of present study concluded that the hydroethanolic extract of Passiflora incarnata suppress PTZ-induced seizures, and ameliorates its associated post-ictal depression, which has been found to be get worsened with the standard antiepileptic drug, diazepam.

Amygdala volume and psychopathology in childhood complex partial seizures

OBJECTIVE

The purpose of this study was to compare amygdala volume in children with cryptogenic epilepsy who have complex partial seizures (CPS) with that of age- and gender-matched normal children. The relationship of amygdala volume to seizure variables and presence of psychopathology was also examined in these patients.

METHODS

Twenty-eight children with cryptogenic epilepsy, all of whom had CPS, and gender-matched normal children, all aged 6-16 years, underwent magnetic resonance imaging (MRI) at 1.5T. Tissue was segmented, and total brain volume and amygdala volumes obtained from manual tracings were computed.

RESULTS

There were no significant differences in amygdala volume between the CPS and normal groups. Within the CPS group, the children with an affective/anxiety disorder had significantly larger left amygdala volumes, as well as greater amygdala asymmetry, compared with those with no psychopathology. Exploring the association between seizure variables and amygdala volume yielded no significant predictors.

CONCLUSIONS

In pediatric CPS, left amygdala involvement may reflect effects of the neuropathology underlying comorbid affective or anxiety disorders on amygdala development rather than effects of ongoing seizures.

Interactions between seizure frequency, psychopathology, and severity of intellectual disability in a population with epilepsy and a learning disability

Despite observations associating lower IQ and psychopathology in epilepsy, the possible differential effects of varying severity of learning (intellectual) disability (LD) on the manifestation of psychopathology in people with LD and epilepsy have not been clarified. In this study of retrospectively collected data describing the epilepsy, learning disability, and psychopathology of 175 patients with epilepsy and LD over a 3-month period, we observed that 65 patients had no recent seizures, whereas 110 had experienced at least one seizure in the preceding 3 months. We found that depression and psychoses were more common in those with no seizures in the preceding 3 months, but that which of these psychiatric states was manifest was related to the severity of LD. Psychosis rates were higher in those with mild LD, whereas depression rates were higher in those with severe LD.

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.

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.

Depression and Anxiety Disorders in Pediatric Epilepsy

PURPOSE

This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables.

METHODS

A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children, aged 5 to 16 years. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist.

RESULTS

Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation.

CONCLUSIONS

These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.

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.

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.

The impact of epilepsy on subjective health status

Epilepsy is a chronic disorder that has complex effects on many aspects of personal health. Recent advances in the methods to reliably and validly assess subjective health status have allowed major advances in our understanding of these diverse effects, and have also provided evidence to guide treatment and future research. Studies that have included measures of quality of life, patient preferences, and disability in epilepsy have shown that the magnitude of the adverse effects of recurrent seizures on many aspects of subjective health status is as large as that seen with diabetes mellitus and active cardiovascular disease. Studies of patient-oriented, comprehensive outcomes after epilepsy surgery indicate positive treatment effects in broad areas of function and well-being. Although few trials of epilepsy drugs have included health outcome instruments, available studies suggest that greater than 50% seizure reduction is associated with improved quality of life. Adverse medication effects and depression appear to have a strong association with subjective health status in epilepsy, independent of seizure frequency.