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

Microglia as a Game Changer in Epilepsy Comorbid Depression

As one of the most common neurological diseases, epilepsy is often accompanied by psychiatric disorders. Depression is the most universal comorbidity of epilepsy, especially in temporal lobe epilepsy (TLE). Therefore, it is urgently needed to figure out potential mechanisms and the optimization of therapeutic strategies. Microglia play a pivotal role in the coexistent relationship between epilepsy and depression. Activated microglia released cytokines like IL-6 and IL-1β, orchestrating neuroinflammation especially in the hippocampus, worsening both depression and epilepsy. The decrease of intracellular K+ is a common part in various molecular changes. The P2X7-NLRP3-IL-1β is a major inflammatory pathway that disrupts brain network. Extra ATP and CX3CL1 also lead to neuronal excitotoxicity and blood-brain barrier (BBB) disruption. Regulating neuroinflammation aiming at microglia-related molecules is capable of suspending the vicious mutual aggravating circle of epilepsy and depression. Other overlaps between epilepsy and depression lie in transcriptomic, neuroimaging, diagnosis and treatment. Hippocampal sclerosis (HS) and amygdala enlargement (AE) may be the underlying macroscopic pathological changes according to current studies. Extant evidence shows that cognitive behavioral therapy (CBT) and antidepressants like selective serotonin-reuptake inhibitors (SSRIs) are safe, but the effect is limited. Improvement in depression is likely to reduce the frequency of seizure. More comprehensive experiments are warranted to better understand the relationship between them.

A nationwide study of initiation of antidepressant pharmacotherapy and the risk of seizures

OBJECTIVE

The present study aimed to examine whether antidepressant initiation increases the risk of hospitalizations and unplanned outpatient visits for seizures. Research has provided conflicting evidence as to whether antidepressant initiation causes seizures. Because epilepsy and depression are comorbid, this remains an important question, particularly in the care of those already at-risk for seizures.

METHODS

We used Swedish-register data, including 658,766 antidepressant initiators and 1:1 age-, region-, and sex-matched non-initiators, ages 12-65. We used filled prescriptions to identify any antidepressant and serotonergic antidepressant and inpatient hospitalizations and unplanned outpatient (to avoid coding routine epilepsy maintenance as a seizure) visits to identify seizures, respectively. We first compared seizure visit incidence between antidepressant-initiators and matched non-users in the year following initiation from 2006 to 2013. To examine seizure risk over months pre- and post-initiation, within-individual analyses compared risk during the month one year prior to initiation with all subsequent months. We examined associations for any antidepressant and serotonergic antidepressants, as well as for any initiator and initiators with a history of seizures.

RESULTS

Our matched-cohort results showed higher incidence of seizure visits among antidepressant users compared with non-users (e.g., adjusted incidence rate ratio [IRR]=3.14, 95% confidence interval [CI]=2.83-3.49). In within-individual analyses, the months after initiation were associated with higher incidence of seizure visits when compared with the month one year prior to initiation (e.g., one month after initiation IRR=1.96, 95%CI=1.64-2.34), but in individuals with a seizure history we observed weaker or no associations in the months after initiation (e.g., two months after initiation IRR=1.12, 95%CI=0.87-1.45). Notably, irrespective of potential seizure history, the months preceding initiation were associated with the greatest risk (e.g., one month before initiation IRR=2.86, 95% CI=2.42-3.38).

CONCLUSIONS

Our findings suggest that there may be an elevated risk of seizures during antidepressant treatment, though the period of highest risk was before the initiation of antidepressants. Risk for seizure visits was lower among individuals with a history of prior seizures, which may be reassuring for the clinical care of these patients or indicate lack of treatment seeking following seizures. This study highlights the need to consider seizure risk across time; the failure to account for these dynamics may help account for discrepant findings in previous studies.

Antidepressant Drugs for Seizures and Epilepsy: Where do we Stand?

People with epilepsy (PWE) are more likely to develop depression and both these complex chronic diseases greatly affect health-related quality of life (QOL). This comorbidity contributes to the deterioration of the QOL further than increasing the severity of epilepsy worsening prognosis. Strong scientific evidence suggests the presence of shared pathogenic mechanisms. The correct identification and management of these factors are crucial in order to improve patients' QOL. This review article discusses recent original research on the most common pathogenic mechanisms of depression in PWE and highlights the effects of antidepressant drugs (ADs) against seizures in PWE and animal models of seizures and epilepsy. Newer ADs, such as selective serotonin reuptake inhibitors (SRRI) or serotonin-noradrenaline reuptake inhibitors (SNRI), particularly sertraline, citalopram, mirtazapine, reboxetine, paroxetine, fluoxetine, escitalopram, fluvoxamine, venlafaxine, duloxetine may lead to improvements in epilepsy severity whereas the use of older tricyclic antidepressant (TCAs) can increase the occurrence of seizures. Most of the data demonstrate the acute effects of ADs in animal models of epilepsy while there is a limited number of studies about the chronic antidepressant effects in epilepsy and epileptogenesis or on clinical efficacy. Much longer treatments are needed in order to validate the effectiveness of these new alternatives in the treatment and the development of epilepsy, while further clinical studies with appropriate protocols are warranted in order to understand the real potential contribution of these drugs in the management of PWE (besides their effects on mood).

Parvalbumin Role in Epilepsy and Psychiatric Comorbidities: From Mechanism to Intervention

Parvalbumin is a calcium-binding protein present in inhibitory interneurons that play an essential role in regulating many physiological processes, such as intracellular signaling and synaptic transmission. Changes in parvalbumin expression are deeply related to epilepsy, which is considered one of the most disabling neuropathologies. Epilepsy is a complex multi-factor group of disorders characterized by periods of hypersynchronous activity and hyperexcitability within brain networks. In this scenario, inhibitory neurotransmission dysfunction in modulating excitatory transmission related to the loss of subsets of parvalbumin-expressing inhibitory interneuron may have a prominent role in disrupted excitability. Some studies also reported that parvalbumin-positive interneurons altered function might contribute to psychiatric comorbidities associated with epilepsy, such as depression, anxiety, and psychosis. Understanding the epileptogenic process and comorbidities associated with epilepsy have significantly advanced through preclinical and clinical investigation. In this review, evidence from parvalbumin altered function in epilepsy and associated psychiatric comorbidities were explored with a translational perspective. Some advances in potential therapeutic interventions are highlighted, from current antiepileptic and neuroprotective drugs to cutting edge modulation of parvalbumin subpopulations using optogenetics, designer receptors exclusively activated by designer drugs (DREADD) techniques, transcranial magnetic stimulation, genome engineering, and cell grafting. Creating new perspectives on mechanisms and therapeutic strategies is valuable for understanding the pathophysiology of epilepsy and its psychiatric comorbidities and improving efficiency in clinical intervention.

Comorbidity of Epilepsy and Depression: Associated Pathophysiology and Management

Epilepsy is a neurological disorder characterized by recurrent unprovoked seizures. Depression may arise as a result of other mental or physical problems or as a side effect of the drugs used to treat such illnesses, or it could be caused by epilepsy-related structural abnormalities. However, physicians are hesitant to prescribe antidepressants to patients with epilepsy due to concerns about decreasing seizure thresholds and the harmful drug interactions between antidepressants and antiepileptic medicines. As a result, the question about the optimal care of epileptic patients who suffer from depression remains unanswered. Despite the complicated link between epilepsy and depression, the co-administration of antidepressants and antiepileptic drugs (AEDs) is safe and beneficial when appropriately managed. A focused evaluation for depression (regardless of social, economic, or personal circumstances) might identify people who benefit from medical care and therapeutic assistance. Vagus nerve stimulation and psychological therapies such as cognitive-behavioral therapy, individual or group psychotherapy, patient support groups, family therapy, and counseling are nonpharmacological therapeutic alternatives. In terms of treatment strategy, it is critical to optimize seizure control and limit antiepileptic medications' adverse effects. Psychotherapy for depression in epilepsy is underused, even though it has been shown to be helpful in well-controlled studies. This review article has discussed some parts of the most common pathophysiologies of depression in patients with epilepsy, highlighted the efficacy of psychotherapy and antidepressant drugs, and explored the optimal care of patients with epilepsy who suffer from depression.

ILAE clinical practice recommendations for the medical treatment of depression in adults with epilepsy

The aim of this document is to provide evidence-based recommendations for the medical treatment of depression in adults with epilepsy. The working group consisted of members of an ad hoc Task Force of the International League Against Epilepsy (ILAE) Commission on Psychiatry, ILAE Executive and the International Bureau for Epilepsy (IBE) representatives. The development of these recommendations is based on a systematic review of studies on the treatment of depression in adults with epilepsy, and a formal adaptation process of existing guidelines and recommendations of treatment of depression outside epilepsy using the ADAPTE process. The systematic review identified 11 studies on drug treatments (788 participants, class of evidence III and IV); 13 studies on psychological treatments (998 participants, class of evidence II, III and IV); and 2 studies comparing sertraline with cognitive behavioral therapy (CBT; 155 participants, class of evidence I and IV). The ADAPTE process identified the World Federation of Societies of Biological Psychiatry guidelines for the biological treatment of unipolar depression as the starting point for the adaptation process. This document focuses on first-line drug treatment, inadequate response to first-line antidepressant treatment, and duration of such treatment and augmentation strategies within the broader context of electroconvulsive therapy, psychological, and other treatments. For mild depressive episodes, psychological interventions are first-line treatments, and where medication is used, selective serotonin reuptake inhibitors (SSRIs) are first-choice medications (Level B). SSRIs remain the first-choice medications (Level B) for moderate to severe depressive episodes; however, in patients who are partially or non-responding to first-line treatment, switching to venlafaxine appears legitimate (Level C). Antidepressant treatment should be maintained for at least 6 months following remission from a first depressive episode but it should be prolonged to 9 months in patients with a history of previous episodes and should continue even longer in severe depression or in cases of residual symptomatology until such symptoms have subsided.

Antidepressants for people with epilepsy and depression

BACKGROUND

Depressive disorders are the most common psychiatric comorbidity in people with epilepsy, affecting around one-third, with a significant negative impact on quality of life. There is concern that people may not be receiving appropriate treatment for their depression because of uncertainty regarding which antidepressant or class works best, and the perceived risk of exacerbating seizures. This review aimed to address these issues, and inform clinical practice and future research. This is an updated version of the original Cochrane Review published in Issue 12, 2014.

OBJECTIVES

To evaluate the efficacy and safety of antidepressants in treating depressive symptoms and the effect on seizure recurrence, in people with epilepsy and depression.

SEARCH METHODS

For this update, we searched CRS Web, MEDLINE, SCOPUS, PsycINFO, and ClinicalTrials.gov (February 2021). We searched the World Health Organization Clinical Trials Registry in October 2019, but were unable to update it because it was inaccessible. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and prospective non-randomised studies of interventions (NRSIs), investigating children or adults with epilepsy, who were treated with an antidepressant and compared to placebo, comparative antidepressant, psychotherapy, or no treatment for depressive symptoms.  DATA COLLECTION AND ANALYSIS: The primary outcomes were changes in depression scores (proportion with a greater than 50% improvement, mean difference, and proportion who achieved complete remission) and change in seizure frequency (mean difference, proportion with a seizure recurrence, or episode of status epilepticus). Secondary outcomes included the number of participants who withdrew from the study and reasons for withdrawal, quality of life, cognitive functioning, and adverse events. Two review authors independently extracted data for each included study. We then cross-checked the data extraction. We assessed risk of bias using the Cochrane tool for RCTs, and the ROBINS-I for NRSIs. We presented binary outcomes as risk ratios (RRs) with 95% confidence intervals (CIs) or 99% CIs for specific adverse events. We presented continuous outcomes as standardised mean differences (SMDs) with 95% CIs, and mean differences (MDs) with 95% CIs.  MAIN RESULTS: We included 10 studies in the review (four RCTs and six NRSIs), with 626 participants with epilepsy and depression, examining the effects of antidepressants. One RCT was a multi-centre study comparing an antidepressant with cognitive behavioural therapy (CBT). The other three RCTs were single-centre studies comparing an antidepressant with an active control, placebo, or no treatment. The NRSIs reported on outcomes mainly in participants with focal epilepsy before and after treatment for depression with a selective serotonin reuptake inhibitor (SSRI); one NRSI compared SSRIs to CBT.  We rated one RCT at low risk of bias, three RCTs at unclear risk of bias, and all six NRSIs at serious risk of bias. We were unable to conduct any meta-analysis of RCT data due to heterogeneity of treatment comparisons. We judged the certainty of evidence to be moderate to very low across comparisons, because single studies contributed limited outcome data, and because of risk of bias, particularly for NRSIs, which did not adjust for confounding variables. More than 50% improvement in depressive symptoms ranged from 43% to 82% in RCTs, and from 24% to 97% in NRSIs, depending on the antidepressant given. Venlafaxine improved depressive symptoms by more than 50% compared to no treatment (mean difference (MD) -7.59 (95% confidence interval (CI) -11.52 to -3.66; 1 study, 64 participants; low-certainty evidence); the results between other comparisons were inconclusive. Two studies comparing SSRIs to CBT reported inconclusive results for the proportion of participants who achieved complete remission of depressive symptoms.  Seizure frequency data did not suggest an increased risk of seizures with antidepressants compared to control treatments or baseline. Two studies measured quality of life; antidepressants did not appear to improve quality of life over control. No studies reported on cognitive functioning. Two RCTs and one NRSI reported comparative data on adverse events; antidepressants did not appear to increase the severity or number of adverse events compared to controls. The NSRIs reported higher rates of withdrawals due to adverse events than lack of efficacy. Reported adverse events for antidepressants included nausea, dizziness, sedation, headache, gastrointestinal disturbance, insomnia, and sexual dysfunction.  AUTHORS' CONCLUSIONS: Existing evidence on the effectiveness of antidepressants in treating depressive symptoms associated with epilepsy is still very limited. Rates of response to antidepressants were highly variable. There is low certainty evidence from one small RCT (64 participants) that venlafaxine may improve depressive symptoms more than no treatment; this evidence is limited to treatment between 8 and 16 weeks, and does not inform longer-term effects. Moderate to low evidence suggests neither an increase nor exacerbation of seizures with SSRIs.  There are no available comparative data to inform the choice of antidepressant drug or classes of drug for efficacy or safety for treating people with epilepsy and depression. RCTs of antidepressants utilising interventions from other treatment classes besides SSRIs, in large samples of patients with epilepsy and depression, are needed to better inform treatment policy. Future studies should assess interventions across a longer treatment duration to account for delayed onset of action, sustainability of treatment responses, and to provide a better understanding of the impact on seizure control.

Serotonergic therapy in epilepsy

PURPOSE OF REVIEW

The serotonergic system is implicated in multiple aspects of epilepsy, including seizure susceptibility, sudden unexpected death in epilepsy (SUDEP), and comorbid depression. Despite the complexity of serotonin's effects on various neuronal networks, ongoing research provides considerable insight into the role of serotonin in human epilepsy. This review explores the potential roles of serotonergic therapies to improve clinical outcomes in epilepsy.

RECENT FINDINGS

In recent decades, research has markedly increased our knowledge of the diverse effects of serotonin on brain function. Animal models of epilepsy have identified the influence of serotonin on seizure threshold in specific brain regions, serotoninergic augmentation's protective effects on terminal apnea and mortality in SUDEP, and mechanisms underlying behavioral improvement in some models of comorbid depression. Human clinical studies are largely consistent with animal data but the translation into definitive treatment decisions has moved less rapidly.

SUMMARY

Evidence for serotonergic therapy is promising for improvement in seizure control and prevention of SUDEP. For some epilepsies, such as Dravet syndrome, basic research on serotonin receptor agonists has translated into a positive clinical trial for fenfluramine. The cumulative results of safety and efficacy studies support the routine use of SSRIs for comorbid depression in epilepsy.

Epilepsy Associated Depression: An Update on Current Scenario, Suggested Mechanisms, and Opportunities

Depression is one of the most frequent psychiatric comorbidities associated with epilepsy having a major impact on the patient's quality of life. Several screening tools are available to identify and follow up psychiatric disorders in epilepsy. Out of various psychiatric disorders, people with epilepsy (PWE) are at greater risk of developing depression. This bidirectional relationship further hinders pharmacotherapy of comorbid depression in PWE as some antiepileptic drugs (AEDs) worsen associated depression and coadministration of existing antidepressants (ADs) to alleviate comorbid depression has been reported to worsen seizures. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) are first choice of ADs and are considered safe in PWE, but there are no high-quality evidences. Similar to observations in people with depression, PWE also showed pharmacoresistant to available SSRI/SNRIs, which further complicates the disease prognosis. Randomized double-blind placebo-controlled clinical trials are necessary to report efficacy and safety of available ADs in PWE. We should also move beyond ADs, and therefore, we reviewed common pathological mechanisms such as neuroinflammation, dysregulated hypothalamus pituitary adrenal (HPA) axis, altered neurogenesis, and altered tryptophan metabolism responsible for coexistent relationship of epilepsy and depression. Based on these common pertinent pathways involved in the genesis of epilepsy and depression, we suggested novel targets and therapeutic approaches for safe management of comorbid depression in epilepsy.

Evaluation of reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E)

INTRODUCTION

Major depression is common among people with epilepsy (PWE), but it is underdiagnosed. The aim of the present study was to assess the reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E) as a screening tool for major depression in patients with epilepsy.

METHOD

A total of 210 patients suffering from epilepsy have been assessed using the NDDI-E and the Beck Depression Inventory-II (BDI-II) with no difficulty in understanding or answering the Persian version of the questionnaire. Patients identified as depressed under BDI-II underwent a psychiatric evaluation to confirm depression according to 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) criteria.

RESULT

According to the BDI-II and the ICD-10 criteria, major depression was diagnosed in 75 patients (32% men, 68% women). Cronbach's α coefficient was 0.826, suggesting a very good internal consistency. The receiver operating characteristic analysis showed an area under the curve of 0.90 (95% confidence interval [CI] = 0.86-0.94, standard error [SE]: 0.02, p < 0.001). A cutoff of ≥14 resulted in an 83% sensitivity, an 80% specificity, a 70.1% positive predictive value, and an 88.6% negative predictive value. A significant and positive correlation between the P-NDDI-E and the BDI-II was shown (Spearman's ρ = 0.604, p < 0.001).

DISCUSSION

The P-NDDI-E could be used as a reliable and valid instrument in detecting major depression in PWE.

Interactions of antiepileptic drugs with drugs approved for the treatment of indications other than epilepsy

Introduction: Comorbidities of epilepsy may significantly interfere with its treatment as diseases in the general population are also encountered in epilepsy patients and some of them even more frequently (for instance, depression, anxiety, or heart disease). Obviously, some drugs approved for other than epilepsy indications can modify the anticonvulsant activity of antiepileptics. Areas covered: This review highlights the drug-drug interactions between antiepileptics and aminophylline, some antidepressant, antiarrhythmic (class I-IV), selected antihypertensive drugs and non-barbiturate injectable anesthetics (ketamine, propofol, etomidate, and alphaxalone). The data were reviewed mainly from experimental models of seizures. Whenever possible, clinical data were provided. PUBMED data base was the main search source.Expert opinion: Aminophylline generally reduced the protective activity of antiepileptics, which, to a certain degree, was consistent with scarce clinical data on methylxanthine derivatives and worse seizure control. The only antiarrhythmic with this profile of action was mexiletine when co-administered with VPA. Among antidepressants and non-barbiturate injectable anesthetics, trazodone, mianserin and etomidate or alphaxalone, respectively, negatively affected the anticonvulsant action of some antiepileptic drugs. Clinical data indicate that only amoxapine, bupropion, clomipramine and maprotiline should be used with caution. Possibly, drugs reducing the anticonvulsant potential of antiepileptics should be avoided in epilepsy patients.

Epilepsy: Workup and Management in Adults

When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.

Risk of seizures with antidepressants: what is the evidence?

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Prevalence and treatment of neurological and psychiatric disorders among tertiary hospitals in Pakistan; findings and implications

INTRODUCTION

Mental health and neurological disorders are prevalent in Pakistan. However, there are considerable concerns with their management due to issues of access, availability of trained personnel and stigma alongside paucity of such data. Consequently, there is a need to document current treatment approaches starting with tertiary hospitals in Pakistan where patients with more severe mental and neurological disorders are typically treated. Subsequently, use the findings to help direct future policies and initiatives.

METHODS

Multi-centered, cross-sectional, prospective study principally evaluating current medicine usage among patients attending tertiary hospitals in Pakistan with psychiatric and neurological disorders. In addition, possible factors contributing to the prevalence of these disorders in this population to help with future care. All 23 tertiary care hospitals in the ten major Districts in Pakistan were included, which cover 75% of the population.

RESULTS

57,664 patients were evaluated of which 35.3% were females. Both females and males had multiple brain disorders and multiple co-morbidities. Schizophrenia was the most prevalent disorder overall among both females (25.2%) and males (30.4%). A median of six medicines were prescribed per patient, with antipsychotics and antidepressants the most prescribed medicines. Clozapine was the most prescribed medicine in males (12.25%) and females (11.83%) including for psychiatric disorders, with sodium valproate the most prescribed medicine in epilepsy in males (42.44% of all anti-epileptic medicines) as well as females (46.38%). There was a greater prevalence of both disorders among the lower classes. A greater prevalence of schizophrenia was seen in patients abusing alcohol and smokers. The divorce rate was higher among the studied patients and the prevalence of depression was higher among the widowed population.

CONCLUSIONS

There were concerns with the quality of prescribing including the extent of polypharmacy as well as possible overuse of clozapine especially in patients with epilepsy, both of which need addressing.

Depression in People with Epilepsy. What is the Connection?

INTRODUCTION

Depression is the most common psychiatric comorbidity in people with epilepsy. It worsens the prognosis and quality of life of these patients. Despite this, depression is poorly diagnosed and when the treatment is given, it is frequently suboptimal.

OBJECTIVE

To perform a narrative review of the medical literature, seeking to collect useful information regarding the relationship between epilepsy and depression.

RESULTS

Narrative reviews, systematic reviews, meta-analyses, clinical trials, and follow-up studies were identified in English and Spanish with no time limit, including epidemiological, clinical, associated factors, etiological explanations, diagnostic and therapeutic approaches to comorbid depression in epilepsy.

CONCLUSION

The relationship between epilepsy and depression is complex. The available scientific evidence suggests the possibility of a bidirectional relationship that could be explained from common aetiopathogenic mechanisms. Despite the high prevalence of depression in epileptic patients, this mental disorder continues to be poorly identified by clinicians. To improve this, we have easy-to-apply instruments that routinely screen this patient population and contribute substantially to making the problem more visible and seek to improve the quality of life for this population.

Counseling and Management of the Risks of Living With Epilepsy

PURPOSE OF REVIEW

For patients living with epilepsy, quality of life is determined not only by seizure control but by mood, antiepileptic drug adverse effects, relationships, and access to education, employment, and transportation. This article reviews some of the most commonly encountered concerns associated with epilepsy, including mood disorders, driving, injuries, mortality, bone health, genetic burden, and impact on relationships.

RECENT FINDINGS

People with epilepsy are at increased risk for anxiety, depression, and suicide. Depression is underrecognized in patients with epilepsy, but effective validated screening tools are available for use. Mortality rates for people with epilepsy are 2 times higher than those of the general population, but much of this is attributable to underlying conditions rather than seizures. Sudden unexpected death in epilepsy (SUDEP) occurs in an estimated 1:1000 adults with epilepsy per year, and the risk can be reduced by improved observation and seizure control. An increased risk of injury, including fractures, is also present in patients with epilepsy. Reduced bone health leading to increased fracture risk is an important negative consequence of long-term use of antiepileptic medication. Seizures while driving can also cause accidents and injury. Despite the importance of driving for people with epilepsy, physicians are underperforming in providing counsel about driving.

SUMMARY

Optimal care of the patient with epilepsy includes addressing risks to emotional health, physical health including fractures and SUDEP, social health, and an independent lifestyle. Identification of and treatments to reduce these risks can do more to improve quality of life than a narrow clinical focus on seizure control alone.

Developments in depression in epilepsy: screening, diagnosis, and treatment

INTRODUCTION

Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated. Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur. Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.

Current and emerging drug therapies for the treatment of depression in adults with epilepsy

INTRODUCTION

Depression is the most frequent psychiatric comorbidity among people with epilepsy. It can impact on quality of life and increases the risk of morbidity and premature mortality.

AREAS COVERED

The authors review the available data on current and emerging drug treatments for depression in epilepsy. Sources have been identified through Medline/PubMed searches while ongoing clinical trials have been identified through a ClinicalTrials.gov search

EXPERT OPINION

SSRIs are the drug class with the largest amount of data. Though promising, the level of evidence provided by these studies is still low as the majority have relevant methodological limitations. Antiepileptic drugs under development have the unique opportunity to be of multi-use in the treatment of epilepsy and depression. The serotoninergic system has already been identified as a potential area of interest, but new targets are still needed in epilepsy and depression. For this reason, it is important that basic scientists working on these two conditions develop collaborative projects and integrate findings.

Antidepressants in epilepsy

People with epilepsy (PWE) frequently suffer from comorbid mood and anxiety disorders. Depression is one of the major psychiatric comorbidities having a negative impact on the quality of life in people with epilepsy. A review of the literature indicates that the majority of antidepressant-related seizures have been associated with either ultra-high doses or overdosing and, generally, the risk of antidepressant-associated seizures is low. Correspondingly, there is some evidence indicating that antidepressants of most widely used groups may additionally lower the risk of triggering seizures. Four antidepressants are not recommended for patients with epilepsy, i.e.: amoxapine, bupropion, clomipramine and maprotiline. Clinicians applying first line of depression treatment in patients with epilepsy should consider use of SSRIs or SNRIs, particularly sertraline, citalopram, mirtazapine, reboxetine, paroxetine, fluoxetine, escitalopram, fluvoxamine, venlafaxine, duloxetine. Implementation of anticonvulsive drugs in depressed patients should include valproate, carbamazepine, lamotrigine, gabapentin, pregabalin. The paper reviews the evidence for the clinical use of antidepressants in PWE.

De Novo Myoclonic Status Epilepticus After Benzodiazepine Withdrawal

Myoclonic status epilepticus (MSE) in patients without epilepsy, or de novo MSE, is a rare condition associated with several acute symptomatic etiologies, including drugs and toxins. We describe a 94-year-old woman with Alzheimer dementia and long use of mirtazapine 30 mg/d and alprazolam 1 mg/d who developed MSE approximately 24 hours after abrupt discontinuation of alprazolam. The patient was taking sulfamethoxazole/trimethoprim for urinary tract infection, diagnosed 2 weeks before admission. She had no history of seizures. Routine laboratory examinations were normal and head computed tomography showed no acute injuries. She received a loading dose of 1000 mg of intravenous valproate (VPA). Continuous electroencephalogram monitoring revealed very frequent generalized spikes and polyspikes in a markedly slowed background activity. Intravenous VPA 500 mg thrice a day and alprazolam 0.5 mg twice a day were prescribed, and antibiotic was switched to piperacillin/tazobactam. Myoclonic jerks ceased completely and electroencephalogram showed no epileptiform discharges 2 days after VPA treatment onset, with recovery of baseline neurological status. This is, to the best of our knowledge, the first report of de novo MSE related to abrupt discontinuation of benzodiazepines. Seizures and status epilepticus are potential adverse events after abrupt withdrawal of chronically used benzodiazepines, especially in conditions with intrinsic epileptogenic susceptibility, such as Alzheimer disease.

A case of interictal dysphoric disorder comorbid with interictal psychosis: Part of the same spectrum or separate entities?

Depressive disorders in epilepsy often present characteristic clinical manifestations atypical in primary, endogenous depression. Here, we report a case of a 64-year-old woman with right mesial temporal lobe epilepsy, who complained of bizarre, antipsychotic-refractory cenesthetic hallucinations in her interictal phase, and was hospitalized after a suicide attempt. Detailed clinical observations revealed mood symptoms, which led to the diagnosis of interictal dysphoric disorder comorbid with interictal psychosis. Sertraline with low-dose aripiprazole markedly alleviated both depressive and psychotic symptoms. This case suggested that the two diagnostic entities may overlap and that depressive symptoms tend to be concurrent when concurring with psychosis, which hampers the appropriate choice of a treatment option.

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Prominent psychosis overshadowed symptoms of interictal dysphoric disorder (IDD).

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Interictal psychosis (IIP) may be more severe form of IDD.

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Self-report inventories may miss IDD with psychotic features.

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Sertraline with low-dose aripiprazole may be a promising pharmacological treatment in severe IDD.

Managing epilepsy-associated depression: Serotonin enhancers or serotonin producers?

Depression is one of the major psychiatric comorbidities having a major impact on the quality of life in people with epilepsy (PWE). Selective serotonin reuptake inhibitors (SSRIs) are considered as safest therapy for the treatment of depression in PWE. Although administration of SSRIs increases the synaptic serotonin levels, it decreases the overall serotonin synthesis in the brain. Long-term therapy with SSRIs has been reported to decrease serotonin synthesis, which may be the possible reason for lessening of their antidepressant effect over time as well as elevated seizure outcomes observed in PWE. Thus the present scenario warrants streamlined studies to explore the safety and efficacy of SSRIs as well as approaches beyond SSRIs for treatment of depression in epilepsy. In this review, we outline the approaches which may restore serotonin levels rather than a pseudo enhancement of serotonin with SSRIs. The potential of various anti-inflammatory approaches such as selective cyclooxygenase-2 inhibitors, inflammatory cytokine inhibitors, and indoleamine 2,3-dioxygenase inhibitors pertaining to their serotonin restoring effects is discussed as possible therapy for treatment of depression in epilepsy.

Two distinct symptom-based phenotypes of depression in epilepsy yield specific clinical and etiological insights

Depression is common but underdiagnosed in epilepsy. A quarter of patients meet criteria for a depressive disorder, yet few receive active treatment. We hypothesize that the presentation of depression is less recognizable in epilepsy because the symptoms are heterogeneous and often incorrectly attributed to the secondary effects of seizures or medication. Extending the ILAE's new phenomenological approach to classification of the epilepsies to include psychiatric comorbidity, we use data-driven profiling of the symptoms of depression to perform a preliminary investigation of whether there is a distinctive symptom-based phenotype of depression in epilepsy that could facilitate its recognition in the neurology clinic. The psychiatric and neuropsychological functioning of 91 patients with focal epilepsy was compared with that of 77 healthy controls (N=168). Cluster analysis of current depressive symptoms identified three clusters: one comprising nondepressed patients and two symptom-based phenotypes of depression. The 'Cognitive' phenotype (base rate=17%) was characterized by symptoms taking the form of self-critical cognitions and dysphoria and was accompanied by pervasive memory deficits. The 'Somatic' phenotype (7%) was characterized by vegetative depressive symptoms and anhedonia and was accompanied by greater anxiety. It is hoped that identification of the features of these two phenotypes will ultimately facilitate improved detection and diagnosis of depression in patients with epilepsy and thereby lead to appropriate and timely treatment, to the benefit of patient wellbeing and the potential efficacy of treatment of the seizure disorder. This article is part of a Special Issue entitled "The new approach to classification: Rethinking cognition and behavior in epilepsy".

Mood Disorders in Epilepsy

Mood disorders associated with epilepsy are very common and overrepresented compared with other chronic medical conditions. Depression is a particularly common and worrisome comorbidity, especially because suicidality seems to be increased significantly in the context of epilepsy. Although psychosocial stressors commonly are associated, intrinsic characteristics of seizure disorders may contribute to the expression of depressive symptoms. Depression and epilepsy may exacerbate each other. Epilepsy with seizure foci in the temporal lobe may represent a higher risk of developing depression, especially if the seizures do not generalize. Treatment of depression is multifaceted and includes psychotherapy and sophisticated regimens of anticonvulsants. Most antidepressants may be used safely and effectively in the context of depression, although high-quality evidence is lacking. Ultimately, treatment of comorbid mood disorder has important implications for outcome and quality of life, perhaps even more than treatment of epilepsy itself.

Proconvulsant effects of antidepressants - What is the current evidence?

Antidepressant drugs may have proconvulsant effects. Psychiatric comorbidity in epilepsy is common. Prescribers might be reluctant to initiate treatment with antidepressants in fear of seizure aggravation. The purpose of this review was to focus upon the current evidence for proconvulsant effects of antidepressants and possible clinical implications. Most antidepressants are regarded as safe and may be used in patients with epilepsy, such as the newer serotonin and/or noradrenaline reuptake inhibitors. Four older drugs should, however, be avoided or used with caution; amoxapine, bupropion, clomipramine and maprotiline. Proconvulsant effects are concentration-related. Optimization of drug treatment includes considerations of pharmacokinetic variability to avoid high serum concentrations of the most proconvulsant antidepressants. The risk of seizures is regarded as small and should, therefore, not hamper the pharmacological treatment of depression in people with epilepsy.

The pharmacological management of psychiatric comorbidities in patients with epilepsy

Psychiatric disorders represent a frequent comorbidity in patients with epilepsy affecting quality of life, morbidity and mortality. Evidence-based data on the management of these conditions are limited but a number of recommendations are now available to guide clinical practice. The present paper reviews the pharmacological treatment of psychiatric problems in epilepsy with special attention to data coming from randomised controlled trials (RCTs), pharmacological interactions with AEDs and the issue of seizure worsening during treatment with psychotropic drugs. Epidemiologically or clinically relevant psychiatric conditions are discussed namely mood and anxiety disorders, psychoses and attention deficit hyperactivity disorder.

Treatment of depression in patients with temporal lobe epilepsy: A pilot study of cognitive behavioral therapy vs. selective serotonin reuptake inhibitors

There is a high prevalence of depression in patients with epilepsy, which negatively impacts their quality of life (QOL) and seizure control. Currently, the first-line of treatment for depression in patients with epilepsy is based on selective serotonin reuptake inhibitors (SSRIs). The main objective of this pilot study was to compare cognitive behavioral therapy (CBT) versus SSRIs for the treatment of major depressive disorder (MDD) in patients with temporal lobe epilepsy (TLE). Seven patients who received group CBT were compared with eight patients treated with SSRIs. All were diagnosed with MDD and TLE. Patients were assessed at baseline before treatment and at six and 12weeks during treatment with the Quality of Life in Epilepsy Scale of 31 items (QOLIE 31), the Beck Depression Inventory (BDI), and the Hospital Anxiety and Depression Scale (HADS). Seizure records were also taken on a monthly basis. After 12weeks of treatment, both groups showed improved QOL and reduced severity of depression symptoms. There were no statistically significant group differences in the final scores for the BDI (p=0.40) and QOLIE 31 (p=0.72), although the effect size on QOL was higher for the group receiving CBT. In conclusion, the present study suggests that both CBT and SSRIs may improve MDD and QOL in patients with TLE. We found no significant outcome differences between both treatment modalities. These findings support further study using a double-blind controlled design to demonstrate the efficacy of CBT and SSRIs in the treatment of MDD and QOL in patients with TLE.

Interactions between an antidepressant reboxetine and four classic antiepileptic drugs in the mouse model of myoclonic seizures

BACKGROUND

The incidence rate of depression among patients with epilepsy is relatively high. The basis of proper therapy is knowledge of drug interactions, which may enable to maximize therapeutic effects and minimize undesired effects of the combined treatment. The purpose of this study was to evaluate the influence of reboxetine, a selective norepinephrine reuptake inhibitor, on the seizure threshold and anticonvulsant effects of four classic antiepileptic drugs: valproate, phenobarbital, ethosuximide, and clonazepam. Moreover, we assessed the adverse effects of reboxetine and combinations of reboxetine with antiepileptic drugs on motor coordination and long-term memory.

METHODS

The subcutaneous pentylenetetrazole (PTZ) test in mice was used to determine effects of anticonvulsant activity of antiepileptic drugs and reboxetine. Undesired effects of either reboxetine or and its combinations with antiepileptics were evaluated in the chimney test (motor coordination) and the step-through passive-avoidance task (long-term memory).

RESULTS

Analysis of obtained results revealed that reboxetine given at doses of 10 and 15 mg/kg doses exhibits anticonvulsant activity expressed by increasing the median convulsive dose (CD(50)) for pentylenetetrazole (p < 0.01). However, the antidepressant did not affect the anticonvulsant action of antiepileptic drugs studied in this seizure model. Moreover, no adverse reactions were found after administration of reboxetine alone or in combinations.

CONCLUSION

If further research confirms the obtained results, reboxetine may be categorized as an antidepressant which can be safely administered to epileptic patients treated with valproate, phenobarbital, ethosuximide or clonazepam.

Key issues in addressing the comorbidity of depression and pediatric epilepsy

Depression is a common comorbidity associated with epilepsy. However, the etiology of depression is difficult to establish given the heterogeneity in both epilepsy and depression. Nevertheless, the co-occurrence is so common that a bidirectional relationship between depression and epilepsy has been theorized. Persons with temporal lobe seizure foci and partial-onset epilepsy may be more vulnerable to the development of depression. In pediatrics, depression differs but may be readily identified by understanding nuances of mood states and variability of neurovegetative symptom presentation. Although no clear treatment guidance exists in the context of epilepsy, antidepressants have been relatively well studied in pediatrics and are effective and well tolerated. Anticonvulsant drugs may also improve depressive symptoms though clinical research is lacking in pediatrics. Treatment of depression may independently improve outcome for epilepsy and for quality of life. Future studies will clarify etiologies of depression in the context of epilepsy and improve the evidence base for treatment outcomes.

Antidepressants for people with epilepsy and depression

BACKGROUND

Depressive disorders are the most common psychiatric comorbidity in patients with epilepsy, affecting around one-third, with a significant negative impact on quality of life. There is concern that patients may not be receiving appropriate treatment for their depression because of uncertainty regarding which antidepressant or class works best and the perceived risk of exacerbating seizures. This review aims to address these issues and inform clinical practice and future research.

OBJECTIVES

We aimed to review and synthesise evidence from randomised controlled trials of antidepressants and prospective non-randomised studies of antidepressants used for treating depression in patients with epilepsy. The primary objectives were to evaluate the efficacy and safety of antidepressants in treating depressive symptoms and the effect on seizure recurrence.

SEARCH METHODS

We conducted a search of the following databases: the Cochrane Epilepsy Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (Ovid), SCOPUS, PsycINFO, www.clinicaltrials.gov and conference proceedings, including studies published up to 31 May 2014. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and prospective non-randomised cohort controlled and uncontrolled studies investigating children or adults with epilepsy treated with an antidepressant for depressive symptoms. The intervention group consisted of patients receiving an antidepressant drug in addition to an existing antiepileptic drug regimen. The control group(s) consisted of patients receiving a placebo, comparative antidepressant, psychotherapy or no treatment in addition to an existing antiepileptic drug regimen.

DATA COLLECTION AND ANALYSIS

We extracted data on trial design factors, patient demographics and outcomes for each study. The primary outcomes were changes in depression scores (proportion with a greater than 50% improvement or mean difference) and change in seizure frequency (mean difference or proportion with a seizure recurrence or episode of status epilepticus, or both). Secondary outcomes included the number of patients withdrawing from the study and reasons for withdrawal, as well as any adverse events. Two authors undertook data extraction separately for each included study. We then cross-checked the data extraction. We assessed risk of bias using a version of the extended Cochrane Collaboration tool for assessing risk of bias in both randomised and non-randomised studies. We presented binary outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We presented continuous outcomes as standardised mean differences (SMDs) with 95% CIs, and mean differences (MDs) with 95% CIs. If possible we intended to use meta-regression techniques to investigate possible sources of heterogeneity however this was not possible due to lack of data.

MAIN RESULTS

We included in the review eight studies (three RCTs and five prospective cohort studies) including 471 patients with epilepsy treated with an antidepressant. The RCTs were all single-centre studies comparing an antidepressant versus active control, placebo or no treatment. The five non-randomised prospective cohort studies reported on outcomes mainly in patients with partial epilepsy treated for depression with a selective serotonin reuptake inhibitor (SSRI). We rated all the RCTs and one prospective cohort study as having unclear risk of bias. We rated the four other prospective cohort studies as having high risk of bias. We were unable to perform any meta-analysis for the proportion with a greater than 50% improvement in depression scores because the studies reported on different treatment comparisons. The results are presented descriptively and show a varied responder rate of between 24% and 97%, depending on the antidepressant given. For the mean difference in depression score we were able to perform a limited meta-analysis of two prospective cohort studies of citalopram, including a total of 88 patients. This gave low quality evidence for the effect estimate of 1.17 (95% CI 0.96 to 1.38) in depression scores. Seizure frequency data were not reported in any RCTs and we were unable to perform any meta-analysis for prospective cohort studies due to the different treatment comparisons. The results are presented descriptively and show that treatment in three studies with a selective serotonin reuptake inhibitor did not significantly increase seizure frequency. Patients given an antidepressant were more likely to withdraw due to adverse events than inefficacy. Reported adverse events for SSRIs included nausea, dizziness, sedation, gastrointestinal disturbance and sexual dysfunction. Across three comparisons we rated the evidence as moderate quality due to the small sizes of the contributing studies and only one study each contributing to the comparisons. We rated the evidence for the final comparison as low quality as there was concern over the study methods in the two contributing studies.

AUTHORS' CONCLUSIONS

Existing evidence on the effectiveness of antidepressants in treating depressive symptoms associated with epilepsy is very limited. Only one small RCT demonstrated a statistically significant effect of venlafaxine on depressive symptoms. We have no high quality evidence to inform the choice of antidepressant drug or class of drug in treating depression in people with epilepsy. This review provides low quality evidence of safety in terms of seizure exacerbation with SSRIs, but there are no available comparative data on antidepressant classes and safety in relation to seizures. There are currently no comparative data on antidepressants and psychotherapy in treating depression in epilepsy, although psychotherapy could be considered in patients unwilling to take antidepressants or where there are unacceptable side effects. Further comparative clinical trials of antidepressants and psychotherapy in large cohorts of patients with epilepsy and depression are required to better inform treatment policy in the future.

A synthetic bioisoster of trimethadione and phenytoin elicits anticonvulsant effect, protects the brain oxidative damage produced by seizures and exerts antidepressant action in mice

Epilepsy is recognized as one of the most common and serious neurological disorder affecting 1-2% of the world׳s population. The present study demonstrates that systemic administration of 3-butyl-5,5-dimethyl-1,2,3-oxathiazolidine-4-one-2,2-dioxide (DIOXIDE), a synthetic compound bioisoster of trimethadione and phenytoin (classical anticonvulsants), elicits a dose dependent anticonvulsant response in mice submitted to the subcutaneous pentylenetetrazole seizure test (scPTZ). Among various factors supposed to play role in epilepsy, oxidative stress and reactive species have strongly emerged. The protection exerted by DIOXIDE over the extent of brain oxidative damage produced by PTZ was determined, by measuring the levels of lipid peroxidation and reduced glutathione and the activity of Na(+)/K(+)-ATPase. Psychiatric disorders represent frequent comorbidities in persons with epilepsy. In this report, the potential anxiolytic and antidepressant activities of DIOXIDE were evaluated in several widely used models for assessing anxiolytic and antidepressant activities in rodents. Although DIOXIDE did not evidence anxiolytic activity at the doses tested, it revealed a significant antidepressant-like effect. Preliminary studies of its mechanism of action, by means of its capacity to act via the GABAA receptor (using the [(3)H]flunitrazepam binding assay in vitro and the picrotoxin test in vivo) and the Na(+) channel (using the alkaloid veratrine, a voltage-Na(+) channel agonist) demonstrated that the anticonvulsant effect is not likely related to the GABAergic pathway and the antidepressant-like effect could be due to its Na(+) channel blocking properties. The results for DIOXIDE suggested it as a new anticonvulsant-antioxidant and antidepressant compound that deserves further development.

Depression in glioma: a primer for clinicians and researchers

Depression is one of the leading causes of global disability, and a considerable hidden morbidity among patients with glioma. In this narrative review, we summarise what is currently known about depression in glioma, the main unanswered questions and the types of studies that should be prioritised in order to find out. We conclude by calling for a prospective Phase II study of antidepressants in depressed glioma patients, to test methodologies for a multicentre randomised controlled trial.

A review of therapeutic uses of mirtazapine in psychiatric and medical conditions

OBJECTIVE

To review the literature examining the use of mirtazapine with an emphasis on its therapeutic benefits for psychiatric patients with comorbid medical conditions.

DATA SOURCES

MEDLINE, PsycINFO, Global Health, and AGRICOLA were searched using the terms mirtazapine OR Remeron. Limits were English language, human, year 1980-2012, treatment and prevention, and therapy.

STUDY SELECTION

Two hundred ninety-three articles were identified.

DATA EXTRACTION

Identified articles were reviewed with a focus on indications and therapeutic benefits in patients with medical comorbidities.

RESULTS

Mirtazapine is an effective antidepressant with unique mechanisms of action. It is characterized by a relatively rapid onset of action, high response and remission rates, a favorable side-effect profile, and several unique therapeutic benefits over other antidepressants. Mirtazapine has also shown promise in treating some medical disorders, including neurologic conditions, and ameliorating some of the associated debilitating symptoms of weight loss, insomnia, and postoperative nausea and vomiting.

CONCLUSIONS

Mirtazapine offers clinicians multiple therapeutic advantages especially when treating patients with comorbid medical illness.

Pharmacological treatment of psychiatric comorbidity in patients with refractory epilepsy

The purpose of the present study was to describe the use of psychopharmacological drugs for the treatment of a stated or presumed psychiatric comorbid condition in patients with refractory epilepsy and discuss the clinical implications of such treatment. The study was a retrospective descriptive study in patients admitted to the National Center for Epilepsy in Norway based on medication described in medical records. The mean age was 40 years (range: 9-90), and the gender ratio was 56/44% female/male. Psychotropic drugs (antidepressants and antipsychotics) were used to a lower extent than in the general population in Norway. Drugs for ADHD were predominantly used in children. The prevalence of patients treated with psychiatric comedication was 13% (143 of 1139 patients). The patients used two to eight concomitant CNS-active drugs, which calls for the close monitoring of potential pharmacodynamic and pharmacokinetic interactions and should challenge clinicians to achieve a less complex pharmacotherapy. Psychiatric comorbidity is an important concern in patients with refractory epilepsy and may be undertreated.

The treatment of depressive disorders in epilepsy: what all neurologists should know

One of every three patients with epilepsy (PWE) will experience a depressive disorder in the course of their life, often associated with anxiety symptoms or a full blown anxiety disorder. Clearly, the high prevalence of these psychiatric comorbidities calls for their early identification and management. This article provides practical strategies in the management of depressive episodes in PWE. Contrary to long-held beliefs, the use of antidepressant drugs are safe in PWE when used at therapeutic doses. Antidepressant drugs of the selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) families are the first line of therapy in depressive disorders, and failure to achieve complete symptom remission after a trial of an SSRI or SNRI at optimal doses should be followed by a second trial with a drug from the other antidepressant family. In developing countries, antidepressant drugs of these two antidepressant families are not always available, and tricyclic antidepressants (TCAs) are the drugs of choice. Although there are no differences in efficacy among the three families of antidepressants, TCAs have a lower tolerability and higher toxicity, with greater mortality risk associated with cardiotoxic effects in overdoses. Cognitive behavior therapy is another treatment modality that has been shown to be effective in the treatment of depressive disorders in patients with and without epilepsy. Its use should be considered together with pharmacotherapy or by itself.

Antidepressant therapy in epilepsy: can treating the comorbidities affect the underlying disorder?

There is a high incidence of psychiatric comorbidity in people with epilepsy (PWE), particularly depression. The manifold adverse consequences of comorbid depression have been more clearly mapped in recent years. Accordingly, considerable efforts have been made to improve detection and diagnosis, with the result that many PWE are treated with antidepressant drugs, medications with the potential to influence both epilepsy and depression. Exposure to older generations of antidepressants (notably tricyclic antidepressants and bupropion) can increase seizure frequency. However, a growing body of evidence suggests that newer ('second generation') antidepressants, such as selective serotonin reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors, have markedly less effect on excitability and may lead to improvements in epilepsy severity. Although a great deal is known about how antidepressants affect excitability on short time scales in experimental models, little is known about the effects of chronic antidepressant exposure on the underlying processes subsumed under the term 'epileptogenesis': the progressive neurobiological processes by which the non-epileptic brain changes so that it generates spontaneous, recurrent seizures. This paper reviews the literature concerning the influences of antidepressants in PWE and in animal models. The second section describes neurobiological mechanisms implicated in both antidepressant actions and in epileptogenesis, highlighting potential substrates that may mediate any effects of antidepressants on the development and progression of epilepsy. Although much indirect evidence suggests the overall clinical effects of antidepressants on epilepsy itself are beneficial, there are reasons for caution and the need for further research, discussed in the concluding section.

Validation of the Spanish version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)

INTRODUCTION

To translate and validate into Spanish (Spain) the screening instrument of major depressive episodes (MDEs), Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), in patients with epilepsy.

METHODS

A total of 121 outpatients, aged 18 years and older, with a diagnosis of epilepsy were included. The diagnosis of a current major depressive episode (MDE) was established with the Mini International Neuropsychiatric Interview (MINI).

RESULTS

A diagnosis of current MDE was established in 20% of the patients with the MINI. Receiver operator characteristics (ROC) analysis showed an area under the curve of 0.89, with an internal consistency of 0.78. At a cutoff score >13, 22% of patients were considered to suffer from MDE with the NDDI-E (sensitivity: 84%; specificity: 78%; positive predictive value: 64.7%; and negative predictive value: 92.2%).

DISCUSSION

The Spanish-Spain version of the NDDI-E appears to be a good screening instrument to identify MDE.

Citalopram versus other anti-depressive agents for depression

BACKGROUND

Recent US and UK clinical practice guidelines recommend that second-generation antidepressants should be considered amongst the best first-line options when drug therapy is indicated for a depressive episode. Systematic reviews have already highlighted some differences in efficacy between second-generation antidepressants. Citalopram, one of the first selective serotonin reuptake inhibitors (SSRI) introduced in the market, is one of these antidepressant drugs that clinicians use for routine depression care.

OBJECTIVES

To assess the evidence for the efficacy, acceptability and tolerability of citalopram in comparison with tricyclics, heterocyclics, other SSRIs and other conventional and non-conventional antidepressants in the acute-phase treatment of major depression.

SEARCH METHODS

We searched The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to February 2012. No language restriction was applied. We contacted pharmaceutical companies and experts in this field for supplemental data.

SELECTION CRITERIA

Randomised controlled trials allocating patients with major depression to citalopram versus any other antidepressants.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy (the number of patients who responded or remitted), patient acceptability (the number of patients who failed to complete the study) and tolerability (side-effects).

MAIN RESULTS

Thirty-seven trials compared citalopram with other antidepressants (such as tricyclics, heterocyclics, SSRIs and other antidepressants, either conventional ones, such as mirtazapine, venlafaxine and reboxetine, or non-conventional, like hypericum). Citalopram was shown to be significantly less effective than escitalopram in achieving acute response (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.08 to 2.02), but more effective than paroxetine (OR 0.65, 95% CI 0.44 to 0.96) and reboxetine (OR 0.63, 95% CI 0.43 to 0.91). Significantly fewer patients allocated to citalopram withdrew from trials due to adverse events compared with patients allocated to tricyclics (OR 0.54, 95% CI 0.38 to 0.78) and fewer patients allocated to citalopram reported at least one side effect than reboxetine or venlafaxine (OR 0.64, 95% CI 0.42 to 0.97 and OR 0.46, 95% CI 0.24 to 0.88, respectively).

AUTHORS' CONCLUSIONS

Some statistically significant differences between citalopram and other antidepressants for the acute phase treatment of major depression were found in terms of efficacy, tolerability and acceptability. Citalopram was more efficacious than paroxetine and reboxetine and more acceptable than tricyclics, reboxetine and venlafaxine, however, it seemed to be less efficacious than escitalopram. As with most systematic reviews in psychopharmacology, the potential for overestimation of treatment effect due to sponsorship bias and publication bias should be borne in mind when interpreting review findings. Economic analyses were not reported in the included studies, however, cost effectiveness information is needed in the field of antidepressant trials.

Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives

The clinical manifestations of depression in people with epilepsy (PWE) are pleomorphic, often associated with anxiety symptoms and anxiety disorders. The ongoing debate of whether the clinical presentation of depression in PWE is unique to this neurologic disorder is reviewed. Comorbid depression can impact the recruitment of PWE for pharmacologic trials with antiepileptic drugs (AEDs). Yet, the impact of depression on the response of the seizure disorder to pharmacotherapy with AEDs and its impact on worse adverse events may bias the interpretation of the trial findings, particularly when depressed patients are included in the AED trials. PWE have a greater suicidal risk than the general population. This risk is mediated by multiple factors, and recent data from the FDA have imputed a potential pathogenic role to all AEDs. The recognition of patients at risk is reviewed. Yet, the validity of the FDA data has been questioned, and the status of this controversial question is analyzed. As in the case of epilepsy, depression and pain syndromes have a relatively high comorbidity. The negative impact of depression on pain is reminiscent of that of depression in PWE; furthermore, the high comorbidity may be also associated with the existence of common pathogenic mechanisms. Neurologists and in particular, epileptologists establish the diagnosis of psychogenic non-epileptic seizures (PNES) in whom a comorbid depressive disorder is very often identified. The role of depression in the course of PNES and its treatment are discussed. Scarce data are available on the treatment of depression in PWE. Thus, clinicians have had to adopt data from patients with primary depressive disorders. We outline a consensus strategy on the identification and treatment of depressive disorders in adult and pediatric patients with epilepsy.

The antidepressants citalopram and reboxetine reduce seizure frequency in rats with chronic epilepsy

PURPOSE

  For a long time, antidepressants have been thought to possess proconvulsant properties. This assumption, however, remains controversial, since anticonvulsant effects have been attributed to certain antidepressants. To date, it remains unclear which antidepressants can be used for the treatment of depression in patients with epilepsy. In this respect, studies investigating the convulsant liability of antidepressants in a chronic epilepsy model can give valuable information. The present study was designed to determine the seizure liability of citalopram and reboxetine in the kainic acid-induced post-status epilepticus model for temporal lobe epilepsy.

METHODS

  Two months after the induction of status epilepticus, chronic epileptic rats (n = 16) were video-electroencephalography (EEG) monitored during seven consecutive weeks. Weeks 1, 3, 5, and 7 served as sham weeks during which the rats received intraperitoneal saline injections for four consecutive days, followed by a 3-day sham washout period during which no injections were given. During weeks 2, 4, and 6, rats received intraperitoneal injections with either citalopram (5, 10, and 15 mg/kg, once daily, n = 8) or reboxetine (10, 20, and 30 mg/kg, twice daily, n = 8) for 4 days, again followed by a washout period of 3 days. Drugs were administered in a randomly assigned fixed-dose regimen per week. Each rat served as its own control. The drug doses were selected based on the doses reported to have antidepressant effects in rats.

KEY FINDINGS

  Citalopram significantly decreased the spontaneous seizure frequency at the highest dose tested, that is, the mean number of seizures decreased from 12.8 seizures to 8.8 seizures per week (31%) after treatment with 15 mg/kg citalopram. This dose also significantly decreased the cumulative seizure duration. Administration of 5 and 10 mg/kg citalopram did not alter the seizure frequency. The two highest doses of reboxetine significantly decreased the spontaneous seizure frequency, that is, 20 mg/kg reboxetine decreased the seizure frequency from 14.1 to 7.9 (44%) and 30 mg/kg reboxetine decreased the seizure frequency from 11.8 to 7.2 (39%). In addition, both doses significantly decreased the cumulative seizure duration. Administration of 10 mg/kg reboxetine did not alter seizure frequency. Citalopram and reboxetine had no effect on seizure severity and seizure duration in any of the doses tested.

SIGNIFICANCE

  In general we can conclude that antidepressant doses of citalopram and reboxetine have, depending on the dose, an anticonvulsant effect or no effect on spontaneous seizures in the kainic acid-induced post-status epilepticus rat model.

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

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

Assessment of the convulsant liability of antidepressants using zebrafish and mouse seizure models

In the past, antidepressants have been thought to possess proconvulsant properties. This assumption remains controversial, however, because anticonvulsant effects have been attributed to certain antidepressants. To date, it remains unclear which antidepressants can be used for the treatment of patients with epilepsy with depression. The present study was designed to determine the anticonvulsant and/or proconvulsant effects of three antidepressants (citalopram, reboxetine, bupropion) against pilocarpine- and pentylenetetrazole-induced acute seizures in larval zebrafish and mice. In zebrafish, all antidepressants were anticonvulsant in the pentylenetetrazole model. In addition, citalopram was anticonvulsant in the zebrafish pilocarpine model, whereas reboxetine and bupropion were without significant effect. In mice all three antidepressants increased some thresholds for pentylenetetrazole-induced convulsive-like behaviors at varying doses, whereas thresholds for pilocarpine-induced convulsive-like behaviors were generally lowered, particularly at the highest doses tested. In general we conclude that the convulsant liability of antidepressants is model and concentration dependent.

One-year seizure prognosis in epilepsy patients treated with antidepressants

To investigate the clinical effects of antidepressants on seizure frequency of patients with epilepsy treated with antiepileptic drugs, we retrospectively evaluated the 1-year course of seizure frequency. One hundred twenty-one patients with epilepsy treated with antidepressants and 300 patients with epilepsy not treated with antidepressants (controls) were the subjects of this study. Seizure frequency over the 1-year period of administration of antidepressants was retrospectively evaluated and compared with that for controls. In the patients with epilepsy taking antidepressants, seizure frequencies at four observation points (1, 3, 6, and 12 months after starting antidepressants) were equivalent to those of the control group. There was no significant difference in seizure frequency between first- and second-generation antidepressants. Patients with epilepsy treated with antiepileptic drugs can take antidepressants without a significant risk of exacerbation of seizures. Most antidepressants can be used for psychiatric treatment of patients with epilepsy.

Treatment of depression in patients with epilepsy

OPINION STATEMENT

In this article, we review the current best evidence for the treatment of depression in patients with epilepsy. Depression is a common epilepsy comorbidity, but it is often unrecognized. The most important step in appropriately managing mood disorders in this population is making the diagnosis. Clinical vigilance and routine use of a validated screening tool can improve detection and quality of care. As is increasingly the case for the general population, persons with epilepsy are often interested in exploring alternative therapies for chronic conditions, including depression. Unfortunately, the benefit of complementary and alternative therapies for depression currently is largely unproven for persons with a seizure history, although an early study of exercise for mild depression has shown some benefit. Concerns about drug interactions, side effects, and expense may be barriers to the prescription of antidepressant medications for people requiring chronic antiepileptic drug (AED) therapy. For this reason, use of an AED with mood-stabilizing properties has appeal and may be appropriate for selected individuals with mild depressive symptoms. Undue fear of lowering seizure threshold should not preclude the prescription of an antidepressant medication, as the perceived risks are often overestimated and rarely outweigh the risk of leaving depression untreated. At present, the best evidence for efficacy and safety support the use of citalopram, sertraline, or mirtazapine as initial pharmacotherapy, whereas bupropion should be avoided. Start low, go slow, and use the lowest effective dose. Cognitive behavioral therapy is a valuable adjunct to antidepressant therapy in this population. For people with refractory partial epilepsy and refractory depression, vagus nerve stimulation has some appeal, in that it may be beneficial for both conditions, but the efficacy of vagus nerve stimulation in improving mood in patients with epilepsy remains unclear.