Impact of psychiatric comorbidities on the treatment of epilepsies in adults

INTRODUCTION

Epilepsy is often accompanied by psychiatric comorbidities and the management of epilepsy in these patients presents unique challenges due to the interplay between the underlying neurological condition and the psychiatric symptoms and the combined use of multiple medications.

AREAS COVERED

This paper aims to explore the complexities associated with managing epilepsy in the presence of psychiatric comorbidities, focusing on the impact of psychiatric disorders on epilepsy treatment strategies and the challenges posed by the simultaneous administration of multiple medications.

EXPERT OPINION

Patients with epilepsy and psychiatric comorbidities seem to present with a more severe form of epilepsy that is resistant to drug treatments and burdened by an increased morbidity and mortality. Whether prompt treatment of psychiatric disorders can influence the long-term prognosis of the epilepsy is still unclear as well as the role of specific treatment strategies, such as neuromodulation, in this group of patients. Clinical practice recommendations and guidelines will prompt the development of new models of integrated care to be implemented.

Suicide in Deep Brain Stimulation for Parkinson's Disease: A Retrospective Case-Control Study

 Deep brain stimulation (DBS), a treatment of Parkinson's disease (PD), has been associated with suicidality. We conducted a case-control study comparing suicide in four pairs of cohorts: PD patients with DBS or not, epilepsy patients with resection surgery or not, subjects with BMI≥30 with bariatric surgery or not, and patients with chronic kidney disease with transplantation or not. PD patients with DBS demonstrated a lower risk of suicide relative to PD patients without DBS. Findings from other elective surgeries indicate that patients receiving operative treatments do not possess predictable differences in suicide rates relative to their medically managed counterparts.

Psychiatric mimics of neurosurgical disorders

Every year there are about 22.6 million people in need of neurosurgical care around the world, and one or several interventions are required to save lives and restore functional losses in more than half of these cases (13.8 million). Most neurosurgical interventions are performed in patients with traumatic brain and spinal cord injuries, strokes, central nervous system (CNS) tumors, hydrocephalus, and epilepsy. In addition to neurological symptoms, many CNS disorders are often accompanied by cognitive and/or behavioral changes. Physical and psychological symptoms can be intertwined as follows: 1) neurological symptoms may be manifested as a result of complex psychological processes; 2) psychological disorders may be manifested as neurological symptoms; 3) neurological disorders commonly cause secondary psychological responses; 4) psychological disorder may be induced more or less directly by an organic brain disease. In the present paper, we focus on the psychiatric conditions occurring in the patients with neurosurgical disorders who either get prepared for surgery or have already received it.

"Is this normal after such a major surgery?" Memory complaint after right temporal lobe excision in an adolescent

Memory deficits are commonly associated with temporal-lobe epilepsy. Memory may worsen after surgical resection of the temporal lobe. Risk factors for decline are structural integrity of the mesial temporal lobe structures and intact pre-operative memory. Subjective memory complaints are influenced by depression or other psychological disorders. A 16-year-old girl underwent resection from the right lateral and medial temporal lobe and after surgery she complained of a significant memory impairment, which was unexpected given her baseline assessment. Before undertaking a neuropsychological assessment, she was referred for a psychiatric consultation which revealed depression, leading to treatment with anditdepressant medication. Over time she also admitted to severe headaches and inadequate sleep. With these issues addressed, assessment indicated memory performance had not changed relative to her preoperative baseline with stability or improvement in memory across longitudinal assessments. This case illustrates the contribution of mood state and other potential factors in contributing to subjective memory complaints.

Depression could modulate neuropsychological status in epilepsy

While cognition and depression have often been studied in patients with epilepsy, only a few studies have so far attempted to link these two domains, and more specifically to investigate the specific impact of depression on cognition in epilepsy. In this review, we performed an extensive search of the literature database to provide a better understanding of this subject. Using several inclusion criteria (adult population, quantitative depression/neuropsychological assessment, statistical analyses of the impact of depression on cognitive scores, patients with epilepsy (PWE) and no other neurological disease, and studies including at least 20 patients), we identified 20 articles (out of 712 search results) that investigated both depression and cognition in PWE. Their results were summarized using a narrative and descriptive approach. This review highlights a variable impact of depression on cognition in PWE, depending on the laterality of the seizure onset zone, the type of epilepsy and the surgical context. We emphasize the need for a systematic depression assessment in these patients, especially since depressed PWE will benefit from prompt and appropriate care to help them avoid cognitive decline, particularly in a surgical context.

Treatment of psychoses in patients with epilepsy: an update

Psychotic disorders represent a relatively rare but serious comorbidity in epilepsy. Current epidemiological studies are showing a point prevalence of 5.6% in unselected samples of people with epilepsy going up to 7% in patients with temporal lobe epilepsy, with a pooled odds ratio of 7.8 as compared with the general population. This is a narrative review of the most recent updates in the management of psychotic disorders in epilepsy, taking into account the clinical scenarios where psychotic symptoms occur in epilepsy, interactions with antiepileptic drugs (AEDs) and the risk of seizures with antipsychotics. Psychotic symptoms in epilepsy can arise in a number of different clinical scenarios from peri-ictal symptoms, to chronic interictal psychoses, comorbid schizophrenia and related disorders to the so-called forced normalization phenomenon. Data on the treatment of psychotic disorders in epilepsy are still limited and the management of these problems is still based on individual clinical experience. For this reason, guidelines of treatment outside epilepsy should be adopted taking into account epilepsy-related issues including interactions with AEDs and seizure risk. Second-generation antipsychotics, especially risperidone, can represent a reasonable first-line option because of the low propensity for drug-drug interactions and the low risk of seizures. Quetiapine is burdened by a clinically significant pharmacokinetic interaction with enzyme-inducing drugs leading to undetectable levels of the antipsychotic, even for dosages up to 700 mg per day.

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.

Psychiatric Symptoms in Refractory Epilepsy During the First Year After Surgery

Psychiatric morbidity in drug-resistant epilepsy is frequent. Surgery is the best therapeutic alternative for treating seizures, but the current evidence concerning the effects of surgery on psychiatric disorders (PDs) is inconclusive. We aim to clarify surgery's role in long-term PDs. Using a prospective controlled study, we analyzed the psychopathologic outcomes of patients with drug-resistant epilepsy, comparing those who underwent surgery to those who did not due to not being suitable. Surgical candidates were paired (n = 84) with the immediately following nonsurgical candidates (n = 68). Both groups continued their usual medical treatment. We studied psychiatric changes for each group and analyzed de novo and remission cases. The assessments were made during the presurgical evaluation, and at 6 months (6-M) and 12 months (12-M) after surgery. Finally, we determined associated factors for postsurgical PDs. At 12 months, using the Hospital Anxiety and Depression Scale (HADS), anxiety improved in both groups (p = 0.000), while depression improved only in the surgical group (p = 0.016). Moreover, all symptom dimensions on the Symptom Checklist-90-R (SCL-90), as well as severity, distress, and total symptoms, decreased only in the surgical group. These ameliorations reached not only statistical significance but also clinical significance for depression (HADS) (p = 0.014) and the interictal dysphoric disorder (p = 0.013). The main predictors for PDs after surgery were as follows: the presurgical and 6-month psychiatric symptoms, the absence of surgery, seizure outcomes, and some antiepileptic and psychiatric drugs. This study provides evidence that surgery for epilepsy could have a role in improving some symptoms of psychiatric disorders 12-M after the surgery.

Pre- and post-surgical psychiatric assessments and intervention by major epilepsy centers in Japan - Nationwide survey

BACKGROUND

Although psychiatric issues following epilepsy surgery are now widely recognized as a major problem, actual awareness of these issues by epilepsy centers remains to be elucidated. This is the first known report regarding the use of psychiatric assessments and interventions by epilepsy centers throughout Japan.

PARTICIPANTS AND METHODS

At the beginning of 2016, we sent a questionnaire regarding psychiatric assessments performed before and after epilepsy surgery, psychiatric intervention after surgery, and future plans for dealing with psychiatric issues in relation to epilepsy surgery, which consisted of a total of 24 items, to all members of the Japan Epilepsy Center Association (JEPICA). Nearly all major epilepsy centers in Japan are included in JEPICA, which had 31 members in 2016. Twenty-four (77%) of the 31 centers responded to the questionnaire.

RESULTS

Seventeen (70.8%) centers answered that a psychiatrist was incorporated as part of their epilepsy surgery unit. In addition, 17 (70.8%) noted that psychiatric assessments were obtained prior to surgery, which were performed by psychiatrists in 8 (33.3%) centers and psychologists in 11 (45.8%). In 23 (95.8%) of the centers, the risk of occurrence of psychiatric illness following surgery was routinely explained prior to surgery, at least to surgical candidates with high susceptibility. In total, cases of psychiatric illness following surgery had been experienced in 16 (66.7%) centers, with depression as the most commonly encountered (41.7%), followed by anxiety (33.3%), psychosis (25.0%), and psychogenic non-epileptic seizures (8.3%).

DISCUSSION

Strong points of epilepsy centers in Japan include serious concern regarding post-surgical psychiatric illness by nearly all members of JEPICA and explanation of the risk of psychiatric adverse events provided beforehand to their patients. On the other hand, the small size of some epilepsy centers, along with lack of a standardized method for evaluation of psychiatric symptoms as well as dependence on the individual willingness of psychiatrists assigned as members of the epilepsy units, seem to have led to significant diagnostic and therapeutic gaps among epilepsy centers regarding psychiatric issues related to epilepsy surgery.

Psychiatric lifetime diagnoses are associated with a reduced chance of seizure freedom after temporal lobe surgery

OBJECTIVE

To examine whether psychiatric comorbidity is a predictor of long-term seizure outcome following temporal lobe epilepsy surgery.

METHODS

A sample of 434 adult patients who received temporal lobe resection to treat epilepsy between 1991 and 2009 and were psychiatrically assessed before surgery were followed for 2 years to assess seizure outcome. Stepwise multivariate logistic regression analyses were used to assess the impact of psychiatric variables on complete seizure freedom (Engel class IA), and freedom from disabling seizures (Engel class I). Lifetime histories of three psychiatric syndromes (PS: psychosis; depression; other) and five personality disorders (PD: DSM-IV Clusters A, B, and C; organic personality disorder; other) were considered as predictors, complemented by age at onset, duration of epilepsy, type of lesion (mesiotemporal sclerosis vs. other), and year of surgery.

RESULTS

Seizure-freedom rates were significantly higher (p < 0.001) in patients with no history of PS or PD (N = 138; Engel class IA: 61.6%; Engel class I: 87.7%) than in those with any PS or PD (N = 296; Engel class IA: 39.5%; Engel class I: 58.8%). Particularly low seizure-freedom rates were found in patients with a diagnosis of psychosis (N = 32, Engel class IA: 21.9%; Engel class I: 40.6%), organic PD (N = 48, Engel class IA: 25.0%; Engel class I: 35.4%) or a double diagnosis of PS plus PD (N = 97; Engel class IA: 27.8%; Engel class I: 45.5%). No other variables emerged as significant risk factors in multivariate logistic regression analyses.

SIGNIFICANCE

Patients with and without psychiatric comorbidities can benefit from temporal lobe epilepsy surgery; however, psychiatric comorbidities are negatively associated with postoperative seizure-freedom rates. Surgical outcome is related to the type and extent of preoperative psychiatric morbidity, which underscores the prognostic value of presurgical psychiatric evaluation. The data support the argument that there are common pathogenetic mechanisms underlying both epilepsy and psychiatric conditions.

Effects of surgical side and site on psychological symptoms following epilepsy surgery in adults

This retrospective study examined the potential role of side and site of surgery in psychological symptom change after epilepsy surgery and determined the base rate of psychological change at the individual level. Two-hundred twenty-eight adults completed the Personality Assessment Inventory (PAI) before and after temporal (TLR; n=190) or frontal lobe resection (FLR; n=38). Repeated measures ANOVAs with bootstrapping examined differences in psychological outcome as a function of surgical site separately in patients who underwent left- versus right-sided resections. Individual's PAI score changes were then used to determine the prevalence of clinically meaningful postoperative symptom change. Following left-sided resections, there were significant group-by-time interactions on Somatic Complaints, Anxiety, and Anxiety Related Disorders. There was also a trend in this direction on the Depression scale. TLR patients endorsed greater preoperative symptoms than FLR patients on all of these scales, except the Somatic Complaints scale. After surgery, TLR patients reported symptom improvement on all four scales, while scores of FLR patients remained relatively stable over time. Endorsement of Mania-related symptoms increased in both TLR and FLR groups from pre-to post-surgical testing. Following right-sided resections, both groups endorsed symptom improvements on Somatic Complaints, Anxiety, and Depression scales following surgery. In addition, the TLR group endorsed more Mania-related symptoms than the FLR group regardless of time. Patterns of meaningful change in individual patients were generally consistent with group findings, with the most frequent improvements observed following TLR. However, there were a small subset of patients who reported symptom exacerbation after surgery. Our results suggest that surgical lateralization and localization are important factors in postoperative psychological outcome and highlight the importance of considering psychological change at the individual patient level. Further research is needed to identify potential risk factors for symptom exacerbation to aid in preoperative counseling and identify those patients most in need of postoperative psychological surveillance.

A prospective study contrasting the psychiatric outcome in drug-resistant epilepsy between patients who underwent surgery and a control group

OBJECTIVE

Psychiatric morbidity in drug-resistant epilepsy is frequent and has a negative influence on quality of life. Surgery is proven to be the best therapeutic alternative for treating seizures. However, it is inconclusive with the current evidence whether surgery, per se, is a risk factor or promotes amelioration of psychiatric disorders. Until now, most studies have been cross-sectional with small or heterogeneous groups. In addition, the few prospective studies did not have an identical control group. The present study aims to clarify the role of surgery in psychopathologic alterations.

METHODS

We analyzed, through a prospective case-control study, the psychopathologic outcomes of patients with drug-resistant epilepsy, comparing those who underwent surgery and those who continued with pharmacologic treatment due to not being suitable for surgery. The assessments were performed during presurgical evaluation and 6 months after surgery. We studied psychiatric changes for each group, compared differences between groups, and also analyzed de novo and remission cases. Finally, we determined associated factors for postsurgical psychiatric disturbances.

RESULTS

The surgical group experienced a significant decrease in psychopathologic alterations in comparison with the control group. In addition, distress perception of surgical patients also improved, whereas it did not decrease in the control group. Patients who underwent surgery presented a decrease in depressive and anxiety symptoms, whereas the nonsurgical group increased its anxiety levels. De novo disturbances that appeared after surgery were less frequent than in nonsurgical patients. We observed significant favorable outcomes considering de novo versus remission cases for anxiety, depression, and total symptoms only in the surgical group. The two main predictors for psychiatric disorders after surgery were presurgical psychiatric functioning and surgery.

SIGNIFICANCE

Provides evidence that surgery improves psychiatric functioning in drug-resistant epilepsy through a prospective controlled study.

MRI-guided stereotactic amygdalohippocampectomy: a single center experience

BACKGROUND

This paper presents our experience of stereotactic radiofrequency amygdalohippocampectomy performed for intractable mesial temporal lobe epilepsy.

METHODS

The article describes the cases of 61 patients who were treated during the period from 2004 to 2010. Mean postoperative follow-up was 5.3 years. Neuropsychological results were obtained for a subset of 31 patients.

RESULTS

At their last postsurgical visit, 43 (70.5%) patients were Engel class I, six (9.8%) class II, nine (14.8%) class III, and three (4.9%) class IV. The surgery was complicated by four intracranial hematomas. One of them caused acute hydrocephalus and was treated by shunting and resolved without sequelae, while another caused transitory aphasia. The remaining hematomas were asymptomatic. There were two cases of meningitis which required antibiotic treatment. One patient committed suicide due to postoperative depression. After the procedure, we performed open epilepsy surgery and rethermolesions in three and two patients, respectively (8.2%). Patients showed increases in their mean full scale, verbal, and performance intelligence quotient (IQ) scores of 4, 3, and 4 IQ points, respectively (P<0.05). Five (17.2%), four (13.8%), and four (13.3%) patients improved their full scale, verbal, and performance IQ scores, respectively. No significant changes were found in memory performance, with a mean increase of 1, 3, and 0 memory quotient points in global, verbal, and visual memory, respectively (P<0.05). Global memory improved in three (10.3%) patients, verbal memory in one (3.4%), and one patient (3.3%) showed deterioration in visual memory.

CONCLUSION

Stereotactic radiofrequency amygdalohippocampectomy offers a safe, effective, and less aggressive treatment modality in cases of well-defined mesial temporal lobe epilepsy. Seizure outcome is comparable with the results of conventional epilepsy surgery and cognitive results could be even better.