Mood disorders in patients with epilepsy: epidemiology and management

Development and validation of the epilepsy scale among the system of quality of life instruments for chronic diseases QLICD-EP (V2.0):A multicenter longitudinal study

OBJECTIVES

To develop and evaluate the epilepsy scale among the System of Quality of Life Instruments for Chronic Diseases QLICD-EP(V2.0).

METHODS

The QLICD-EP(V2.0) was developed based on a modular approach and programmed decision procedures with multiple nominal and focus group discussions. The data measuring quality of life (QOL) three times before and after treatment of patients with epilepsy (PWE) was used to evaluate the psychometric properties of the scale, including reliability, validity, and responsiveness.

RESULTS

The Cronbach's α coefficient of the total scale was 0.902. The test-retest reliability of the total scale was 0.913, and the ICC(95 %CI) of the total scale was 0.953(0.928,0.969). Correlation and confirmatory factor analyses by the structural equation model confirmed good construct validity. Correlation analysis showed good criterion-related validity when using the Short Form-36 Health Survey (SF-36) as a criterion. The paired t-test results showed that the special mentality facet was statistically significant (P < 0.05) before and after the treatment with standard response mean (SRM) being 0.31, there was no statistical significance in other domains and facets with SRM being less than 0.50, which was a low effect.

CONCLUSION

QLICD-EP (V2.0) can be used to clinically assess the QOL of PWE in China. Providing a scientific basis for precision medicine and contributing to global health.

Longitudinal Comparison of PNES spell and ASM reduction in PNES Patients with and without Epilepsy Discharged from an Epilepsy Monitoring Unit

OBJECTIVE

To examine trends of Antiseizure Medication (ASM) reduction and discontinuation, as well as Psychogenic Non-Epileptic Seizure (PNES) spell reduction and resolution in patients with PNES, with and without comorbid epileptic seizures (ES).

METHODS

A retrospective analysis was conducted on data from 145 patients with PNES, including 109 with PNES alone and 36 with PNES plus comorbid epilepsy. Patients were admitted to the Epilepsy Monitoring Unit (EMU) between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Clinical records were thoroughly examined, encompassing the period preceding the PNES diagnosis until either loss to follow-up or September 2015. A subsequent chart review was conducted by two neurologists, covering the period following the diagnosis of PNES until either loss to follow-up or September 2015, which ever came first.

RESULTS

Patients with PNES alone had higher rates of ASM reduction for all variables of ASM reduction measured compared to those with comorbid epilepsy (all at p < 001). Among patients with PNES alone, reductions in ASMs were observed after EMU discharge, but an uptick and plateau were seen in later follow-up years (100% of patients free of ASMs at years 2-3, 20% on at least one ASM by year 7). This pattern differs greatly in PNES + ES patients, in which the only time point at which any patient was able to discontinue all ASMs was at EMU discharge (4.5% of patients), with all patients taking at least one ASM for every other follow-up time point. Reductions in PNES spell frequency did not differ significantly between the two groups (for example PNES spells reduced at final FU 47.2% vs 42.9%, p = 0.65). In both groups, despite an initial drop in variables of PNES spell reduction and resolution in the early years post discharge, there is an eventual rebound and plateau (for example in PNES only patients, 33.9% of patients having no resolution in 1st year FU, which rises to 78% at years 4-5, and plateus around 52.8% at more than 7 years follow-up.) SIGNIFICANCE: This study contributes to the growing body of research focused on improving the current approach to management and prognostic outlook of PNES. Although PNES only patients had higher rates of ASM reduction, the uptick and plateau observed in later years highlights the challenges in managing PNES. Similarly, the continued persistence and rebound of PNES spells underline the continued poor prognostic outcomes associated with this condition.

Patients with psychogenic nonepileptic seizures and suspected epilepsy: An antiseizure medication reduction study

OBJECTIVE

To examine predictors of ASM reduction/discontinuation and PNES reduction/resolution in patients with PNES with a confirmed or strong suspicion of comorbid ES.

METHODS

A retrospective analysis of 271 newly diagnosed Patients with PNESs admitted to the EMU between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Forty-seven patients met our criteria of PNES with either confirmed or probable ES.

RESULTS

Patients with PNES reduction were significantly more likely to have come off all ASMs by the time of final follow-up (21.7 vs. 0.0%, p = 0.018), while documented generalized (i.e. epileptic) seizures were much more common in patients with no reduction in PNES frequency (47.8 vs 8.7%, p = 0.003). When comparing patients that reduced their ASMs (n = 18) with those that did not (n = 27), the former were more likely to have neurological comorbid disorders (p = 0.004). When comparing patients with PNES resolution (n = 12) vs not (n = 34), those with PNES resolution were more likely to have a neurological comorbid disorder (p = 0.027), had a younger age at EMU admission (29.8 vs 37.4, p = 0.05) and a greater proportion of patients with ASMs reduced in EMU (66.7% vs 30.3%, p = 0.028). Similarly, those with ASM reduction had more unknown (non-generalized, non-focal) seizures (33.3 vs 3.7%, p = 0.029). On hierarchical regression analysis, a higher level of education and absence of generalized epilepsy remain as positive predictors of PNES reduction (p = 0.042, 0.015), while the presence of some other neurological disorder besides epilepsy (p = 0.04) and being on more ASMs at EMU admission (p = 0.03) were positive predictors of ASM reduction by final follow-up.

SIGNIFICANCE

Patients with PNES and epilepsy have distinct demographic predictors of PNES frequency and ASM reduction by final follow-up. Patients with PNES reduction and resolution had higher level education, less generalized epileptic seizures, younger age at EMU admission, more likely to have presence of a neurological disorder besides epilepsy, and a greater proportion of patients had a reduction in the number of ASMs in the EMU. Similarly, patients with ASM reduction and discontinuation were on more ASMs at initial EMU admission and also were more likely to have a neurological disorder besides epilepsy. The positive relationship between reduction in psychogenic nonepileptic seizure frequency and discontinuation of ASMs at final follow-up elucidates that tapering medication in a safe environment may reinforce psychogenic nonepileptic seizure diagnosis. This can be reassuring to both patients and clinicians, resulting in the observed improvements at the final follow-up.

Effects of progressive muscle relaxation exercises on patients with epilepsy on level of depression, quality of sleep, and quality of life: A randomized controlled trial

OBJECTIVE

This study aims to evaluate the effects of progressive relaxation exercises applied to patients with epilepsy on patients' depressive symptom severity, quality of sleep, and quality of life.

METHODS

The study was designed as a randomized controlled interventional study with a control group and pre-and post-test intervention. It was conducted with 70 patients with epilepsy, 35 in the intervention group and 35 in the control group, between November 1, 2021, and April 15, 2022. The patients in the intervention group were required to perform 12 progressive muscle relaxation exercise sessions 3 days a week for a total of 4 weeks. No interventions were made in the control group during the study. The data were collected with a "Personal Information Form," "Pittsburgh Sleep Quality Index (PSQI)," "Beck Depression Inventory (BDI)," and "Quality of Life in Epilepsy Inventory (QUOLIE -31)."

RESULTS

The mean PSQI total score, subscale scores, and mean BDI total scores of the patients in the intervention group decreased significantly compared to those in the control group after the intervention (p<0.05). Additionally, a significant difference was found between the mean QUOLIE-31 total scores and subscale scores of the patients in the intervention and control group after the intervention (p<0.05), the mean scores of the intervention group were significantly higher than those of the control group (p<0.05).

CONCLUSION

Progressive muscle relaxation exercises decreased depressive symptoms severity and improved sleep and life quality in patients with epilepsy. Progressive relaxation exercises may be recommended as a complementary nursing intervention in treating epilepsy.

Comorbid epilepsy and depression—pharmacokinetic and pharmacodynamic drug interactions

Background: Major depressive disorder may be encountered in 17% of patients with epilepsy and in patients with drug-resistant epilepsy its prevalence may reach 30%. This indicates that patients with epilepsy may require antidepressant treatment.

Purpose: Both pharmacodynamic and pharmacokinetic interactions between antiepileptic (antiseizure) and antidepressant drugs have been reviewed. Also, data on the adverse effects of co-administration of antiepileptic with antidepressant drugs have been added. This article was submitted to Neuropharmacology, a section of the journal Frontiers in Pharmacology.

Methods: The review of relevant literature was confined to English-language publications in PUBMED databases. Table data show effects of antidepressants on the seizure susceptibility in experimental animals, results of pharmacodynamic interactions between antiepileptic and antidepressant drugs mainly derived from electroconvulsions in mice, as well as results concerning pharmacokinetic interactions between these drugs in clinical conditions.

Conclusion: Antidepressant drugs may exert differentiated effects upon the convulsive threshold which may differ in their acute and chronic administration. Animal data indicate that chronic administration of antidepressants could reduce (mianserin, trazodone) or potentiate the anticonvulsant activity of some antiepileptics (fluoxetine, reboxetine, venlafaxine). There are also examples of neutral interactions (milnacipran).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Radiomic features as a risk factor for early postoperative seizure in patients with meningioma

PURPOSE

This study aim to identify the clinical risk factors of and to develop a radiomics-based predictive model for early postoperative seizure.

METHODS

We retrospectively assessed 322 operative patients with meningioma who met the inclusion criteria from January 2014 to December 2016 at The First Affiliated Hospital of Wenzhou Medical University. Univariate and multivariate analyses were performed to determine the predictive value of clinical variables. Magnetic resonance imaging (MRI) was performed to obtain the radiomic score (Rscore) for early postoperative seizure. Radiological features were evaluated using the AK software. The minimal redundancy (mRMR) and least absolute shrinkage and selection operator (LASSO) methods were used to assess for radiomic features, and the Rscore was obtained based on radiomic characteristics using a specific formula.

RESULTS

In total, 260 patients who met the inclusion criteria were finally enrolled in this study. Among them, 20 experienced early postoperative seizure. Logistic regression analysis showed that Rscore was associated with a significantly high risk of seizure (p<0.000). Receiver operating characteristic (ROC) curve analysis revealed that the area under the ROC curve of the Rscore was 0.92 (95% confidence interval: 0.853-0.987). The model had a high accuracy for predicting early postoperative seizure.

CONCLUSIONS

The Rscore was found to be associated with a high risk of early postoperative seizures. Thus, a higher Rscore (>-1.644) can identify high-risk patients requiring intensive care.

Decentralized, primary-care delivered epilepsy services in Burera District, Rwanda: Service use, feasibility, and treatment

Background

Integrating epilepsy care into primary care settings could reduce the global burden of illness attributable to epilepsy. Since 2012, the Rwandan Ministry of Health and the international nonprofit Partners In Health have collaboratively used a multi-faceted implementation program- MESH MH—to integrate and scale-up care for epilepsy and mental disorders within rural primary care settings in Burera district, Rwanda. We here describe demographics, service use and treatment patterns for patients with epilepsy seeking care at MESH-MH supported primary care health centers.

Methods and findings

This was a retrospective cohort study using routinely collected data from fifteen health centers in Burera district, from January 2015 to December 2016. 286 patients with epilepsy completed 3307 visits at MESH-MH participating health centers over a two year period (Jan 1st 2015 to Dec 31st 2016). Men were over twice as likely to be diagnosed with epilepsy than women (OR 2.38, CI [1.77–3.19]), and children under 10 were thirteen times as likely to be diagnosed with epilepsy as those 10 and older (OR 13.27, CI [7.18–24.51]). Carbamazepine monotherapy was prescribed most frequently (34% of patients).

Conclusion

Task-sharing of epilepsy care to primary care via implementation programs such as MESH-MH has the potential to reduce the global burden of illness attributable to epilepsy.

•

Primary-care delivered epilepsy services in rural Rwanda are described.

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High epilepsy service use, treatment uptake and follow-up was observed.

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Primary-care integration could increase epilepsy treatment availability globally.

The association between temperament features and childhood traumas in patients with juvenile myoclonic epilepsy

Background/aim

Epilepsy is a common chronic neurological problem that impairs daily activities, functionality, and quality of life. Childhood traumas (CTs) are known to be critical factors in the onset or development of many psychiatric and medical disorders. They also play a critical role in the development of temperament and personality. This study aimed to investigate the association between CTs and common temperament patterns and features seen in epilepsy patients.

Materials and methods

The study included 38 patients who were diagnosed with juvenile myoclonic epilepsy (JME) and volunteered to participate in the study. In addition to the sociodemographic form and questions on disease features, Structured Clinical Interview for DSM-IV Axis I Disorders, Temperament Evaluation of Memphis, Pisa, Paris and San Diego Questionnaire (TEMPS-A), Childhood Trauma Questionnaire (CTQ), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) were administered to all participants. In the present study, a cut-off value of 35 was used for the CTQ scale. The patients with CTQ scores lower than 35 (50%, n = 19, Group 1) and the patients with CTQ scores above 35 (50%, n = 19, Group 2) were compared.

Results

The comparison of TEMPS-A and its subscale scores in the JME patients in the groups with CTQ scores above or below a cut-off value detected significant differences between the groups in depressive and irritable temperament scores. The mean BDI scores were also different between the two groups. Furthermore, a significant positive correlation was detected between the disease duration, anxiety, and depression scores in the JME patients. A significant relationship was detected between the emotional neglect subscale score of the JME patients and the BDI scores. A significant positive correlation was found between the total disease duration, BDI, and BAI. Significant moderate-level relationships were found between the BDI score and irritable, depressive, cyclothymic, and anxious temperaments and between the BAI score and irritable, depressive, cyclothymic, and anxious temperaments.

Conclusion

Several temperamental features of JME patients are related to CTs. More depressive symptoms are seen in JME patients with higher disease durations.

Neuropsychological assessment and clinical evaluation in temporal lobe epilepsy with associated cortical dysplasia

Temporal Lobe Epilepsy (TLE) is a chronic neurological disorder, often associated to cognitive deficits. Focal cortical dysplasia (FCD), frequently associated to high risk of epilepsy, can lead to abnormalities in cognition. The aim of this study was to explore neuropsychological performance and to identify potential risk factors for cognitive impairment in TLE subjects with associated FCD. Our sample was composed by 46 TLE patients with FCD (37.76 ± 12.60 years; 29 females and 16 males) and 44 healthy controls (41.05 ± 9.74 years; 25 females and 19 males). All subjects performed a neuropsychological battery associated to a measurement of depression and anxiety. Results showed a poor performance of all domains of cognitive functioning and identified age of epilepsy onset as potential risk factor of cognitive impairment. These findings support the importance to focus on cognitive impairment in TLE patients with FCD to better clarify the impact of epilepsy features and FCD in therapeutic and everyday management.

Polyamines: The possible missing link between mental disorders and epilepsy (Review)

Polyamines are small positively charged alkylamines that are essential in a number of crucial eukaryotic processes, like normal cell growth and development. In normal physiological conditions, intracellular polyamine content is tightly regulated through a fine regulated network of biosynthetic and catabolic enzymes and a transport system. The dysregulation of this network is frequently associated to different tumors, where high levels of polyamines has been detected. Polyamines also modulate ion channels and ionotropic glutamate receptors and altered levels of polyamines have been observed in different brain diseases, including mental disorders and epilepsy. The goal of this article is to review the role of polyamines in mental disorders and epilepsy within a frame of the possible link between these two brain pathologies. The high comorbidity between these two neurological illnesses is strongly suggestive that they share a common background in the central nervous system. This review proposes an additional association between the noradrenalin/serotonin and glutamatergic neuronal circuits with polyamines. Polyamines can be considered supplementary defensive shielding molecules, important to protect the brain from the development of epilepsy and mental illnesses that are caused by different types of neurons. In this contest, the modulation of polyamine metabolism may be a novel important target for the prevention and therapeutic treatment of these diseases that have a high impact on the costs of public health and considerably affect quality of life.

A guide to intellectual disability psychiatry assessments in the community

Psychiatric assessment in the community is an important part of both the initial assessment process and delivery of follow-up care in adult intellectual disability services in the UK. This article examines how such assessments can be carried out safely and explores the clinical skills required to perform them effectively. Use of the psychiatric interview and mental state examination to elicit information is discussed. Communication difficulties experienced by people with intellectual disabilities and strategies that may be employed to address these in the assessment process are also explored. The article is directed at psychiatrists, in particular specialty trainees, and other healthcare professionals who work with intellectually disabled people.

Recent advances in epilepsy

This paper reviews advances in epilepsy in recent years with an emphasis on therapeutics and underlying mechanisms, including status epilepticus, drug and surgical treatments. Lessons from rarer epilepsies regarding the relationship between epilepsy type, mechanisms and choice of antiepileptic drugs (AED) are explored and data regarding AED use in pregnancy are reviewed. Concepts evolving towards a move from treating seizures to treating epilepsy are discussed, both in terms of the mechanisms of epileptogenesis, and in terms of epilepsy's broader comorbidity, especially depression.

Affective disorders and functional (non-epileptic) seizures in persons with epilepsy

OBJECTIVE

This paper aims to describe the prevalence, assessment and management of affective disorders as well as functional (non-epileptic) seizures in people with epilepsy.

METHOD

This paper comprises a selective review of the literature of the common affective manifestations of epilepsy.

RESULTS

Affective disorders are the most common psychiatric comorbidity seen in people with epilepsy and assessment and management parallels that of the general population. Additionally, people with epilepsy may experience higher rates of mood instability, irritability and euphoria, classified together as a group, interictal dysphoric disorder and resembling an unstable bipolar Type II disorder. Functional seizures present unique challenges in terms of identification of the disorder and a lack of specific management.

CONCLUSIONS

Given their high prevalence, it is important to be able to recognise affective disorders in people with epilepsy. Management principles parallel those in the general population with specific caution exercised regarding the potential interactions between antidepressant medications and antiepileptic drugs. Functional seizures are more complex and require a coordinated approach involving neurologists, psychiatrists, general practitioners, nursing and allied health. There is very limited evidence to guide psychological and behavioural interventions for neurotic disorders in epilepsy and much more research is needed.

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.

Common Mechanisms Underlying Epileptogenesis and the Comorbidities of Epilepsy

The importance of comorbidities in determining the quality of life of individuals with epilepsy and their families has received increasing attention in the past decade. Along with it has come a recognition that in some individuals, certain comorbidities may have preexisted, and may have contributed to their developing epilepsy. Many mechanisms are capable of interconnecting different dysfunctions that manifest as distinct disorders, often diagnosed and managed by different specialists. We review the human data from the perspective of epidemiology as well as insights gathered from neurodiagnostic and endocrine studies. Animal studies are reviewed to refine our mechanistic understanding of the connections, because they permit the narrowing of variables, which is not possible when studying humans.

Pharmacokinetic/pharmacodynamic considerations for epilepsy - depression comorbidities

INTRODUCTION

Epilepsy may be frequently associated with psychiatric disorders and its co-existence with depression usually results in the reduced quality of life of patients with epilepsy. Also, the efficacy of antiepileptic treatment in depressed patients with epilepsy may be significantly reduced.

AREAS COVERED

Results of experimental studies indicate that antidepressants co-administered with antiepileptic drugs may either increase their anticonvulsant activity, remain neutral or decrease the protective action of antiepileptic drugs in models of seizures. Apart from purely pharmacodynamic interactions, pharmacokinetic mechanisms have been proven to contribute to the final outcome. We report on clinical data regarding the pharmacokinetic interactions of enzyme-inducing antiepileptic drugs with various antidepressants, whose plasma concentration may be significantly reduced. On the other hand, antidepressants (especially selective serotonin reuptake inhibitors) may influence the metabolism of antiepileptics, in many cases resulting in the elevation of plasma concentration of antiepileptic drugs.

EXPERT OPINION

The preclinical data may provide valuable clues on how to combine these two groups of drugs - antidepressant drugs neutral or potentiating the anticonvulsant action of antiepileptics are recommended in this regard. Avoidance of antidepressants clearly decreasing the convulsive threshold or decreasing the anticonvulsant efficacy of antiepileptic drugs (f.e. bupropion or mianserin) in patients with epilepsy is recommended.

Hypothalamic-pituitary-adrenocortical axis dysfunction in epilepsy

Epilepsy is a common neurological disease, affecting 2.4million people in the US. Among the many different forms of the disease, temporal lobe epilepsy (TLE) is one of the most frequent in adults. Recent studies indicate the presence of a hyperactive hypothalamopituitary- adrenocortical (HPA) axis and elevated levels of glucocorticoids in TLE patients. Moreover, in these patients, stress is a commonly reported trigger of seizures, and stress-related psychopathologies, including depression and anxiety, are highly prevalent. Elevated glucocorticoids have been implicated in the development of stress-related psychopathologies. Similarly, excess glucocorticoids have been found to increase neuronal excitability, epileptiform activity and seizure susceptibility. Thus, patients with TLE may generate abnormal stress responses that both facilitate ictal discharges and increase vulnerability for the development of comorbid psychopathologies. Here, we will examine the evidence that the HPA axis is disrupted in TLE, consider potential mechanisms by which this might occur, and discuss the implications of HPA dysfunction for seizuretriggering and psychiatric comorbidities.

Gabapentin Therapy in Psychiatric Disorders: A Systematic Review

OBJECTIVE

Gabapentin is commonly used off-label in the treatment of psychiatric disorders with success, failure, and controversy. A systematic review of the literature was performed to elucidate the evidence for clinical benefit of gabapentin in psychiatric disorders.

DATA SOURCES

Bibliographic reference searches for gabapentin use in psychiatric disorders were performed in PubMed and Ovid MEDLINE search engines with no language restrictions from January 1, 1983, to October 1, 2014, excluding nonhuman studies. For psychiatric references, the keywords bipolar, depression, anxiety, mood, posttraumatic stress disorder (posttraumatic stress disorder and PTSD), obsessive-compulsive disorder (obsessive-compulsive disorder and OCD), alcohol (abuse, dependence, withdraw), drug (abuse, dependence, withdraw), opioid (abuse, dependence, withdraw), cocaine (abuse, dependence, withdraw), and amphetamine (abuse, dependence, withdraw) were crossed with gabapentin OR neurontin.

STUDY SELECTION AND DATA EXTRACTION

The resulting 988 abstracts were read by 2 reviewers; references were excluded if gabapentin was not a study compound or psychiatric symptoms were not studied. The resulting references were subsequently read, reviewed, and analyzed; 219 pertinent to gabapentin use in psychiatric disorders were retained. Only 34 clinical trials investigating psychiatric disorders contained quality of evidence level II-2 or higher.

RESULTS

Gabapentin may have benefit for some anxiety disorders, although there are no studies for generalized anxiety disorder. Gabapentin has less likely benefit adjunctively for bipolar disorder. Gabapentin has clearer efficacy for alcohol craving and withdrawal symptoms and may have a role in adjunctive treatment of opioid dependence. There is no clear evidence for gabapentin therapy in depression, PTSD prevention, OCD, or other types of substance abuse. Limitations of available data include variation in dosing between studies, gabapentin as monotherapy or adjunctive treatment, and differing primary outcomes between trials.

CONCLUSIONS

Further research is required to better clarify the benefit of gabapentin in psychiatric disorders.

The anti-inflammatory activity of duloxetine, a serotonin/norepinephrine reuptake inhibitor, prevents kainic acid-induced hippocampal neuronal death in mice

Duloxetine (DXT), a potent serotonin/norepinephrine reuptake inhibitor, is widely used in the treatment of major depressive disorder. In the present study, we examined the effects of DXT treatment on seizure behavior and excitotoxic neuronal damage in the mouse hippocampal CA3 region following intraperitoneal kainic acid (KA) injection. DXT treatment showed no effect on KA-induced behavioral seizure activity. However, treatment with 10mg/kg DXT reduced KA-induced neuronal death in the hippocampal CA3 region at 72h after KA administration, and treatment with 20 and 40mg/kg DXT showed a noticeable neuroprotection in the hippocampal CA3 region after KA injection. In addition, KA-induced activations of microglia and astrocytes as well as KA-induced increases of TNF-α and IL-1β levels were also suppressed by DXT treatment. These results indicate that DXT displays the neuroprotective effect against KA-induced excitotoxic neuronal death through anti-inflammatory action.

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.

The dilemma of treatments for epileptic patients with depression

Depression is a state of low mood and aversion to activity. It may occur due to existence of other mental or physical diseases or from the medications for those illnesses. It is one of the leading sources of disability. Among these physical diseases, epilepsy is widely recognized as one of the main causes of depression. Patients with epilepsy are at high risk of developing depressive symptoms, and the suicide rates in patients with epilepsy have been reported to be much higher than in the general population. However, due to fears of lowering seizure threshold and adverse drug interactions between antidepressants and antiepileptic drugs, physician are reluctant to place patients with epilepsy on antidepressant medication. As a result, the question has been raised that what the best managements should be used to treat epileptic patients with depression. In this review, the currently used medications for antidepressants and antiepileptic drugs were summarized by their working targets in order to establish appropriate pharmacological management of depression and epilepsy. Despite the complex relationship between epilepsy and depression, coadministration of antidepressants and AEDs can still be done safely and effectively under the conditions of good clinical management. The ideal antidepressants for people with epilepsy should be efficacious but with few adverse effects, which will not antagonize GABAergic mechanisms or interfere with plasma anticonvulsant concentrations.

Pharmacokinetic and pharmacodynamic interactions between antiepileptics and antidepressants

INTRODUCTION

Antiepileptic-antidepressant combinations are frequently used by clinicians; their pharmacokinetic (PK) and pharmacodynamic (PD) drug interactions (DIs) have not been well studied but are frequently likely to be clinically relevant.

AREAS COVERED

This article provides a comprehensive review of PK DIs between antiepileptics and antidepressants. In the absence of PD DI studies, PD information on pharmacological mechanisms and studies on efficacy and safety of individual drugs are reviewed.

EXPERT OPINION

The clinical relevance of the inductive properties of carbamazepine, phenytoin, phenobarbital and primidone and the inhibitory properties of valproic acid and some antidepressants are well understood; correction factors are provided if appropriate DI studies have been completed. More PK studies are needed for: i) antiepileptics with potent inductive effects for all recently approved antidepressants; ii) high doses of mild CYP3A4 inducers, such as clobazam, eslicarbazepine, oxcarbazepine, rufinamide and topiramate for reboxetine and vilazodone; iii) valproate as a possible inhibitor, mild inducer or both a mild inducer and competitive inhibitor of some antidepressants; and iv) inhibitory effects of long-term fluoxetine use on clobazam, lacosamide, phenobarbital, primidone, carbamazepine, felbamate, tiagabine and zonisamide. Possible synergistic or additive beneficial PD DIs in generalized anxiety disorder, chronic pain, migraine prophylaxis, weight control and menopausal symptoms need study.

The social context of anxiety and depression: exploring the role of anxiety and depression in the lives of Australian adults with epilepsy

AIM

To examine key determinants of anxiety and depression in a community sample of people with epilepsy.

METHOD

Data were analyzed from the 2010 Australian Epilepsy Longitudinal Survey, examining living with epilepsy in Australia. The HADS was analyzed, and Pearson correlations and block recursive regression were undertaken to identify key associations between anxiety, depression, and a range of variables and to identify key determinants of anxiety and depression.

RESULTS

Key factors to influence anxiety were social aspects of stigma, effectiveness of seizure control, whether in employment, and the number of different epilepsy drugs. Determinants for depression were social aspects of stigma, whether in employment, and the effectiveness of seizure control. Stigma was also found to be an important mediating variable for employment, control, and the number of drugs.

CONCLUSION

Understanding the mechanisms involved in anxiety and depression in a community sample of people with epilepsy requires the inclusion of opportunities for paid employment and the effects of psychosocial factors such as stigma. Without this fuller social context, there are limitations on understanding factors that influence anxiety and depression and how to deal with the outcomes.

Prevalence and quality of anxiety in patients with epilepsy

BACKGROUND

Depression and anxiety are the most frequent psychiatric disorders identified in patients with epilepsy. We aimed to determine the prevalence of state and trait anxiety in patients with epilepsy compared with people without epilepsy.

METHODS

We recruited patients and healthy controls in the outpatient neurology clinic of Kurdistan University of Medical Sciences, Iran, during 2011. Eighty-four patients with epilepsy and 168 healthy persons from relatives of the patients in the case group were recruited and filled out the inventory. The State-Trait Anxiety Inventory (STAI) was used to measure anxiety. After selection of participants and neurological evaluation, all subjects were clinically interviewed at the outpatient clinic of neurology. Data were analyzed using SPSS software, version 16. Fisher's exact and chi-square tests were used for nominal variables, and the t-test was used for anxiety scores.

RESULTS

The average ages of the patients in the case and control groups were 28 and 27.5 years, respectively. State anxiety was significantly higher in patients with epilepsy than in the control group (p=0.042). Also, a higher trait anxiety score was reported in the case group compared with the control group (p=0.009).

CONCLUSION

The rates of both state and trait anxiety were higher in patients in the case group. It appears that anxiety in epilepsy is not just a reaction to a stressful situation, and there may be genetic or temperamental factors that contribute to the relationship between epilepsy and anxiety.

Effect of acute and chronic tianeptine on the action of classical antiepileptics in the mouse maximal electroshock model

BACKGROUND

The aim of the study was to analyze the influence of acute and chronic treatment with tianeptine, an antidepressant selectively accelerating presynaptic serotonin reuptake, on the protective activity of classical antiepileptic drugs in the maximal electroshock test in mice.

METHODS

Electroconvulsions were produced by means of an alternating current (50 Hz, 25 mA, 0.2 s) delivered via ear-clip electrodes. Motor impairment and long-term memory deficits in animals were quantified in the chimney test and in the passive-avoidance task, respectively. Brain concentrations of antiepileptic drugs were measured by fluorescence polarization immunoassay.

RESULTS

Acute and chronic treatment with tianeptine (25-50 mg/kg) did not affect the electroconvulsive threshold. Furthermore, tianeptine applied in both acute and chronic protocols enhanced the anticonvulsant action of valproate and carbamazepine, but not that of phenytoin. Neither acute nor chronic tianeptine changed the brain concentrations of valproate, carbamazepine or phenytoin. On the other hand, both single and chronic administration of tianeptine diminished the brain concentration of phenobarbital. In spite of this pharmacokinetic interaction, the antidepressant enhanced the antielectroshock action of phenobarbital. In terms of adverse effects, acute/chronic tianeptine (50 mg/kg) and its combinations with classic antiepileptic drugs did not impair motor performance or long-term memory in mice.

CONCLUSION

The obtained results justify the conclusion that tianeptine may be beneficial in the treatment of depressive disorders in the course of epilepsy.

Patterns of depressive symptoms in epilepsy

OBJECTIVE

The purpose of this study was to determine the nature and extent of depressive symptoms among patients with epilepsy.

METHODS

Ninety patients were investigated over a three-month period: 42 were suffering from generalized epilepsy, 29 from focal epilepsy and 19 from undetermined epilepsy. All completed the Zung self-rating scale for assessment of the depressive symptoms.

RESULTS

Sixty-seven patients felt stigmatized because of epilepsy (67%): 73.6% in the undetermined epilepsy group, 55.1% in the focal epilepsy group and 88% in the generalized epilepsy group. Moreover, among the 90 epileptic patients studied, symptoms of irritability, indecisiveness, personal devaluation and emptiness showed a constant increasing trend for their presence from the undetermined epilepsy group through the generalized epilepsy group to the focal epilepsy group.

CONCLUSIONS

These findings indicate that although the focal epilepsy patients felt less stigmatized, they did not differ greatly in terms of depressive symptoms, in relation to the undetermined epilepsy and generalized epilepsy patients.

Antidepressant drugs

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Epilepsy, mental health disorder, or both?

Temporal lobe epilepsy (TLE), a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management. This paper outlines a spectrum of mental health presentations, including psychosis, mood, anxiety, panic, and dissociative states, associated with epilepsy that make the correct diagnosis a challenge.

Effect of acutely and chronically administered venlafaxine on the anticonvulsant action of classical antiepileptic drugs in the mouse maximal electroshock model

The influence of acute and chronic treatments with intraperitoneal venlafaxine, a selective serotonin/norepinephrine reuptake inhibitor, on the anticonvulsant activity of selected antiepileptic drugs was studied in the maximal electroshock test in mice. Venlafaxine (12.5 and 25mg/kg), given either acutely or chronically, significantly increased the electroconvulsive threshold. Moreover, both acute and chronic venlafaxine, applied at the highest subprotective dose of 6.25mg/kg, enhanced the anticonvulsant effect of valproate, without affecting the protective action of carbamazepine, phenobarbital and phenytoin. The antidepressant did not affect brain concentration of valproate, indicating that the interaction between the two drugs seems pharmacodynamic in nature. Despite the lack of effect on the antielectroshock action of the remaining antiepileptics, acute venlafaxine increased the brain concentration of phenobarbital, while chronic venlafaxine reduced the brain level of phenytoin. In terms of adverse effects, acute/chronic venlafaxine and antiepileptic drugs alone, as well as their combinations, did not produce significant motor or long-term memory deficits in mice. Summing up, it seems that venlafaxine may be considered as a safe drug for the clinical use in patients with epilepsy and depressive disorders.

Metabolic, digestive, and reproductive adverse events associated with antimanic treatment in children and adolescents: a retrospective cohort study

OBJECTIVE

To identify factors associated with incident metabolic and reproductive adverse events in children and adolescents.

METHOD

A retrospective cohort design evaluating Medicaid medical and pharmacy claims made in South Carolina between January 1996 and December 2005 was employed for 3,657 children and adolescents (aged 17 years old and younger) prescribed 1 of 3 antimanic medications (ie, lithium, carbamazepine, or valproic acid derivatives) and a random sample of 4,500 children and adolescents not treated with psychotropic medications.

RESULTS

Compared to the control sample, the treated cohort was more likely to be diagnosed with obesity/weight gain (odds ratio [OR] = 1.89), type 2 diabetes mellitus (OR = 2.50), dyslipidemia (OR = 1.89), nausea (OR = 1.61), anorexia (OR = 3.85), and sexual/reproductive adverse events (OR = 2.04). Within the treated cohort, incident dyslipidemia was more likely for those prescribed carbamazepine (OR = 1.52) compared to valproate and coprescribed antipsychotics (OR = 1.47) or selective serotonin reuptake inhibitors (SSRIs) (OR = 1.49) compared to those not taking antipsychotics or taking serotonin-norepinephrine reuptake inhibitor/heterocyclic (SNRI/other) antidepressants. The odds of developing nausea/vomiting were higher for those prescribed carbamazepine (OR = 1.70) or lithium (OR = 1.49) compared to valproate, and those coprescribed psychostimulants (OR = 1.25) compared to those not taking psychostimulants. The odds of developing obesity/weight gain and type 2 diabetes mellitus were higher for those coprescribed SSRIs (ORs = 1.72, 2.58) or antipsychotics (ORs = 1.69, 1.77) compared to those taking SNRI/other antidepressants or not taking antipsychotics. Incident sexual/reproductive adverse events were more likely for those coprescribed SSRIs (OR = 2.02) compared to those taking SNRI/other antidepressants.

CONCLUSION

Commonly employed psychotropic agents are associated with clinically significant metabolic, digestive, and reproductive-related adverse events. Treatment decisions in young populations are usefully informed by the somatic consequences of the medication options.

Antiepileptic drugs and suicidality

The risk of suicide in patients with epilepsy is significantly higher than the general population. There are many hypotheses as to the reasons for this, but the potential role of anti-epileptic drugs (AEDs) in increasing suicidality has recently been brought into question. In 2008, the U.S. Food and Drug Administration (FDA) published a warning after a meta-analysis of data from all clinical trials involving AEDs found a suicidality risk of 0.43 per 1000 patients in active drug arms of these clinical trials compared to a rate in the placebo arm of 0.22. While an increased risk for individual AEDs was found in two, the FDA decided to issue a warning for the entire AED class. While this decision and the meta-analysis findings have been considered controversial, and have created concern that this stated risk may dissuade use of AEDs by patients who would benefit from them, it has led to increased awareness of the risk of suicidality and psychiatric co-morbidity in this patient group. In this article, the association of epilepsy and AEDs with psychiatric disease and suicidality are reviewed, perspective as to the significance and limitations of the FDA’s findings are discussed, and some options for suicidality screening and their potential utility in clinical care are evaluated.

Effect of acute and chronic treatment with milnacipran potentiates the anticonvulsant activity of conventional antiepileptic drugs in the maximal electroshock-induced seizures in mice

RATIONALE

Depression often coexists with epilepsy. Simultaneous therapy of the two diseases may be associated with pharmacodynamic and/or pharmacokinetic interactions between antiepileptic and antidepressant drugs.

OBJECTIVES

The aim of this study was to investigate the influence of acute and chronic treatment with intraperitoneal milnacipran (MLN), a selective serotonin/noradrenaline reuptake inhibitor, on the protective activity of valproate, carbamazepine (CBZ), phenytoin, or phenobarbital (PB) in the maximal electroshock (MES) test in mice.

MATERIALS AND METHODS

Electroconvulsions were produced by an alternating current (50 Hz, 25 mA) delivered via ear-clip electrodes. Motor coordination and long-term memory were evaluated in the chimney test and passive-avoidance task, respectively. Brain concentrations of antiepileptic drugs (AEDs) were assessed by immunofluorescence.

RESULTS

Given acutely, MLN at 10 mg/kg increased the convulsive threshold. Acute MLN applied at the subprotective dose of 5 mg/kg enhanced the anticonvulsant effects of CBZ and PB. Chronic treatment with MLN (5-30 mg/kg once daily for 2 weeks) did not affect either the electroconvulsive threshold or the anticonvulsant action of all studied conventional antiepileptic drugs. Since the antidepressant did not affect brain concentrations of antiepileptics used in the study, the revealed interactions seem to be of pharmacodynamic nature. Moreover, acute and chronic MLN, AEDs, and their combinations did not produce significant motor and long-term memory impairment.

CONCLUSIONS

Acute, but not chronic, treatment with MLN can increase the effectiveness of some AEDs against MES-induced seizures in mice. It seems that MLN may also be considered as a candidate drug for clinical trials in patients with epilepsy and depressive disorders.

Determination of prevalence of depression in an epilepsy clinic using a brief DSM-IV-based self-report questionnaire

Depression in epilepsy is common, underrecognized, and an indicator of quality of life. The Patient Health Questionnaire nine-item depression scale (PHQ-9) is a self-administered questionnaire based on Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria with high sensitivity and specificity for diagnosing depression. Using the PHQ-9, we determined that one-third of 263 patients seen in an epilepsy clinic had scores consistent with major depression. Seizure-free patients had lower depression scores than those with persistent seizures. Depression scores were not related to the number or type of antiepileptic drugs used. One-half of patients with scores consistent with major depression were not on antidepressant medication. The brevity of the PHQ-9 is conducive to routine screening of patients with epilepsy.

The effects of epilepsy and its treatments on affect and emotion

Epilepsy creates significant morbidity, disability, and loss of productivity worldwide. Although unpredictable seizures define epilepsy, the cognitive and emotional difficulties encountered by people with epilepsy may have an even greater impact on everyday function. Epilepsy is associated with lower quality of life (QOL); while this is partially attributable to ongoing seizures, QOL is independently affected by comorbid affective disorders like depression and anxiety. These can accompany all types of epilepsy, but may be especially noteworthy in partial epilepsy syndromes with foci in the frontal or temporal lobes. There is growing evidence that epileptogenic lesions disrupt cortical networks that carry out emotional processing. In addition to epilepsy itself, treatment strategies also affect cognitive functioning and mood. Antiepileptic drugs, vagal nerve stimulation, and surgical resection have all been associated with changes in mood, emotional processing, and social cognition. Overall, the relationship between epilepsy and emotion is vastly complex; when assessing emotional difficulties in a person with epilepsy, we must consider the psychosocial impact of the disease on the patient, the underlying pathophysiology of the disease, and the effects of ongoing treatments.

Serious psychological distress among persons with epilepsy based on the 2005 California Health Interview Survey

PURPOSE

To compare the prevalence of self-reported serious psychological distress using the Kessler 6 (K6) in persons with a history of epilepsy (PWE) to those without epilepsy from a population-based survey.

METHODS

Data were analyzed from adults aged >or=18 years (n = 43,020) who participated in the 2005 California Health Interview Survey (CHIS).

RESULTS

California adults with a history of epilepsy, after controlling for demographics and comorbidities, reported higher rates of feeling nervous [odds ratio (OR) 2.22], feeling hopeless (OR 1.35), feeling restless (OR 2.07), feeling depressed (OR 3.14), and feeling worthless (OR 2.57), and reported that everything has been an effort (OR 2.28) in the last 30 days. The K6 score showed that serious psychological distress is more common in PWE (OR 2.24). After adjusting for demographics, comorbidities, and serious psychological distress, PWE are more likely to report having 14 or more physical, mental, and general unhealthy days in the last 30 days.

DISCUSSION

PWE have significantly higher rates of serious psychological distress and poor health-related quality of life after controlling for demographics, comorbidities. These comorbid conditions need to be factored into any comprehensive treatment strategy for managing PWE to achieve optimum quality of life.

Depression and anxiety in children and adolescents with epilepsy: prevalence, risk factors, and treatment

Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions.

Serious psychological distress and health outcomes for persons with epilepsy in poverty

Epidemiology literature demonstrates socioeconomic status as an important variable for outcomes in persons with epilepsy. However, no previous studies have analyzed the association between poverty and epilepsy in the United States. Forty-one percent (246/604) of persons with a history of epilepsy (PWHE) in the 2005 California Health Interview Survey (n=43,020) had an annual income <200% Federal Poverty Level (FPL), adjusted lifetime prevalence rate 0.5% [98.33% CI 0.4-0.7]. Four groups are presented in the analyses: (1) those with a history of epilepsy <200% FPL, (2) those with a history of epilepsy > or =200% FPL, (3) those not reporting a history of epilepsy <200% FPL and (4) those not reporting a history of epilepsy > or =200% FPL. PWHE in poverty reported significantly higher amounts of serious psychological distress, based on the validated Kessler 6 (K6) scale, than both non-epilepsy populations. After adjusting for demographics and other comorbid conditions, logistic regression analyses show PWHE in poverty are significantly more likely to report fair or poor self-rated health status when compared to the PWHE not in poverty and both non-epilepsy populations. PWHE in poverty are also more likely to report > or =14 generally unhealthy days and > or =14 physically unhealthy days in the past 30 days compared to the PWHE not in poverty and both non-epilepsy populations. Psychological well-being needs to be incorporated into any comprehensive treatment strategy for managing epilepsy.

Medical and substance-related comorbidity in bipolar disorder: translational research and treatment opportunities

It is well established that individuals with bipolar disorder are differentially affected by substance-related as well as medical disorders (ie, cardiometabolic disorders, respiratory disorders, neurological disorders, and infectious diseases). Emerging evidence indicates that some comorbid conditions (eg, diabetes mellitus) in bipolar individuals may be subserved by overlapping neurobiological networks. Disturbances in glucocorticoid/insulin signaling and immunoinflammatory effector systems are points of pathophysiological commonality between bipolar disorder and “stress-sensitive” medical disorders. Subphenotyping bipolar disorder as a function of comorbidity and temporality of onset may provide an opportunity for refining disease pathophysiological models and developing innovative disease-modifying therapies.

Which clinical and experimental data link temporal lobe epilepsy with depression?

The association of temporal lobe epilepsy with depression and other neuropsychiatric disorders has been known since the early beginnings of neurology and psychiatry. However, only recently have in vivo and ex vivo techniques such as Positron Emission Tomography, Magnetic Resonance Imaging and Magnetic Resonance Spectroscopy in combination with refined animal models and behavioral tests made it possible to identify an emerging pattern of common pathophysiological mechanisms. We now have growing evidence that in both disorders altered interaction of serotonergic and noradrenergic neurons with glutamatergic systems is associated with abnormal neuronal circuits and hyperexcitability. Neuronal hyperexcitability can possibly evoke seizure activity as well as disturbed emotions. Moreover, decreased synaptic levels of neurotransmitters and high glucocorticoid levels influence intracellular signaling pathways such as cAMP, causing disturbances of brain-derived and other neurotrophic factors. These may be associated with hippocampal atrophy seen on Magnetic Resonance Imaging and memory impairment as well as altered fear processing and transient hypertrophy of the amygdala. Positron Emission Tomography studies additionally suggest hypometabolism of glucose in temporal and frontal lobes. Last, but not least, in temporal lobe epilepsy and depression astrocytes play a role that reaches far beyond their involvement in hippocampal sclerosis and ultimately, therapeutic regulation of glial-neuronal interactions may be a target for future research. All these mechanisms are strongly intertwined and probably bidirectional such that the structural and functional alterations from one disease increase the risk for developing the other. This review provides an integrative update of the most relevant experimental and clinical data on temporal lobe epilepsy and its association with depression.