© Springer International Publishing Switzerland 2015
Kristina Malmgren, Sallie Baxendale and J. Helen Cross (eds.)Long-Term Outcomes of Epilepsy Surgery in Adults and Children10.1007/978-3-319-17783-0_77. Long-Term Psychiatric Outcomes After Epilepsy Surgery in Adults
(1)
Department of Neurology, Miller School of Medicine, University of Miami, Room #1324, NE 14th Street, Miami, FL 33136, USA
Abstract
Psychiatric aspects of epilepsy surgery are very complex and have a pleomorphic expression, as an anterotemporal lobectomy (ATL) can be followed by remission, exacerbation in severity or recurrence of a presurgical psychiatric disorder, or the development of de novo psychopathology. Furthermore, presurgical psychiatric history appears to be associated with postsurgical persistence of epileptic seizures.
There is a dearth of studies on the long-term (>5 years) psychiatric trajectories of epilepsy surgery candidates. Most studies in this field report follow-up periods of 2 years or less. Postsurgical depression and/or anxiety disorders are the most frequent psychiatric disorders identified after resective surgeries, particularly following ATL, as 30 % are expected to experience depressive and/or anxiety episodes within the first 3–6 months. A presurgical psychiatric history has been found to be associated with an increased risk of postsurgical recurrences or exacerbations. In a majority of patients, symptoms are expected to remit by 1 year, though persistent psychopathology has been found in up to 15 % of patients. De novo postsurgical psychotic episodes and psychogenic non-epileptic seizures (PNES) on the other hand have been identified with a relatively low frequency.
Despite the relatively high frequency of postsurgical psychiatric complications (PPC), they remain under-recognized and undertreated. Furthermore, patients and families are often not informed of their potential occurrence. In this chapter, we review the prevalence of the various postsurgical psychiatric complications and their risk factors.
Keywords
Major depressive episodesGeneralized anxiety disorderPostictal psychosisTreatment-resistant epilepsyMesial temporal sclerosisIntroduction
The lifetime and cross-section prevalence rates of psychiatric comorbidities in epilepsy are relatively high in patients with epilepsy (PWE), ranging between 30 and 35 % [1, 2] and it is even higher in patients who are being evaluated for epilepsy surgery, ranging from 43 to 80 % [3–6]. In fact, psychiatric comorbidities and epilepsy have a very complex relation, which is clearly illustrated in the pleomorphic psychiatric aspects of epilepsy surgery. For example, anterotemporal lobectomies (ATLs) can be associated with a remission of presurgical psychiatric disorders or postsurgical psychiatric complications (PPC), which include a recurrence and/or an exacerbation in severity of presurgical psychiatric disorders, or the development of de novo psychiatric episodes. Postsurgical psychiatric complications were initially reported by Hill et al. in 1957 [7], who described depressive episodes occurring independently of seizure outcome and which remitted within 18 months.
In the last 30 years, epilepsy surgery has been recognized as a leading therapeutic modality in the management of treatment-resistant focal epilepsy. Postsurgical psychiatric complications have been recognized in approximately 30 % of patients undergoing an ATL [8, 9]. Yet despite this relatively high prevalence, they remain unrecognized and untreated in many epilepsy surgery programs worldwide. In this chapter, we review the negative and positive impacts of epilepsy surgery on presurgical psychiatric disorders as well the available data on the development of de novo postsurgical psychopathology.
Postsurgical Psychiatric Complications: A Relatively Frequent Occurrence
Postsurgical mood and anxiety disorders are the most commonly recognized PPC, and with significantly lower frequency psychotic episodes, obsessive-compulsive disorders (OCDs), and psychogenic non-epileptic seizures (PNES). The following study illustrates the pleomorphic aspects of psychiatric aspects of epilepsy surgery:
The study included 100 consecutive patients (60 men and 40 women) age, who had undergone an anterotemporal lobectomy (ATL) for the management of treatment-resistant temporal lobe epilepsy (TLE) at the Rush Epilepsy Center in Chicago. Patients were followed postsurgically for a period of 8.3 ± 3.3 years [10, 11]. During their presurgical evaluation, a lifetime psychiatric history was identified in 56 patients; 21 had a depressive disorder, and 25 mixed depression and anxiety disorders, while 12 patients had other (non-psychotic) psychiatric disorders. Among the 100 patients, 41 experienced a PPC: 22 developed a de novo psychiatric episode, which consisted of a depressive/anxiety disorder in nine, a psychotic episode in four, PNES in seven and somatoform disorder in two. Twenty-six patients experienced an exacerbation in severity or recurrence of a presurgical depressive/anxiety disorders. Among the four patients who developed a de novo psychotic episode, these occurred within the first 6 months after an ATL, consisting of a manic episode in two and a paranoid episode in the other two patients. Two of these patients had lesional epilepsy, caused by a dysembryoplastic neuroepithelioma (DNET) in one and a ganglioglioma in the other. Symptoms remitted in two patients with pharmacotherapy without the need for hospitalization while the other two had to be hospitalized in a psychiatric unit. In one patient, symptoms remitted after the first admission, whereas the second patient had to be hospitalized twice. Two years after the ATL, psychiatric disorders were reported by 30, consisting of depressive with and/without anxiety episodes in 26 patients, while 11 had other type of psychiatric disorders (several patients had more than one psychiatric disorder). In 18 of these 30 patients, the PPC were severe and persistent despite multiple therapeutic interventions. At the time of the last contact (mean follow-up period of 8.3 ± 3.3 years), 16 patients continued to experience a persistent psychiatric disorder, 15 of whom had a depressive/anxiety disorder. Multivariate regression model identified a presurgical history of depression as predictors of persistent and severe postsurgical psychiatric complications. The ATL was associated with a reduction in the prevalence of psychiatric disorders by 40 % 2 years after surgery and by 71 % by the last contact.
Among the 100 patients, 7 developed de novo PNES. A presurgical lifetime psychiatric history was significantly associated with the development of postsurgical PNES. Interestingly enough, PNES were not reported in seizure-free patients; in fact, persistent seizures were significantly associated with the development of de novo PNES. Furthermore, failure to obtain gainful employment was not associated with the development of PNES. These findings differ from long-held assumptions that the development of a postsurgical PNES must be caused by the “stress” associated with a “seizure-free” life in patients with chronic epilepsy who are not “emotionally, physically, or economically ready to face their own or their families” increased expectations.
Likewise, the presurgical lifetime history of depression was associated with a worse postsurgical seizure outcome. Indeed, only 12 % of patients who became free of auras and disabling seizures after surgery were found to have a lifetime history of depression; in contrast, 79 % of patients with less than 90 % seizure reduction had a presurgical lifetime history of depression [11]. The findings of this study have been replicated in other studies, as shown below.
Postsurgical Depressive and Anxiety Disorders
As stated above, depressive and anxiety disorders are the most frequent PPCs. Most case series had a relatively short postsurgical follow-up period that ranged between 3 months and 1 year. In a recent review of prospective studies published in the literature, Rayner and Wilson concluded that postsurgical major depressive and anxiety episodes are likely to occur in approximately 30 % of patients undergoing an ATL. Most depressive episodes are diagnosed within the first 3–6 months after surgery and may persist for periods ranging between 6 and 12 months [9]. A presurgical history of mood and anxiety disorders has also been found to be a risk factor for the development of postsurgical anxiety episodes. While some authors have associated persistent postsurgical symptoms of depression with failure to achieve a seizure-free state [12], this has not been a uniform finding.
Postsurgical depressive and anxiety symptoms can be identified within the first 4–6 weeks after surgery. For example, in a study of 62 patients, 43 who had an ATL and 19 an extratemporal lobectomy (ETL), Wrench et al. identified symptoms of anxiety and/or depression in 66 % of ATL and 19 % of ETL patients, respectively [13]. At 3 months, 54 % of ATL and 33 % of ETL patients were still symptomatic with 30 % of ATL and 17 % of ETL patients still experiencing a depressive episode. By that time, 13 % of ATL patients had developed a de novo depressive episode and 15 % a de novo anxiety disorder, whereas 18 % had developed other types of de novo psychiatric disorders. In contrast, only 17 % of ETL patients had developed de novo anxiety, but not depression or other psychopathology. Likewise, Ring et al. [14] found that 45 % of 60 consecutive patients who underwent an ATL experienced emotional lability and anxiety in the first 6 weeks after surgery; in 22 % of these patients, it presented as a de novo phenomenon. These symptoms had remitted by 3 months or improved significantly. In a study of 44 patients who underwent an ATL, Glosser et al. [15] found that by the first month after surgery, 12 patients (31 %) had developed de novo depression and/or anxiety disorders or recurrence of a disorder that had been in remission during the 6 months preceding the surgical procedure. By 6 months, they were still symptomatic but significantly improved, and by 1 year all but two patients had become free of symptoms.
Can postsurgical depressive and anxiety disorders be anticipated?
As stated above, a presurgical history of mood and/or anxiety disorder has been identified in patients who go on to develop postsurgical episodes. For example, a preoperative history of depression and poor postoperative family dynamics (at 1, 6, and 12 months) were predictive of depression after surgery in the study by Wrench et al. cited above [13]. In a separate study of 107 patients, 90 of whom underwent an ATL and 17 an ETL, and who had a postsurgical follow-up period of 1 year, Quigg et al. [16] found that preoperative depressive traits predicted worse postoperative scores on scales measuring symptoms of depression. Likewise, in a study of 150 patients who underwent epilepsy surgery, Barbieri et al. found that the only predictive variable included a presurgical history of depressive episodes and older age at surgery [17].
Other potential predictive variables include epilepsy-related signs and symptoms such as ictal fear. For example, Kohler et al. found that, compared to patients without auras or with auras different than ictal fear, patients with preictal fear were more likely to exhibit postsurgical depressive and anxiety episodes [18]. Furthermore, while postoperative mood and anxiety disorders were more common in patients with persistent seizures, they were equally frequent in seizure-free patients who had experienced presurgical ictal fear. In addition, a majority of patients with ictal fear required the use of psychotropic medication after surgery.
Suicide is a PPC which has also been identified more frequently among patients who undergo an ATL than in the general population. For example, 27 of 360 patients who underwent an ATL died during a 5-year follow-up period [19]. Four of these deaths resulted from suicide, yielding a standardized mortality ratio (compared with suicides in the US population and adjusted for age and gender) of 13.3 (95 % CI = 3.6–34.0). Accordingly, a presurgical psychiatric evaluation in every surgical candidate is of the essence to identify those patients who may have a potential risk of postsurgical depressive and anxiety episodes. Prevention of postsurgical episodes of depression and anxiety can be achieved in such patients by introducing antidepressant medication with a selective-serotonin reuptake inhibitor or a selective serotonin-norepinephrine reuptake inhibitor at the first manifestation of the psychiatric symptomatology. Unfortunately, to date there are no studies on the pharmacologic treatment of postsurgical mood and anxiety disorder and this recommendation is based on expert consensus [20].
Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder (OCD) is a rare postsurgical complication reported following ATL. Indeed, the development of de novo or aggravation of OCD was reported in a small case series of five patients with treatment-resistant TLE and “obsessive traits,” who were followed after undergoing an ATL [21]. Within the first 2 months after surgery, two patients fulfilled OCD diagnostic criteria. While all of these patients became seizure free, they reported a significant worsening of their quality of life after surgery. In a separate case report, a 31-year-old man with dual pathology consisting of right mesial temporal sclerosis (MTS) and right occipital encephalomalacia experienced de novo obsessive-compulsive symptoms following resection of the right hippocampus and right occipital pole. He started to experience compulsions consisting of fear of contamination, constant hand washing, checking things, repeating rituals, and his symptomatology met criteria for OCD [22].
Postsurgical Psychotic Complications
Postsurgical psychotic complications have been identified in an average of 3 % with some case series of patients undergoing an ATL reporting frequencies of 1 % and others up to 10 % [11, 23–32]. Most consist of de novo postsurgical psychotic episodes presenting as schizophreniform-like disorders, manic episodes, and postictal psychotic episodes. Psychotic symptomatology tends to appear within the first year in all patients [23]. In some case series, postsurgical psychotic episodes occur after seizure remission [24], while in others they are associated with persistent seizures.
Postsurgical manic episodes are also psychiatric complications of ATL, as demonstrated in a study of 415 consecutive patients, 16 of whom (3.8 %) experienced a de novo manic episode [29] within the first year after an ATL. These episodes were short-lived in all but one patient.
In addition, the risk of postsurgical psychotic episodes has been associated with right temporal seizure foci. For example, Mace and Trimble [26] reported seven consecutive patients who developed de novo psychotic episodes following an ATL, six of whom had an epileptogenic area in the right temporal lobe: one developed a delusional depression, four developed a schizophrenic-like psychosis, and one patient was diagnosed with Capgras syndrome.
The presence of gangliogliomas or DNET has also been associated with the development of de novo postsurgical psychotic disorders. Andermann et al. reported six patients from four centers who experienced a de novo psychotic disorder and estimated a risk of 2.5 % for the development of de novo psychosis (1 in 39) in patients with this type of lesion who undergo an ATL [27].
A schizotypal personality disorder has also been identified as a potential risk for the development of de novo postsurgical psychotic episodes in a small case series of three patients with MTS who after undergoing an ATL developed an acute psychotic episode the first year after surgery, diagnosed as “a schizoaffective disorder,” “a brief psychotic disorder,” and “a delusional disorder,” respectively [28]. Of note, all patients were free of seizures after surgery. Whether or not the development of de novo postsurgical psychotic episodes reflects a phenomenon of forced normalization has been the source of significant debate that has yet to be settled.
Psychogenic Non-epileptic Seizures
Ferguson and Rayport were the first authors to describe the occurrence of postsurgical de novo PNES [33]. In all case series, the prevalence rates of postsurgical PNES have been low, ranging between 1.8 and 12 %. For example, Ney et al. identified de novo postsurgical PNES in 5 out of 96 patients who underwent epilepsy surgery [34]. They suggested that a low full-scale IQ, preoperative psychiatric comorbidity, and major surgical complications could be potential risk factors. In a study of 220 patients, 22 (10 %) developed postsurgical de novo PNES [35]. In this study, preoperative psychopathology was not identified, in contrast to the other studies and our own data (see above) [11].
Related posts:
Long-Term Cognitive Outcomes After Epilepsy Surgery in Children
Methodological Demands on Observational Studies of Outcomes After Epilepsy Surgery
Quality-of-Life Outcomes in Adults Following Epilepsy Surgery
Subjective Experiences of Epilepsy Surgery in Adults
Managing Expectations of Epilepsy Surgery
Long-Term Seizure and Antiepileptic Drug Outcomes After Epilepsy Surgery in Adults
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