37 Recognizing and Treating Psychiatric Comorbidity in Epilepsy

Jay Salpekar

Center for Neuroscience and Behavioral Medicine, Children’s National Medical Center, George Washington University School of Medicine, Washington, DC, USA

Introduction

Since the days of Hippocrates, scholars have understood that psychiatric comorbidity is significantly overrepresented in patients with epilepsy. Epidemiology studies consistently report that psychiatric illness is more common with epilepsy than with other common diseases such as asthma or diabetes – each of which involves noteworthy lifestyle changes and, in the case of asthma, sudden symptom exacerbation. Today, the common intersection of neurological and psychiatric symptoms is well accepted, and comprehensive care for persons with epilepsy includes thorough psychiatric assessment and treatment.

Although the awareness of treatment needs is well established, it has been challenging to resolve whether psychiatric illness is coincidental or associated with the underlying epilepsy. Psychosocial stress and stigma have a large impact upon patients’ lives and may independently lead to dysfunction. Adding to the complexity is the effect of treatment. Historically, antiepileptic drugs (AEDs) have been viewed as causing cognitive and affective symptoms, even while these same drugs have appeared to be effective treatments for psychiatric conditions.

Although the evidence is limited, the paradigm for understanding the etiology of psychiatric comorbidities has shifted in the last decade. Now it is more widely recognized that psychiatric symptoms reflect an intrinsic process resulting from chemical or physiological changes in key brain regions. In many cases, the same pathophysiological mechanisms may lead to both psychiatric symptoms and seizures. Most importantly, interdisciplinary neuropsychiatric approaches to treatment have greatly informed the management strategies available to clinicians.

Identification of psychiatric illness

Although it is a cliché, the most important step in managing psychiatric comorbidity is to look for it in the first place. Many clinicians are hesitant to ask questions about psychiatric symptoms out of fear of being obliged to solve problems they may feel ill equipped to manage. However, the evidence is compelling that the presence of psychiatric comorbidity has a negative impact upon treatment outcomes for epilepsy itself. In many cases, the psychiatric comorbidity may be more damaging to quality of life than the seizures themselves. Thus, it is in everyone’s interest to ask the questions and proactively address psychiatric comorbidity. Psychiatric conditions will persist and adversely affect treatment outcome, whether a clinician strives to identify them or not.

Table 37.1. Screening questions for depression.

1. Do you often feel unhappy?

2. Do you feel hopeless about the future?

3. Have you ever thought that life was not worth living?

4. Do you think that you would be better off dead?

5. Have you thought about doing something to kill yourself?

A starting point for history taking is the simple acknowledgment that psychiatric symptoms often co-occur with epilepsy. Direct history taking during an office visit often yields higher-quality information than the use of rating scales. Addressing the subject in a straightforward, matter-of-fact way puts patients at ease and avoids any untoward insinuation regarding “flawed” character traits. An approach of universal screening is usually the most successful.

TIPS AND TRICKS

Successful conversation starters for screening for psychiatric comorbidity:

“We now understand that with epilepsy, parts of the brain dealing with emotions or thinking may also be affected. So we are asking all of our patients about problems with nervousness or mood. Have you noticed any feelings of depression or mood swings?”

“Epilepsy can sometimes cause stress in people’s lives. How are you managing?”

“Parts of the brain that cause seizures can sometimes cause sad feelings too. Has that ever happened to you?”

A positive response justifies further inquiry, most effectively accomplished in a progressive, stepwise manner. In the case of depression screening, any “yes” answers to the questions in Table 37.1 warrant asking the next question on the list.

Treatment approaches

The most prudent treatment approach for psychiatric illness comorbid with epilepsy is to use principles established for patients without epilepsy. Comprehensive care for psychiatric illness often includes a combination of psychiatric medications, psychotherapy, and vocational or educational support. However, the initial step in managing psychiatric comorbidity may be to optimally manage epilepsy and adeptly select AEDs with beneficial psychotropic effects. Judicious selection of AEDs may represent the most intuitive initial step for treatment of psychiatric comorbidity.

In addition to medications, psychotherapy and social support may be extremely effective in improving the course of psychiatric illness. Social isolation is a common phenomenon for children and adults with epilepsy. Psychotherapeutic efforts to provide social and family support are related to medication compliance for children and adults with epilepsy and may improve outcome for patients following surgical treatment. Engaging children and adolescents in cognitive behavioral therapy appears to improve social competence.

Antiepileptic drugs

Antiepileptic drugs are broad-spectrum, versatile medications that effectively treat many behavioral target symptoms, including impulsivity, rage outbursts, and mood lability. AEDs are commonly used as first-line or adjunctive agents for major depression and bipolar disorder. Carbamazepine, valproic acid, and lamotrigine have long been key medication treatments for mood disorders without epilepsy, and these medicines have class I level evidence for efficacy in bipolar disorder. Ultimately, seizure and behavior control may go hand in hand; optimizing AED treatment may offer the best chance at symptom control for epilepsy and psychiatric symptoms. As in the treatment of epilepsy, low doses of adjunctive AEDs may be synergistic and lead to improved behavior.

Impulsivity lies at the core of many psychiatric illnesses, including bipolar disorder, attention deficit hyperactivity disorder (ADHD), and substance abuse. AEDs serve to reduce neuronal hyperexcitability, making them ideal treatments for psychiatric illness in which impulsivity is a significant concern. In several small studies, anticonvulsant drugs were effective treatments for agitation, dysphoria, anxiety, and irritability in the context of epilepsy. The initial strategy for clinicians facing behavior problems in the context of epilepsy may be to optimize AED treatment, selecting agents that have proven to be robust “mood stabilizers.”

Psychiatric side effects from AED treatment are common. Although psychiatric and behavioral problems may potentially be associated with any medicine, the risk with some medicines has been more commonly reported. Phenobarbital increases the possibility of depression, irritability, and disinhibition. Irritability has also been associated with levetiracetam. Impairments in short-term memory, verbal fluency, and cognitive processing speed have been reported with topiramate. However, it should be noted that behavioral symptoms may be misattributed as side effects instead of signs of a comorbid psychiatric illness that would be an appropriate target of anticonvulsant medicine.

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