A full and accurate understanding of the extent and nature of the relation between epilepsy and behavioral-psychiatric problems is essential. Baldin E, Hesdorffer DC, Caplan R, et al. Consensus paper of the Task Force on Comorbidities of the ILAE Pediatric Commission. Post-epilepsy surgery psychogenic nonepileptic seizures. For this reason, epilepsy clinics should have a clear pathway for access to mental health care. Wagner JL, Kellermann T, Mueller M, et al.. Development and validation of the NDDI-E-Y: a screening tool for depressive symptoms in pediatric epilepsy. Parents reports are not objective but reflect parents reactions and emotions. Institute of Medical and Biomedical Education (MM), St George's University of London and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, United Kingdom; Department of Neurology (AMK), Comprehensive Epilepsy Center and Epilepsy Division, University of Miami, Miller School of Medicine, FL; Division of Epilepsy and Division of Health Outcomes and Knowledge Translation Research (NJ), Department of Neurology, Icahn School of Medicine at Mount Sinai, New York; NIHR UCL Hospitals Biomedical Research Centre (JWS), UCL Queen Square Institute of Neurology, London, and Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom; and, Stichting Epilepsie Instellingen NederlandSEIN (JWS), Heemstede, the Netherlands. The Food and Drug Administration has issued a black box warning on all antiseizure medications for increased suicidality rates. Diagnostic errors between epilepsy and PNES need careful consideration when evaluating studies demonstrating associations between psychiatric disorders and epilepsy or poorer seizure control in association with psychiatric disorders in people who have epilepsy. Development of an online tool to determine appropriateness for an epilepsy surgery evaluation. Kuyk J, Swinkels WA, Spinhoven P. Psychopathologies in patients with nonepileptic seizures with and without comorbid epilepsy: how different are they? Barba C, Barbati G, Minotti L, et al. Data from a population-based study of over 57,000 people in Sweden showed that females with epilepsy and psychiatric comorbidities had a 5-fold increased risk of sudden unexpected death in epilepsy compared with those without such comorbidities.16, Last, it is evident that psychiatric comorbidities increase the global burden of epilepsy from a public health perspective with increased health costs. An accurate, undistorted understanding of the relation between mental health disorders and epilepsy is essential to insure appropriate therapy and avoid unnecessary and potentially harmful treatments and avoid common misconceptions. The committee recognizes that the availability of expertise in detailed diagnosis and treatment of comorbidities varies across settings and may range from highly qualified medical or allied health professionals to community epilepsy organizations. Nogueira MH, Yasuda CL, Coan AC, Kanner AM, Cendes F. Concurrent mood and anxiety disorders are associated with pharmacoresistant seizures in patients with MTLE. Physical and mental health comorbidities of epilepsy - Seizure Hesdorffer DC, Hauser WA, Olafsson E, et al. The .gov means its official. The few available open studies in epilepsy previously mentioned do not suggest deterioration in seizure frequency on a stable epilepsy drug regime. The boundaries between these scenarios are often blurred, and, as already discussed, people with a psychiatric comorbidity are also more likely to present with psychiatric side effects from antiseizure medications. Psychiatric comorbidities in epilepsy - PubMed Some studies have found a lower probability of achieving seizure freedom after temporal lobectomy,13 whereas others have refuted these findings.14 The same holds true for psychiatric outcomes, as some studies showed an increased risk of recurrence of depression or anxiety during the first year after surgery, whereas other studies showed long-term improvement. Trials in persons with intellectual disabilities and challenging behavior or autism without epilepsy seem to favor risperidone.35. Maiwald T, Blumberg J, Timmer J, et al. National Library of Medicine When adjustment was made for a measure of parental emotional impact (impact associated with the child him or herself) the case-control differences reported by the parents all but disappeared. Psychological Treatments for Adults and Children with Epilepsy Historically, psychiatric symptoms in epilepsy have been categorized according to their temporal relationship with seizures, and the practicality of this is well known as they define different clinical scenarios, which are summarized in table 2. Wissel BD, Dwivedi AK, Gaston TE, et al. Austin JK, Harezlak J, Dunn DW, et al. This notion was established over 10 years ago, and the majority of studies on this subject were published before 2013. Data on potential interactions of methylphenidate are limited to older compounds, but there is no evidence of clinically relevant interactions. Sander reports personal fees from Eisai, UCB, and Zogenix and grants from Eisai, UCB, NEF, and GW Pharma, outside the submitted work; he is a member of the Editorial Board of the Lancet Neurology. Weissman MM, Berry OO, Warner V, et al. Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: results from the 2002 National Health Interview Survey. In all, these findings indicate that caution must be exercised when drawing conclusions about behavioral and psychiatric problems in children with epilepsy based on parent-proxy reports. Ictal clinical and scalp-EEG findings differentiating temporal lobe epilepsies from temporal plus epilepsies. Validated screening instruments are available for mood and anxiety disorders in adults as well as attention-deficit hyperactivity disorder in children with epilepsy. Fooled by randomness: the hidden role of chance in life and in the markets. Which patients with epilepsy are at risk for psychogenic nonepileptic seizures (PNES)? See other industries within the Health Care and Social Assistance sector: Child Care Services , Community Food and Housing, and Emergency and Other Relief Services , Continuing Care Retirement Communities and Assisted Living Facilities for the Elderly , General Medical and Surgical Hospitals , Home Health Care Services , Individual and Family Services , Medical and Diagnostic Laboratories . the contents by NLM or the National Institutes of Health. Peri-ictal phenomenon can be misinterpreted as underlying mood disorders. A lifetime psychiatric history predicts a worse seizure outcome following temporal lobectomy. Co-morbid mental health conditions in people with epilepsy and People with epilepsy, however, can also present with psychiatric symptoms peri-ictally, before, during, or after a seizure, or as a consequence of the treatment like antiseizure medications or epilepsy surgery. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp. CARRIERES ET CONSEIL Company Profile - Dun & Bradstreet In addition, other nonepileptic events were diagnosed in 3% of civilians and 12% of veterans. Five to 33% of patients referred and evaluated for refractory epilepsy and surgical evaluation dont have epilepsy; instead, they have PNES, a conversion disorder. He also receives research support from the Marvin Weil Epilepsy Research Fund, the UK Epilepsy Society, and the Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, The Netherlands. Depression and suicide attempt as risk factors for incident unprovoked seizures. Psychological treatments for adults and children with epilepsy: evidence-based recommendations by the international league against epilepsy psychology task force. The subjects were studied approximately 15 years after the onset of epilepsy, and most were seizure-free and off medication at the time of assessment. 30.3% of people with epilepsy have 3+ comorbidities vs 15.5% of those without. There is no doubt, however, that the incorrect overestimation of the risk of seizures with psychotropic medications has had a deleterious impact on access to proper treatment in people with epilepsy and psychiatric comorbidities. The finding is consistent in previous studies [ 25 , 32 ] This might be due to medical conditions affecting the quality of life epilepsy patients as supported with a study [ 77 ]. Gasparini S, Beghi E, Ferlazzo E, et al.. Management of psychogenic non-epileptic seizures: a multidisciplinary approach. The pathophysiology remains uncertain, but a recent systematic review pointed out that antipsychotic drug use does not predict complete resolution of psychiatric symptoms in comparison with antiepileptic drug withdrawal suggesting a connection with the mechanism underlying seizure control.27. Somatization, dissociation and general psychopathology in patients with psychogenic non-epileptic seizures. Bell GS, de Tisi J, Gonzalez-Fraile JC, et al.. Factors affecting seizure outcome after epilepsy surgery: an observational series, Presurgical depression and anxiety are not associated with worse epilepsy surgery outcome five years postoperatively. Among over 800 EMU-evaluated patients from the Portland, OR VA Medical Center, one fourth of the patients evaluated for epilepsy were found to have PNES without epilepsy. Agreement between youth-reported and parent-reported psychopathology in a referred sample. Judging from the results reported from EMUs, these individuals may represent a substantial proportion of the patients in the population with uncontrolled epilepsy. Any epidemiological or administrative records-based study reporting an association between epilepsy and psychiatric disorders must be interpreted in light of these concerns. He received research support from GW Pharmaceuticals in the Epidiolex Trials, Novartis Pharmaceuticals for an Investigator-Initiated Trial of Everolimus, and PTC Pharmaceuticals in an Investigator-initiated trial of Ataluren for CDKL5 and Dravet Syndrome. Regarding anxiety disorders, a meta-analysis of 27 studies in over 3,000 people with epilepsy showed a pooled prevalence of 20.2% (95% CI 15.326.0; I2 = 92.1), with generalized anxiety disorder being most common (10.2%; 95% CI 7.7%13.5%).2 Another meta-analysis of 57 studies of psychosis and related disorders, including more than 40,000 subjects, showed a pooled prevalence of 5.6% (95% CI 4.8%6.4%; I2 > 70%) in unselected individuals increasing to 7% (95% CI 4.9%9.1%; I2 > 70%) in people with mesial TLE, with a pooled odds ratio (OR) for risk of psychosis compared with the general population of 7.8 (95% CI 2.821.8; I2 > 70%).3 The pooled prevalence of psychogenic nonepileptic seizures (PNES) in people with epilepsy in a meta-analysis was 12% (95% CI 10%14%; I2 = 92.7%), whereas the prevalence of epilepsy in those with PNES was 22% (95% CI 20%25%; I2 = 95.5%).4. Linking molecules to mood: new insight into the biology of depression. Clancy MJ, Clarke MC, Connor DJ, Cannon M, Cotter DR. Systematic Literature Review of Psychiatric Comorbidities in Adults Are prodromes preictal events? Although studies on the validity of the HADS in epilepsy provide conflicting results, the validity and cost-effectiveness of the GAD-7 seem to be well established.21 Discrepancies among studies are due to the fluctuating nature of anxiety symptoms and the nonconforming phenomenology of psychiatric symptoms in epilepsy. Psychiatric comorbidities in epilepsy: We learned to recognize them; it is . The impact of psychiatric comorbidities in terms of seizure outcome and psychiatric outcome, in epilepsy surgery, is complex and yet to be established. Oostrom KJ, Schouten A, Kruitwagen CL, et al. Psychiatric symptoms in children prior to epilepsy surgery differ according to suspected seizure focus. 6; 28 Two studies in school-aged children used the Kiddie Schedule for Affective Disorders (K-SADS) and found a strong association between epilepsy and mood disorders. Krishnamoorthy ES, Brown RJ, Trimble MR. 48 Limited evidence from patients with motor seizures demonstrates cortical excitability changes within the seizure-onset zone during the 24 hours before (increased) and 24 hours after (decreased) a seizure.49 The implications in terms of impact on the functions subserved by these regions is unclear; however the findings suggest a neurophysiological basis for peri-ictal changes that could affect other regions of the brain involved in seizures. Fazel S, Wolf A, Lngstrm N, Newton CR, Lichtenstein P. Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study. If the two different events are not recognized and distinguished, this may further complicate the assessment of therapeutic success and failures.62; 86 Such diagnostic errors cannot usually be definitively corrected without a video monitoring evaluation in which a stereotypical episode is recorded. Bethesda, MD 20894, Web Policies 12; 1418. A population-based cohort study involving 10,595,709 people from the United Kingdom showed that depression is associated with high comorbidity rates, as measured by the Charlson Comorbidity Index, and that the severity of the depression itself (based on the type of treatment received) correlates with lower odds of achieving seizure remission in a Canadian cohort.7 Psychiatric comorbidities are associated with a high risk of side effects, especially cognitive complaints and psychiatric side effects.10 In fact, psychiatric comorbidities, particularly depression, represent an important cause of cognitive complaint. Mula M, Kanner AM. Psychiatric comorbidity in veterans with psychogenic seizures. Prevalence of mental illness is also disproportionately high. Diagnostic errors that lead patients with PNES to be misdiagnosed as having epilepsy need careful consideration when evaluating studies purportedly demonstrating bidirectionality between psychiatric disorders and epilepsy or reporting poorer seizure control in association with psychiatric disorders. Before Mula M, Jauch R, Cavanna A, et al. Full article: The comorbidities of epilepsy explained It is now evident that psychiatric comorbidities have to be considered when informing people about the prospects of long-term prognosis of the epilepsy itself. The notion of psychiatric and behavioral disorders as part of the spectrum of the expression of epilepsy has become generally accepted. Wu YP, Follansbee-Junger K, Rausch J, et al. Further, when cases and control were compared based on self-reported measures either as older adolescents or as young adults, there was no evidence of greater behavioral burden in the epilepsy versus control group. In the first instance, a subsequent extension of the study reported only on the parent-proxy assessments of children (based on the CBCL).26 It is unclear how the children themselves responded or how their responses correlate with their parents assessments. Biases in the current literature must be addressed to provide an accurate understanding of epilepsy-behavioral disorders associations. There were 6635 (0.6%) children with epilepsy. Psychoeducation and psychological interventions still represent first-line treatments for PNES.31 No studies have specifically addressed the management of PNES in people with epilepsy, but it is obvious that explaining the diagnosis and educating individuals and caregivers about the differences between epilepsy and PNES are extremely important. Caplan R, Hermann BP. The CBCL reports total, internalizing, and externalizing problems scores. Agreement between parents and children regarding anxiety and depression diagnoses in children with asthma. Further, PNES may, in a proportion of individuals, co-exist with epileptic seizures. Epilepsy patients are more likely to have poor health outcomes such as frequent hospitalizations, physical disability, and premature mortality. Psychiatric comorbidities in epilepsy: We learned to recognize them; it is time to start treating them. In the general population, a few screening tools are available in primary and secondary care settings for almost all major psychiatric conditions. A 12-item, self-report screening tool for depression in people with epilepsy aged 1217 years, called NDDI-E-Youth, has been developed,23 but further studies in this area are needed. Kanner AM. Data from children with epilepsy are not different despite an obvious emphasis on developmental disorders. First, mood disorders may aggregate in families. Rodenburg R, Marie Meijer A, Dekovic M, et al. Introduction--Treatment of psychiatric disorders in adults with epilepsy: what every epileptologist should know. These occurred in more than half of their seizures and lasted for a median of 24 hours.25, Psychiatric symptoms as side effects of antiseizure medications are frequently reported. Recent trends in the evaluation and referral for epilepsy surgery may partly reflect the frequency of PNES. Reuber M, House AO, Pukrop R, et al. FOIA The https:// ensures that you are connecting to the A.M. Kanner reports personal fees from Eisai and Frontline Medical Communications, outside the submitted work. The .gov means its official. Other United Kingdom studies have suggested a prevalence of 7.7 per 1000 population and 5.6 per 1000 population [23]. Pharmacodynamic interactions are rarely systematically investigated, but they can affect adherence and successful response to treatment. 19408842 Abstract While reviewing the available literature, we noticed comorbidity of epilepsy and psychiatric disorders. A systematic review of studies validating 16 screening tools for depression in adults with epilepsy showed that the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), validated in 13 languages, is the most efficient and practical screening instrument for a major depressive episode in a variety of settings.18 The NDDI-E has also been validated for suicidality with good sensitivity and specificity,19 and this should allow the development of well-defined clinical pathways for suicide prevention. Co-morbid mental health conditions in people with epilepsy and A population-based study in 85 children and adolescents (aged 515) with active epilepsy in England reported a prevalence of attention-deficit hyperactivity disorder (ADHD) of around 33%, autism spectrum disorder of 21%, depression of 7%, and anxiety of 13%.5 A nationwide Norwegian registry study in an unselected pediatric population of over 1,000,000 children reported developmental and psychiatric comorbidities in 43% of children with epilepsy, with overall ORs (compared with the general child population) of 10.7 (95% CI 9.512.1) for autism, 5.4 (95% CI 4.85.9) for ADHD, 2.3 (95% CI 1.83.0) for anxiety disorders, and 1.8 (95% CI 1.42.5) for depression.6 The use of the International Classification of Diseases (ICD) codes to identify psychiatric disorders in many of these studies introduces an important limitation as ICD codes have low sensitivity for psychiatric conditions, leading to possible underestimation of their occurrence. LaFrance WC, Jr, Baird GL, Barry JJ, et al. Only five patients with moderate intellectual disability were included, due to interview difficulties. Abstract Purpose Psychiatric and Behavioral Comorbidities in Epilepsy: A Critical Frequent subclinical or subtle seizures may also have a direct impact [ 10 ]. This may confound assessments of psychiatric co-morbidities, especially when behavioral symptoms fluctuate, data on seizure frequency and severity is incomplete, and antiepileptic and psychotropic medication regimens are in flux. Stevelink R, Koeleman BPC, Sander JW, Jansen FE, Braun KPJ. used the Child Behavior Checklist (CBCL), a well-known and well-respected instrument for assessing current behavioral problems. 71 The association is seen in the civilian population as well. The prevalence of psychosis in epilepsy; a systematic review and meta-analysis. Once accurately diagnosed, such patients would not then go on to have surgery. The odds of mental health comorbidity was 2.20 (95% CI: 2.02-2.39) for children and adolescents with epilepsy and 1.60 (95% CI: 1.48-1.73) for migraine, in reference to children and adolescents with LEF after adjusting for potential confounders. Devinsky O. Postictal psychosis: common, dangerous, and treatable. 16.3% of people with epilepsy have depression vs 9.5% of those without. Salinsky M, Evrard C, Storzbach D, et al. A systematic review showed response rates for methylphenidate in children with ADHD and epilepsy between 65% and 83%.22 Data on atomoxetine and amphetamines are available only at the anecdotal level. This systematic literature review identified original research articles that reported the prevalence of psychiatric comorbidities based upon clinical assessments in a sample of PWE and assessed the clinical features of the populations found in studies included in our review of mental health comorbidity. In the past, the validity of these instruments in people with epilepsy was a major barrier to their use in routine clinical practice. Comments on Key issues in addressing the comorbidity of depression in pediatric epilepsy, Korczyn AD, Schachter SC, Brodie MJ, et al. 10; 77 Psychiatric disorders, particularly depression and PTSD, are a substantial risk factor for suicidality by themselves. Forced normalization is an intriguing phenomenon characterized by the emergence of psychiatric disturbances following the establishment of seizure control or reduction in the epileptic activity in a patient with previous uncontrolled epilepsy. This is, however, a global issue in mental health as highlighted by the Mental Health Action Plan 20132020 developed by the World Health Organization. For this reason, physicians must identify comorbid psychiatric disorders and incorporate them into the comprehensive individual management. The https:// ensures that you are connecting to the An International League Against Epilepsy (ILAE) document has discussed limitations of the Food and Drug Administration meta-analysis on which the black box warning was based, and it has emphasized the need for continuous screening and identification of high-risk individuals to develop prevention strategies.28 Psychiatric side effects of antiseizure medications reported with a prevalence higher than 1% are summarized in table 3. Patients with epilepsy and their relatives should be informed of the risk of mental health problems and the implications. Common Psychiatric Side Effects of Antiseizure Medications. For instance, frontal-temporal dysfunction has been implicated in mood and anxiety disorders,20; 21 including suicide related behavior and post-traumatic stress disorder.22; 23 It is likely that seizure foci in frontal or temporal regions as well as white matter changes affecting functions in or between those regions could disrupt those pathways. Behavioral issues involving children and adolescents with epilepsy and the impact of their families: recent research data. For epilepsy characteristics, 73.8% of patients had focal epilepsy compared to 26.1% with generalized epilepsy. The study reported that parents rated their case children as having higher levels of internalizing disorders relative to control siblings.4 Externalizing disorders were not elevated in the cases relative to sibling-controls, however. Jones JE. Comorbidity Multimorbidity Cohort study 1. Thus, the control group was constructed such that children with the disorders of interest were largely excluded. Huberty TJ, Austin JK, Harezlak J, et al. Data from a US nationwide study assessing almost 400,000 hospital admissions showed that psychiatric comorbidities, depression, and psychosis, in particular, increase length of stay and inpatient costs for people with epilepsy.17. Epilepsy and risk of suicide: a population-based case-control study. Neurobehavioural comorbidities of epilepsy: towards a network-based Personality and Psychopathology in Nonepileptic Attack Disorder and Epilepsy: A Prospective Study. Future studies need to clarify whether these disorders are mediators or moderators of seizure outcome; that is, are psychiatric disorders merely indicators of poor prognosis or can their early identification and prompt treatment have an impact on the prognosis of the epilepsy itself? Interpretation Assessment of adolescent mental health and behavioral problems in institutional care: discrepancies between staff-reported CBCL scores and adolescent-reported YSR scores. Vanstraten AF, Ng YT. Psychiatric features of children and adolescents with pseudoseizures. Psychiatric comorbidity in children with new onset epilepsy. official website and that any information you provide is encrypted Epilepsy and comorbidities -what are we waiting for? Depression and anxiety disorders in pediatric epilepsy. Davies S, Heyman I, Goodman R. A population survey of mental health problems in children with epilepsy. While this could have tremendous implications for treatment and prevention, the errors of misdiagnosis of PNES, which affect a sizable proportion of adults with uncontrolled epilepsy, must first be addressed. Aim: To determine the distribution and risk characteristics of comorbid neurodevelopmental and mental health comorbidities among children and adolescents (6-18y) with epilepsy or migraine (i.e. Despite robust evidence about the frequency and clinical implications of psychiatric disorders in epilepsy, these problems are still underdiagnosed and undertreated. It is essential that we not set up an expectation of limitations, barriers, and ultimately failure that may not exist. Individuals with epilepsy have a lower HRQOL than healthy individuals and individuals with other chronic diseases.1Even a single seizure is associ- ated with reduced HRQOL.2Several factors contribute to poor HRQOL, especially when seizure freedom cannot be achieved, including medication side effects,3-5the number of antiepileptic drugs (AEDs),4,. Cross-informant agreement between parent-reported and adolescent self-reported problems in 25 societies. official website and that any information you provide is encrypted Much research has since been devoted to demonstrating this association in different populations. Bidirectional relation between schizophrenia and epilepsy: a population-based retrospective cohort study. Other well-known, self-rating scales such as the Beck Depression Inventory II (BDI-II) and the Patient Health Questionnaire 9 (PHQ-9) have also been shown to be valid in epilepsy but require use of cutoff scores higher than those adopted in the general population (general population BDI-II = 10, PHQ-9 = 5; epilepsy BDI-II = 15, PHQ-9 = 10).18 This can be partially explained by the heterogeneity of clinical presentations of depression in epilepsy, but also highlights the need to adapt these questionnaires to the specific needs of people with epilepsy to maximize their sensitivity and specificity. The prevalence of psychosis in epilepsy; a systematic review and meta-analysis, Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: systematic review and meta-analysis of frequency, correlates, and outcomes, Neurobehavioral comorbidities in children with active epilepsy: a population-based study. Two main clinical instruments have been validated for symptoms of anxiety in adults with epilepsy: the Hospital Anxiety and Depression Scale (HADS) and the Generalized Anxiety Disorder 7 (GAD-7). Nearly 80% of children with epilepsy had 1 comorbid disorder. Data from prospective observational studies clearly indicate that the relationship between epilepsy and psychiatric disorders is bidirectional. Unlike other postictal behavioral symptoms that typically resolve within hours or days, postictal psychosis can last up to three months (mean duration, 910 days).56 The few studies that examined post-ictal mood used symptom checklists.54; 57 While reporting several mood and anxiety related symptoms post-ictally does not meet clinical criteria for a mood or anxiety disorder, patients with a history of depressive or anxiety disorders was associated with worse post-ictal symptoms.54 These studies are conducted in the setting of the epilepsy monitoring unit (EMU) where patients are participating in pre-surgical work up.
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