Depression and Anxiety in Epilepsy Kirsty Bortnik Ph

Depression and Anxiety in Epilepsy Kirsty Bortnik, Ph. D. Northeast Regional Epilepsy Group

Epilepsy and Psychiatric Disorders • 50 -60% of patients with chronic epilepsy have depressive or anxiety disorders. • Increased risk of suicide in patients with epilepsy compared to people with no epilepsy.

Depression in epilepsy • One of most common psychiatric disorders among people with epilepsy. • Having epilepsy increases the risk of depression (more than 2 times the risk compared to people without epilepsy). • Review of studies have shown 32 -48% rates of depression in individuals with epilepsy. • Depression more common in epilepsy compared to other chronic medical problems. 1. Fiest et al, Neurology, 2013; 2. Rai et al, Epilepsia, 2012; 3. Ettinger et al, Neurology, 2004

Impact of depression in epilepsy • Depression is associated with lack of response to epilepsy treatment. • Depression is the most important predictor of quality of life in patients with epilepsy (more so than seizure frequency). • Depression can happen in any kind of epilepsy, but there has been a stronger association with temporal lobe epilepsy. No laterality preference. • Decrease in depression at 3 months and then again approx. 2 years after epilepsy. Depression may appear “de novo” (for the first time) after surgery. 1. Hitiris et al, Epilepsy Research, 2007; 2. Boylan et al, Neurology, 2004; 3. Foong and Flugel, Epilepsy Research, 2007.

Why depression in epilepsy? • Psychosocial factors: * Psychological reaction to epilepsy * Effects on daily functioning (driving, employment, etc. ) * Effects on social functioning (social stigma/discrimination, etc. ) • Neurobiological factors: * Effect of long-term electrical discharges * Effects of antiepileptic drugs * Changes in “stress hormone” reactivity * Changes in brain structure and function * Changes in chemistry in the brain * Changes in inflammatory response 1. Hoppe and Elger, Nat Rev Neurol, 2011; 2. Kanner, Lancet Neurology, 2012; 3. Clarke et al, Biol Psych, 2012.

Depression in children with epilepsy • Depression rates are higher in children with epilepsy vs. general population and other chronic diseases. • Sometimes there are discrepancies between parental and child ratings • Academic difficulties, behavioral problems, etc. • Bullying

How to recognize depression? • Learn about symptoms of depression • Self-report questionnaires to identify symptoms of depression – but always discuss what it means with a health care professional. • Investigate time relationship to seizures: does the mood change happen ONLY before or after a seizure, and/or depression happens irrespective of seizure occurrence? • Investigate historically when mood changes started: any relationship to medication changes? , or to change in seizure severity or seizure characteristics? , or to change in psychosocial situations?

PHQ-9 (Patient Health Questionnaire – 9) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 Scoring: 0 -4: None; 5 -9: Mild depression; 10 -14: Moderate depression; 15 -19: Moderately severe depression; 20 -27: Severe depression. Spitzer et al, 1999

CES-D (Center for Epidemiologic Studies Depression Scale) Radloff, L. S. (1977).

BYI-II (Beck Youth Inventories) • Self-report scales that assess a child’s experience of depression, anxiety, anger, disruptive behavior, and self-concept • Ages 7 -18 years

Typical symptoms of depression Standard criteria: For 2 or more weeks: • Mood is predominantly “sad” or “down” • There is lack of interest in things that are usually enjoyable • Changes in sleep, appetite, energy levels, sexual desire, concentration • Changes in motor activity (too slowed down or too fidgety) • Increase in negative thoughts about oneself or the future (feeling there is no hope, that one is “less” than others, increased thoughts of guilt) • Thoughts that life is not worth living and/or thoughts of suicide or self-harm Irritability and increased somatic symptoms (i. e. , pain) described in depression in epilepsy. Some patients have a chronic course, interrupted by brief periods of “normal” mood. 1. American Psychiatric Association, DSM-5, 2014; 2. Blumer et al, Epilepsy & Beh, 2004; 3. Kanner, Biol Psych, 2003.

Epilepsy and suicide • Increased risk of suicide in patients with epilepsy compared to people with no epilepsy. • Suicide attempts are more common in epilepsy, even in those without a history of depression. • Anti-epileptic drugs can increase risk of suicide behaviors and their prescription require close monitoring of such symptoms. • High risk subgroups: newly diagnosed epilepsy, tertiary care settings, temporal lobe epilepsy, post-epilepsy surgery, previously having a psychiatric diagnosis, early age of onset. Rai et al, Epilepsia, 2012; Nilsson et al, Epilepsia, 1997; Rafnsson et al, Neuroepidemiology, 2001; Bell et al, Epilepsia, 2009; Nilsson et al, Epilepsia, 2002; Hesdorffer et al, Ann Neurology, 2006; Hesdoffer and Kanner, Epilepsia, 2009.

How to manage depression? • Bring up your concerns to your doctor! Even if your doctor will not treat your depression, he/she will connect you to the right resources for diagnosis and treatment. • Once you initiate treatment, keep your treatment providers informed about your diagnoses and treatments (particularly if receiving antidepressant medication).

Treatments for Depression • Types of treatment include: * Medications: always ensure your providers know about your diagnoses and treatments as some antidepressants (not many, but some) can increase risk of seizures. Also, some antidepressants can interact with your antiepileptic medication. So keep all providers informed! * Talk therapy (psychotherapy) Cognitive behavioral therapy: empirically supported intervention for depression Project UPLIFT: home-based program using CBT and mindfulness * For more severe depression, electro-convulsive therapy (ECT) can be a consideration (not contraindicated in epilepsy, but should be carefully discussed with all your treatment providers). * Transcranial magnetic stimulation (TMS) is approved for the treatment of depression, but effects on seizures are yet not clear (it can rarely cause them). * Vagal nerve stimulation (VNS) is effective for chronic depression (beyond its effectiveness for seizures)

Self-Management Programs for depression in epilepsy • “Using Practice and Learning to Increase Favorable Thoughts” = UPLIFT 1 • 8 -week Internet and telephone based program using cognitive behavioral therapy and mindfulness to treat depression in people with epilepsy. • Has demonstrated significant improvement in symptoms of depression compared to a waitlist control group. • “Program to Encourage Active Rewarding Lives”= PEARLS 2 • 6 -8 weeks home-based program focused on brief behavioral techniques (+ monthly follow-up phone calls for a year). • Has demonstrated significant improvement in symptoms of depression compared to usual care. • For more information on Self-Management Programs: http: //www. epilepsy. com/get-help/managing-your-epilepsy/selfmanagement-programs 1. Thompson et al, Epilepsy & Behavior, 2010; 2. Ciechanowski et al, Epilepsy & Behavior, 2010

Other strategies • Physician-approved exercise: yoga, pilates, non -intense physical exercise, etc. • Diet: consult with nutritionist: proper calorie intake, fruits, veggies, whole grains, lean meats • Relaxation training and deep breathing • Treatment for sleep disorder • Epilepsy support groups and activities

Anxiety in epilepsy • Higher frequency of anxiety in patients with epilepsy compared to people without epilepsy. • Some studies find higher rates of anxiety symptoms in patients with LTLE. • Anxiety also associated with poorly controlled seizures. Raj et al. , Epilepsia, 2012; Mellers, “Lishman’s Organic Psychiatry, ” 2009; Altshuler et al. , Arch Neurol 1990

Different anxiety syndromes • Agoraphobia: safety and avoidance behaviors • Generalized anxiety disorder (GAD): excessive worries • Social anxiety disorder: excessive anxiety related to social encounters, avoidance of social situations. • Panic disorder: recurrent panic attacks • Obsessive compulsive disorder: obsessions and compulsions.

How to recognize anxiety? • Learn about symptoms of anxiety • Self-report questionnaires to identify symptoms of anxiety – but always discuss what it means with a health care professional. • Investigate time relationship to seizures: does the anxiety symptom only happen before, during and/or after a seizure? Some anxiety symptoms (such as “fear” or “panic” or a “sudden intrusive thought” may be a symptom of a seizure). Anxiety may also occur irrespective of seizure occurrence. • When did anxiety symptoms start? any relationship to medication changes? , or to change in seizure severity or seizure characteristics? , or to change in psychosocial situations?

GAD-7 Over the last 2 weeks (or other agreed time period) how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Scoring: 0 -7: no diagnosis; 8 -21: Probable anxiety disorder Spitzer et al, 2006

Other Anxiety self-report measures • Beck Anxiety Inventory (BAI): (Beck, 1990. ) • State-Trait Anxiety Inventory (STAI) - used to identify anxiety and distinguish from depressive syndromes (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983).

How to manage anxiety? • Bring up your concerns to your doctor! • Keep all providers informed. • Options for treatments include: • Medications • Talk therapy (psychotherapy) • Meditation and biofeedback

Medications for anxiety • Antidepressants: SSRI’s (selective serotonin reuptake inhibitors) and SNRI’s (selective norepinephrine and serotonin reuptake inhibitors) are effective to treat anxiety. Some older antidepressants (tricyclic antidepressants) can be helpful too, but they carry a higher risk of seizure. These medications work long-term (they are NOT to be taken as needed). • Benzodiazepines: not recommended due to dependence concerns and long-term cognitive side effects. Their use as a rescue medication for prolonged seizures may lead to inappropriate use. • Other medications may be used for anxiety, although their evidence is not as strong (ie, buspirone, gabapentin).

Psychotherapy for anxiety disorders Cognitive Behavioral Therapy has a wide application to several anxiety disorders. • Problem-focused • Action-oriented • Behaviorists focus on changing relationship between stimulus and behavioral response. • Cognitive therapists focus on conscious thoughts as directing behavior. • CBT merges both approaches. • Many self-help books available.

Other strategies • Physician-approved exercise: yoga, pilates, non -intense physical exercise, etc. • Diet: consult with nutritionist: proper calorie intake, fruits, veggies, whole grains, lean meats • Relaxation training and deep breathing • Treatment for sleep disorder • Epilepsy support groups and activities

Resources Epilepsy Foundation www. epilepsy. com - local epilepsy foundation of NJ and NY