Neuropsychiatric Strategies May Benefit Patients With Refractory Epilepsy
Treating Depression
Neurologists can follow practical steps to address depression. First, determine whether symptoms are attributable to drug side effects. Then, address lifestyle factors, including sleep, exercise, and diet, and consider social stressors, such as family members or employers who do not appreciate the patient’s cognitive or physical limitations. Neurologists should identify targets that help measure whether treatment is working and consider whether low doses of adjunctive AEDs may help treat psychiatric symptoms. Finally, neurologists may consider prescribing an antidepressant. “If you are going to use an antidepressant, get comfortable, skilled, and knowledgeable about using one of them,” he said.
Studies have provided data regarding the use of antidepressants in patients with epilepsy. In an observational pediatric study, 36 patients who received fluoxetine or sertraline improved clinically, whereas two patients who received fluoxetine or sertraline had worsened seizures. Studies also have provided evidence for the use of citalopram and sertraline in adults with epilepsy. Other studies regarding the treatment of depression in epilepsy are ongoing.
Selective serotonin reuptake inhibitors (SSRIs) entail a low risk of lowering seizure threshold, as do certain antipsychotics (eg, haloperidol, risperidone, and aripiprazole). Methylphenidate is considered safe and is widely used for children with epilepsy and comorbid ADHD.
Nonmedical treatment also can benefit patients. Social skills groups, overnight camps, and cognitive behavioral therapy may be effective options. Vocational support also is important. “Meaningful activity can … tip the balance into more functionality,” he said. “Think about seizure control and behavior control as partners,” Dr. Salpekar concluded. “Think about treating both of these types of targets as working together to improve the entire illness.”
—Jake Remaly
Suggested Reading
Hermann BP, Dabbs K, Becker T, et al. Brain development in children with new onset epilepsy: a prospective controlled cohort investigation. Epilepsia. 2010;51(10):2038-2046.
Hesdorffer DC, Hauser WA, Olafsson E, et al. Depression and suicide attempt as risk factors for incident unprovoked seizures. Ann Neurol. 2006;59(1):35-41.
Salpekar JA. Mood disorders in epilepsy. Focus. 2016;14(4):465-472.
Salpekar JA, Berl MM, Havens K, et al. Psychiatric symptoms in children prior to epilepsy surgery differ according to suspected seizure focus. Epilepsia. 2013;54(6):1074-1082.
Salpekar JA, Conry JA, Doss W, et al. Clinical experience with anticonvulsant medication in pediatric epilepsy and comorbid bipolar spectrum disorder. Epilepsy Behav. 2006;9(2):327-334.
Silvestri R, Gagliano A, Calarese T, et al. Ictal and interictal EEG abnormalities in ADHD children recorded over night by video-polysomnography. Epilepsy Res. 2007;75(2-3):130-137.
Waxman SG, Geschwind N. The interictal behavior syndrome of temporal lobe epilepsy. Arch Gen Psychiatry. 1975;32(12):1580-1586.
