Interictal mood and personality disorders in temporal lobe epilepsy and juvenile myoclonic epilepsy.

BACKGROUND: Mood disorders have been described as the commonest psychiatric disorders in patients with temporal lobe epilepsy. Secondary depression in temporal lobe epilepsy could be interpreted either as an adjustment reaction to a chronic disease or as a limbic dysfunction. To clarify this issue, a controlled study of psychiatric disorders was conducted in different forms of epileptic and non-epileptic chronic conditions. METHODS: Twenty outpatients with temporal lobe epilepsy, 18 outpatients with juvenile myoclonic epilepsy--a primary generalised seizure disorder--20 matched type I diabetic patients, and 20 matched normal controls were assessed by a structured interview (SADS) and by self rating scales (Beck depression inventory (BDI) and the state and trait anxiety scales STAIX1 and STAIX2). RESULTS: Sixteen (80%) patients with temporal lobe epilepsy fulfilled the criteria for a psychiatric diagnosis at the SADS interview with a significantly higher frequency than patients with juvenile myoclonic epilepsy (22%) and diabetic patients (10%) (P < 0.0001). The most frequent disorder in temporal lobe epilepsy was a mood disorder: 11 (55%) patients with temporal lobe epilepsy had depression compared with three patients with juvenile myoclonic epilepsy and two diabetic patients (P < 0.001). Eight patients with temporal lobe epilepsy with an affective disorder also had a comorbid personality or anxiety disorder. Patients with temporal lobe epilepsy scored significantly higher on BDI, STAIX1, and STAIX2 than the three control groups (P < 0.001, P < 0.01, P < 0.001). CONCLUSIONS: Patients with temporal lobe epilepsy have a higher incidence of affective and personality disorders, often in comorbidity, than patients with juvenile myoclonic epilepsy and diabetic patients suggesting that these psychiatric disorders are not an adjustment reaction to a chronic disease but rather reflect a limbic dysfunction.     

Psychiatric comorbidity in cardiovascular inpatients: costs, net gain, and length of hospitalization

Objective

Although psychiatric comorbidity often goes undetected and untreated in cardiovascular patients, it is not clear whether the costs for a special treatment of psychiatric comorbidity are appropriately reflected in the reimbursement system. To investigate the economic impact of psychiatric comorbidity, we compared costs, returns, net gain, and duration of hospitalization in cardiovascular inpatients with and without psychiatric comorbidity.

Methods

For a period of 2 years, we analyzed costs, net gain, and other outcome variables according to the diagnosis-related group (DRG) system for cardiovascular inpatients of a German university department (n=940). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared patients with and without a psychiatric disorder, controlling for sociodemographic characteristics.

Results

The average total costs of hospitalization (mean±S.E.) for cardiovascular patients without psychiatric comorbidity and for patients with psychiatric comorbidity differed significantly (€5142±210 vs. €7663±571; d=0.39). The increased costs for patients with psychiatric comorbidity were related to elevated returns, but the net gain for patients without psychiatric comorbidity was €277±119. In contrast, the treatment of internal medicine patients with psychiatric disorders resulted in a net loss of −€624±324 (overall group difference, d=−0.25).

Conclusion

Psychiatric comorbidity in cardiovascular inpatients leads to higher costs that are not reflected in the current reimbursement system in Germany. The inappropriate reimbursement of psychiatric comorbidity in cardiovascular inpatients may result in a serious undertreatment of these patients.     

Patients with epilepsy and anxiety disorders. Diagnosis and treatment

Up to 50-60% of patients with epilepsy may develop psychiatric complications, in particular depression, anxiety, and psychotic disorders. Although this comorbidity has received a great deal of attention in recent years, the anxiety spectrum of psychiatric disturbances in epilepsy patients has not been extensively studied, although this comorbidity has a significant effect on the medical management and quality of life. The etiology is multifactorial, including neurobiological and shared pathophysiological mechanisms as well as psychosocial and iatrogenic factors (e.g., influence of antiepileptic drugs, epilepsy surgery). Despite the high prevalence of comorbid anxiety in epilepsy, very little is known about optimal treatment strategies. This article reviews the complex interrelationships between anxiety disorders and epilepsy from a clinical point of view. The evaluation of anxiety relative to ictal, peri-ictal, and postictal states is described, and medical treatment options for anxiety disorders in patients with epilepsy are discussed, illustrating that their treatment extends far beyond seizure control.     

Anxiety in patients with epilepsy: systematic review and suggestions for clinical management

Up to 50 or 60% of patients with chronic epilepsy have various mood disorders including depression and anxiety. Whereas the relationship between epilepsy and depression has received much attention, less is known about anxiety disorders. It is now recognized that anxiety can have a profound influence on the quality of life of patients with epilepsy. The relationship between anxiety disorders and epilepsy is complex. It is necessary to distinguish between different manifestations of anxiety disorder: ictal, postictal, and interictal anxiety. Preexisting vulnerability factors, neurobiological factors, iatrogenic influences (antiepileptic drugs, epilepsy surgery), and psychosocial factors are all likely to play a role, but with considerable individual differences. Despite the high prevalence of anxiety disorders in patients with epilepsy, there are no systematic treatment studies or evidence-based guidelines for best treatment practice. Nevertheless, a practical approach based on the temporal relationship between anxiety and epileptic seizures allows clinicians to consider appropriate treatment strategies to reduce the psychiatric comorbidity in patients with epilepsy.     

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.     

Concurrent Illnesses in Adults with Childhood-Onset Epilepsy: A Population-Based 35-Year Follow-Up Study

Summary: Purpose: To ascertain the occurrence of concurrent illnesses in adults with epilepsy since childhood.
Method: After a mean follow-up of 35 years of a prospective, population-based long-term followed patient cohort with epilepsy since childhood, comorbidity was examined in 176 surviving (100 of them with epilepsy only) and 44 dead patients and in random and employee controls.
Results: Somatic comorbidity varied from 84 to 95% in patients and from 67 to 74% in controls. No significantly increased risk of somatic diseases could be shown. Psychosomatic disorders were associated in 46-74% of patients and in 42-75% of controls, and psychiatric disorders were associated in 11-23% of patients and in 7% of controls. As compared with random controls, patients with epilepsy had only a 4.0- to 4.2-fold risk of psychiatric disorders or of combinations of somatic, psychosomatic, and/or psychiatric disorders. Patients received psychotropic drugs 8.6 times more frequently than employee controls. The risk for psychiatric and psychsomatic disorders was higher than expected in patients with childhood-onset epilepsy, regardless of whether or not they were still receiving antiepileptic drugs (AEDs).
Conclusion: Epilepsy per se, but not AEDs, has an apparent association with the occurrence of psychiatric and psychosomatic disorders. Risk for somatic comorbidity is not increased.     

The relative impact of anxiety, depression, and clinical seizure features on health-related quality of life in epilepsy

PURPOSE: To determine the independent effects of depression and anxiety on health-related quality of life (HRQOL) in epilepsy as well as the relative explanatory power of psychiatric comorbidity compared with demographic and clinical epilepsy variables (e.g., seizure frequency, severity, and chronicity). METHODS: Subjects (n = 87) with temporal lobe epilepsy completed self-report measures of depression, anxiety, HRQOL, and seizure severity. Information was derived regarding subjects' seizure frequency, duration, and treatment. HRQOL status (QOLIE-89) was examined in relation to self-reported symptoms of anxiety and depression, clinical seizure features, and demographic characteristics. RESULTS: Depression and anxiety were independently associated with reduced HRQOL. Psychiatric comorbidity explained more variance in HRQOL than did combined groups of clinical seizure or demographic variables. Although weaker in explanatory power than psychiatric comorbidity, several epilepsy factors were nonetheless significantly related to HRQOL, including seizure frequency, severity, and chronicity. CONCLUSIONS: Interictal anxiety and depression exert independent adverse effects on HRQOL. In addition, frequent, severe, and chronic seizures reduce HRQOL, but appear less powerful predictors of HRQOL than interictal psychiatric symptoms. Recognition and treatment of comorbid depression and anxiety is an important consideration in improving quality of life in epilepsy.     

Psychiatric comorbidity, health, and function in epilepsy

Epilepsy is a chronic condition that has complex effects on social, vocational, and psychological function. Several psychiatric disorders have been shown to have increased prevalence in persons with epilepsy compared to the general population. Depression appears to be the most common psychiatric comorbidity, but anxiety and other diagnoses have not been extensively investigated. Several studies have found that depression or psychological distress may be the strongest predictors of health-related quality of life, even including seizure frequency and severity, employment, or driving status. Despite the high prevalence and adverse effects of comorbid psychiatric disorders in epilepsy, very little is known about optimal treatment strategies, or even the efficacy of standard treatments. Further research is needed to increase understanding of the mechanisms of psychiatric illness in epilepsy, the effects of depression and anxiety on long-term clinical outcomes, and the most effective treatments.     

Epilepsy and suicide: pathogenesis, risk factors, and prevention

Depression and suicide tendencies are common in chronic diseases, especially in epilepsy and diabetes. Suicide is one of the most important causes of death, and is usually underestimated. We have analyzed several studies that compare mortality as a result of suicide in epileptic patients and in the general population. All the studies show that epileptic patients have a stronger tendency toward suicide than healthy controls. Moreover it seems that some kinds of epilepsy have a higher risk for suicide (temporal-lobe epilepsy). Among the risk factors are surgery therapy (suicide tendency five times higher than patients in pharmacological therapy), absence of seizures for a long time, especially after being very frequent, and psychiatric comorbidity (major depression, anxiety-depression disorders, personality disorders, substance abuse, psychoses). The aim of the review was to analyze the relationship between suicide and epilepsy, to identify the major risk factors, and to analyze effective treatment options.