Mood Disorders and Epilepsy
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Transcript of Mood Disorders and Epilepsy
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Mood Disorders and
Epilepsy Scott E. Hirsch, MD
NYU-Langone Medical CenterMay 2012
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• No financial support from pharmaceutical companies.
• Information obtained from best available evidence from:– Medical Literature– Clinical Experience
Disclosures
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Epilepsy
The management of patients with epilepsy is focused on:
• Controlling seizures
• Avoiding treatment side effects
• Maintaining quality of life.
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Epilepsy and Quality of Life
• If seizure free, people with epilepsy enjoy a quality of life similar to the general population.
• One third of people with epilepsy continue to have seizures despite treatment.
• Because people with recurring seizures may have lower quality of life, every effort must be made to restore quality of life.
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Possible Consequences of Epilepsy
• May be unable to legally drive.
• May have memory problems or cognitive issues.
• May be exposed to stigma or feel embarrassment.
• May have restricted independence.
• Medication dependence.
• Employment problems.
These quality of life issues are important!
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Adjustment Disorder
• When coping and problem-solving strategies fail, depressed mood and anxiety symptoms may result.
• This isn’t necessarily a “disorder,” but rather
acknowledgement that the person is having trouble adjusting to a life change or a new stressor.
• Bolstering social support, attending support groups, and learning new coping skills often helps adjustment and leads to resolution of symptoms.
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Feeling sad sometimes is normal
• Feeling sad, “blue,” or “down” is part of our normal human experience.
• Appropriate when we experience tragedy, loss, or receive bad news.
• When these feelings persist for more than 2 weeks and also interfere with daily functioning, then we think about “Major Depression.”
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Epilepsy and Depression
• Depressed mood is NOT normal in people with epilepsy.
• Depression can be part of a complex partial seizure.
• Depression can also be pre-ictal or post-ictal.
• Untreated depression is associated with more difficulty achieving seizure freedom.
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Depression
• Depression is under-recognized; occurs in up to 43% of people with epilepsy.
• Depression is a significant factor adversely affecting quality of life.
• Risk factors for depression:– Epilepsy-related disability– Unemployment– Activity restriction/Loss of Independence– Impaired social support– Stigma associated with Epilepsy
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What causes Depression in Epilepsy?
• Psychological factors: – difficulty coping with stressors, such as recurrent seizures– real or perceived losses – life experiences that set the stage for later depression
• Biological factors: – prior history of mental illness– family history of mental illness– some seizure types– Epilepsy itself increases the risk of depression
• Social factors:– social isolation– financial issues– limits on independence
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Depression
• Important to treat in both children and adults.
• Treating depression improves quality of life in people with epilepsy.
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Criteria for Major Depression
Over a 2 week period, most of the day, nearly every day:
A. Depressed MoodOR
A. Loss of pleasureAND…
4 or more of the following nearly every day:
• Significant change in appetite or weight• Trouble falling asleep, staying asleep, waking early/late• Observable slowness of thought and movement• Fatigue or loss of energy• Feelings of worthlessness or excessive guilt• Difficulty thinking or concentrating• Recurring thoughts of death or suicide
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Feeling down vs. Major Depression
• Nearly all of the symptoms outlined for Major Depression can be part of our normal experiences.
• BUT… it’s not normal to experience 5 of the 9 possible symptoms together persistently over 2 weeks.
• Major Depression is NOT just a reaction to having Epilepsy.
• Major Depression cannot be willed or wished away.
• When left untreated, Major Depression is associated with worse outcomes.
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Children and Adolescents
• Depression may present with different symptoms than in adults:– Irritable mood– Disruptive behavior– Negative thoughts about themselves– Decline in academic performance– Agitation– Intense worry or phobias – Regressive behaviors, including separation anxiety
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Screening for Depression
Over the past 2 weeks, how often have you been bothered by the following problems:1. Little interest or pleasure in doing things?– Not at all, 0– Several days, 1– More than half the days, 2– Nearly every day, 3
2. Feeling down, depressed, or hopeless?– Not at all, 0– Several days, 1– More than half the days, 2– Nearly every day, 3
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Screening for Depression: PHQ-2
• Patient Health Questionnaire-2– Scored from 0-6– Score greater than 3 indicates a 75% positive
predicative value for presence of a mood disorder.– Score greater than 3 indicates a 40% positive
predicative value for presence of a Major Depressive Disorder diagnosis.
– Score greater than 3 should lead to psychiatric evaluation.
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STAR*D:Efficacy of Treatment for Depression
• Sequenced Treatment Alternatives to Relieve Depression.• Nationwide public health clinical trial funded by the NIH.• NOT funded by pharmaceutical companies!• Largest and longest study to evaluate depression treatment. • Randomized, Double blinded study.• 2,876 participants, ages 18-75 in Level 1.• Fewer participants in subsequent levels by design.• Standardized rating system and treatment.
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STAR D* Study DesignLevel 1: Celexa (an SSRI) for 12-14 weeks
a. Symptom free -> 12 month follow-upb. Symptoms persist or intolerable side effects -> Level 2
Level 2: Participant given option of switching to Talk therapy, a different medication or adding talk therapy or a new medication
a. Symptom free -> 12 month follow-upb. Symptoms persist or intolerable side effects -> Level 3
Level 3: Participant given option of switching or adding different medication a. Symptom free -> 12 month follow-up
b. Symptoms persist or intolerable side effects -> Level 4
Level 4: All medications discontinuedRandomly switched to 4th line medication
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STAR D* Conclusions• 50% of participants had remission after 2
treatments
• 75% of participants had remission after 4 treatments
• May need to try more than one treatment for remission
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Barriers in treating Depression
• People do not recognize or believe they need treatment.
• People think current mood or anxiety problems are related to a temporary situation.
• People do not want to consider taking another medicine.
• Concern about worsening seizures with medication.
• Concern about side effects.
• Stigma.
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Treatments for Depression• Talk therapy: the first line of treatment
– Individual therapy– Group therapy– Family therapy– Support groups– Caregiver support
• Goals of therapy include:– Developing solutions to immediate problems in living.– Implementing lifestyle modifications.– Correcting maladapative thoughts or behaviors.– Uncovering thoughts that lead to feelings of helplessness and
hopelessness. – Overcoming fears of dependency or abandonment. – Learning new coping skills (relaxation techniques, imagery,
focused breathing exercises, meditation, and progressive muscle relaxation).
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Medication for Depression and Anxiety
• Medications are a mainstay of management for people with Major Depression and Anxiety Disorders.
• Antidepressants are safe and effective in people with Major Depression and Anxiety Disorders when taken under a doctor’s care.
• Medications:– Alleviate depressed mood and anxiety symptoms.– Reduce emotional lability, irritability, and worry.– Reduce social withdrawal. – Improve a person’s ability to participate in epilepsy
treatments.– Improve overall functioning.
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• Selective Serontonin Reuptake Inhibitors (SSRI’s):– Prozac– Paxil– Zoloft– Celexa– Lexapro
• Selective Serotonin/Norepinephrine Reuptake Inhibitors (SNRI’s):– Effexor– Cymbalta– Pristiq
• Mediciatons with unique mechanisms of action:– Remeron– Buspar
• GABA-enhancing agents for Anxiety only:– Xanax– Ativan– Valium– Klonopin