A Chat on Moods and Seizure Medicines - Dr. Andres M. Kanner

Dr. Andres M. Kanner was our guest expert for a question and answer chat on Moods and Seizure Medicines. The purpose of this session was to provide general information and resources about this topic. Dr. Kanner’s responses and the information on epilepsy.com are not intended to be medical advice. People are encouraged to direct specific questions to their own doctor for medical advice.

Dr. Kanner is a Professor of Neurological Sciences at Rush Medical College in Chicago, Illinois. He is Director of the EEG Laboratory and Associate Director of the Rush Epilepsy Center. Dr. Kanner is also a member of epilepsy.com’s Editorial Board.

The following transcript includes questions from the chat session held on February 15, 2008. Responses have been edited for ease of reading and completeness where appropriate.

Question: Do doctors understand why some seizure meds cause mood changes?
Answer – Dr. Kanner: Some seizure medicines may cause mood changes through alterations or disturbances in chemical substances in the brain. Medicines may also cause people to feel sedated or overly tired, which can lead to feeling depressed. Mood changes may also occur from a combination of both these mechanisms.

Question: Why do some people feel tired a lot and want to sleep more?
Answer- Dr. Kanner: One symptom of depression is feeling tired a lot and wanting to sleep more than usual. These symptoms may also be side effects of seizure medicines or from both depression and medicine side effects.

Question: Why do medicines get changed?
Answer – Dr. Kanner: Medicines may be changed for a variety of reasons. Most often, medicine doses are changed to optimize treatment of seizures or to minimize side effects of the medication – in essence, to get better seizure control with less or no side effects. Whenever medicines are changed, it’s important to talk with your doctor to make sure you know the reasons and what changes to report back to him or her.

Question: Why are some medicines like Lamictal (lamotrigine) used as both an AED and a mood stabilizer? Would a person be on one drug for both reasons?
Answer – Dr. Kanner: There are several antiepileptic medications (called AEDs) that have been found to be effective both for mood disorders and for epilepsy. For people who suffer from both conditions, choosing an AED that has both effects may help improve both disorders.

Question: Why does gabapentin cause insomnia some of the time?
Answer – Dr. Kanner: I am not aware of insomnia being a side effect of gabapentin. The cause of insomnia may be unrelated to the gabapentin. Please discuss this with your doctor.

Question: A person reported that Zonegran (zonisamide) did not make them feel depressed but the person still had thoughts of suicide. Why do thoughts like that break through or occur?
Answer- Dr. Kanner: Suicidal thoughts can occur following seizures and some medications have been found to be associated with the occurrence of suicidal thoughts. Whether the medication is facilitating the development of these thoughts or they result from the presence of other psychiatric disorders (such as anxiety disorders or depression) is still unclear. If a person has suicidal thoughts (even if it’s just intermittent or once in a while), they should bring it to the attention of their doctor for a thorough evaluation.

Question: Can some medicines contribute to people feeling suicidal? The FDA Alert mentioned that there were some AEDs that appeared to be associated with a greater risk of suicidal feelings.
Answer- Dr. Kanner: As I mentioned in my previous answer, some medicines, including some AEDs, may make a person more likely to develop symptoms of depression or anxiety, and suicidal thoughts may be part of these symptoms. Suicidal thoughts are more likely to occur in people with a prior history of depressive disorders, or with a family history of depression. Certain antiepileptic drugs are more likely to cause depressive episodes such as phenobarbital, primidone, diazepam, topiramate, levetiracetam, or zonisamide. If these problems occur when taking any of these drugs, let your doctor know immediately. Whether the other antiepileptic drugs increase the risk of suicidal thoughts is not yet known.

Question: A teenager reported that they chat with other teens with epilepsy and find that many seem to be on antidepressants. Why is this?
Answer- Dr. Kanner: Mood and anxiety disorders are relatively common in people with epilepsy, particularly when the seizures are not well controlled with antiepileptic medication. Antidepressants are effective in improving the symptoms of depression and anxiety. The use of these medications has been found to be safe in people with epilepsy.

Epi_help: People must keep in mind that mood changes may be common in adolescence for a variety of reasons and it’s important to talk to the doctor and a counselor when these occur. Here is an article that addresses mood and behavior issues in teens with seizures.

http://www.epilepsy.com/pdfs/Except_parent_art5.pdf (PDF)

Question: A person reportedly felt suicidal after a friend became scared seeing the person have a very severe tonic clonic seizure on webcam. Can you comment on this type of situation?
Answer- Dr. Kanner: Some people can have suicidal ideation after having a seizure or a cluster of seizures. If this happens, it’s very important to tell your doctor. It is also possible that people get depressed after having seizures and this depressed mood makes it easier for suicidal thoughts to come out. When a person is feeling depressed or doesn’t feel safe, it may be harder to cope with stressful situations like the one described.

Epi_help: Seizures can be scary to some people when they see one for the first time, usually because the observer doesn’t know what to expect. It’s important to help the person understand what happened, and reassuring them that the event is over and that you are okay can be very helpful. Here’s a link to a section on understanding seizures that many people like to share with family and friends. Once someone has looked at this, they may want to view what an actual seizure looks like in someone else. You can use this as a ‘teachable moment’, helping them understand what a seizure is, and what it is not, and what to do if a seizure occurs.

For more information:

• http://www.epilepsy.com/mmc/animation (animations of seizures)
• http://www.epilepsy.com/epilepsy/main_epilepsy (podcasts on the main home page that address different types of seizures)

Question: A person reported that topiramate has caused problems with blurry eyesight. The blurry vision then caused him to take too many pills. Can the blurry vision be from medicines?
Answer- Dr. Kanner: Blurred vision can be a side effect of most medications when given at high doses. Please let your doctor know about this side effect.

Epi_help: Anyone taking medicine should be sure that they have a system in place to prevent taking too many pills or capsules, or more than what their doctor has prescribed. Using pillboxes is a good idea so you can check that you have taken only the amount in the box for that time period.

Question: I have heard that a medication is being developed in the United States to help prevent seizures related to hormones/catamenial seizures and that if found to be effective it will be produced and prescribed in the United Kingdom.
Answer- Dr. Kanner: We do not know at this time what treatments will be approved in different countries. There are some hormonal treatments that are used for women with catamenial epilepsy, especially progesterone. Ongoing research in the US and UK will hopefully identify women who benefit from this type of therapy.

Question: Does neurofeedback work and is it real?
Answer- Dr. Kanner: Any type of relaxation technique such as yoga, self hypnosis and breathing exercises can help in people whose seizures worsen with stress. However, these modalities do not replace medication!

Epi_help: The term neurofeedback has also been used loosely by some people to refer to forms of EEG biofeedback or other therapies. People looking into this should make sure they ask questions about the specific treatment, the evidence that supports its use in epilepsy, and possible risks.

For more information: http://www.eeginfo.com/info_what.htm

Question: My 8-year-old son is on Keppra (levetiracetam) and takes a B6 vitamin to help with emotions and tiredness. Are there other vitamins that can help with the moodiness or emotional side effects?
Answer- Dr. Kanner: Vitamin B6 has been reported to improve the irritability and moodiness associated with Keppra. When this treatment does not help, it is important to look for other causes of mood changes. For example, the person may have an underlying depressive disorder that was not recognized and treating this appropriately would be very important. If a mood disorder is not present, sometimes low doses of a group of antidepressants called SSRIs could be considered to help the emotional side effects, if Keppra was effective in stopping the seizures. If it was not, a trial of another seizure medication may need to be considered.

Question: Can the body reject a medicine and how would a person know this was happening?
Answer- Dr. Kanner: A person’s seizures can fail to benefit from a medication in two ways. First, seizures may worsen in about 5% of patients started on a medication. Second, people may not tolerate a drug because of side effects. You will know if this is the case if your seizures worsen or you develop side effects in which case you need to contact your doctor immediately.

Epi_help: Whenever a person is starting a new drug, they should talk to their doctor about signs and symptoms of possible allergic reactions and what to do if urgent problems arise.

For more information: http://www.epilepsy.com/epilepsy/medicine_sideeffects

Question: Are picking at the skin and nail biting common in people with epilepsy?
Answer- Dr. Kanner: These symptoms are common in people with anxiety disorders, but are not specific to people with epilepsy per se.

Question: I have heard that a product similar to Diastat that does not have to be given rectally is being produced in the form of an epi-pen. Can you tell me if you have heard of this happening?
Answer – Dr. Kanner: The product being referred to is an autoinjector of diazepam, the medicine found in Diastat. This is being investigated and may be available in the future, but is not yet available now.

Question: What are the differences in the new drugs coming out of the pipeline?
Answer- Dr. Kanner: There are several new medications that are being investigated at the present time. Some of them have a novel mechanism of action, which hopefully will result in better efficacy and cause less side effects.

Question: Do these ‘Pipeline Meds’ attack the seizures different or are they just a sister drug?
Answer- Dr. Kanner: Most of these newer drugs are in early stages of testing, so it’s too soon to tell, as the data are not yet available.

Question: Why do seizure medicines affect memory, coordination, and speech?
Answer- Dr. Kanner: Medications can cause these side effects, when given at high doses. People who also have depression may be more prone to difficulties with memory and concentration, not related to the medication. Some antiepileptic medications are more likely to cause these side effects than others, for example seizure medicines that cause sedation are more likely to cause these other side effects too.

Question: Can any vitamins help improve memory and be good for your brain? If so are they dangerous or could they cause problems in relation to seizure medicines?
Answer – Dr. Kanner: Not that I know. However, if you are taking medications, you should take one multivitamin a day, as part of your regular diet.

Question: Why also do you recommend a multivitamin?
Answer- Dr. Kanner: Any woman of child bearing age who is taking an antiepileptic medication should be taking a multivitamin with folic acid. In addition, certain antiepileptic medications like phenytoin (Dilantin), phenobarbital, primidone (Mysoline), and carbamazpeine (Tegretol) can increase the risk of osteopenia or osteoporosis (decreased deposit of calcium in the bones, leading to thinning of the bones). In patients taking these medications, supplemental calcium and vitamin D is recommended.

Question: What does the term concomitant depression mean?
Answer – Dr. Kanner: Concomitant depression refers to depressive disorders that occur in people with epilepsy or other medical or neurologic conditions.

Question: Are there any vitamins or foods that provoke epilepsy?
Answer – Dr. Kanner: There is a small number of patients who may notice an increase in seizure frequency when they take food with nutrasweet in excessive amounts.

Epi_help: Some people report associations between certain foods and seizures, but it’s hard to prove a cause and effect relationship. For example, if someone has an intolerance to a certain food, it’s possible that this food could also affect their seizures. Some people who have stomach problems and don’t absorb certain food products or substances may notice a change in seizures as well. If people notice a relationship between foods or other triggers and their seizures, make sure to talk to the doctor about this and how to manage it.

For more information about factors that may provoke seizures, including nutritional deficiencies: http://www.epilepsy.com/epilepsy/provoke_seizure

Question: Someone shared that their seizures have been worsening over a number of months and they now may be having daily seizures. Could you comment on what might be causing this?
Answer- Dr. Kanner: Seizures can worsen over time for a variety of reasons. It’s possible that the person is not responding well to the medication, that the type of medicine is not best for their type of seizures, or because the dose is too low. Seizures may also worsen because of the cause of the seizures. It’s often not easy to sort out what’s the cause so it’s important to contact your doctor if seizures are getting worse.

Question: Do you feel that epilepsy and depression go hand in hand?
Answer- Dr. Kanner: People with epilepsy have a higher risk of developing depression, but there is now evidence that people with depression have a greater risk of developing epilepsy. This does not mean that one is the cause of the other, but probably indicates that both conditions share common mechanisms that facilitate the development of one disorder in the presence of the other.

Question: Do our bodies become immune to doses of medicine after a time?
Answer- Dr. Kanner: It is not unusual for people to respond to medication for a limited period of time and then start having seizures as before.

SUMMARY

Epi_help: Thank you so much for all the great questions! We could take a few hours talking about each one of these. I hope that you have enjoyed the time with Dr. Kanner and I’d like to thank him for sharing his time and expertise with us. Please let us know what you think about these chats and about other topics you’d like to hear.

Dr. Kanner: Just to remind everyone that the treatment for epilepsy should not be worse than having seizures! If you have side effects, do not wait. Call your doctor. If medications do not work after a few trials, investigate the possibility of surgery and if you have symptoms of depression and anxiety, bring it to the attention of your doctor. They can be treated and this will result in an improved quality of life!

Edited by Steven C. Schachter, MD