Public Enemy No. 1: Depression and Mood Disorders in People with Epilepsy
A link between mood disorders and epilepsy has been noted for more than 2,000 years. While we understand this association more today than in the past, much work needs to be done to more clearly clarify whether this is a causative association.
What is relatively clear, however, is the fact that depression adversely affects the quality of life of people with epilepsy, and it needs to be recognized and treated when appropriate. This article will cover definitions of mood disorders in people with epilepsy, as well as their incidence, recognition, causes and treatment options.
What are Mood Disorders?
To put it simply, mood disorders are conditions that negatively affect an individual’s emotional state. For people with epilepsy, the most common mood disorders are major depression and dysthymia.
Sadness, albeit a common occurrence in our daily lives, is a primary symptom of depression. Yet, persistent and excessive sadness is considered abnormal and open to treatment.
There are a host of symptoms that point to treatable depression: sadness associated with a lack of pleasure in performing activities; problems with weight and sleep; tiredness; difficulty concentrating and making decisions; feelings of worthlessness or guilt; and frequent thoughts of suicide and death. If five or more of these symptoms persist for at least two weeks, that qualifies as major depressive disorder.
A dysthymic disorder is similar to major depressive disorder, but it is less intense and includes depression for most days for at least two years. During this interval, two or more of the following symptoms need to be present: change in appetite, lack of sleep, decreased energy, low self-esteem, poor concentration, difficulty making decisions and feelings of hopelessness.
Another common mood disorder in people with epilepsy is bipolar affective disorder. It is characterized by two types of symptoms: depression and mania. Bipolar disorder is also known as manic-depressive illness.
Manic symptoms are characterized by excessive energy (agitation), excessive feelings of self importance (grandiosity), excessive interest in sex (hypersexuality) and inability to sleep (insomnia), as well as distractibility and high risk behavior.
Symptoms of bipolar disorder may come and go. People typically exhibit depressed and manic symptoms separately, but both can occur simultaneously. Different subtypes of the disorder also exist. The depressed symptoms can be very severe and lead to problems at work or at school. They may also cause problems with relationships and even lead to thoughts of suicide. In addition, patients may sometimes lose touch with reality, which is referred to as psychosis.
Recognition and Incidence of Mood Disorders
Certainly everyone has episodes of depression in his or her life; that is a component of the human experience. However, only when it becomes persistent or intense does it require treatment. In this case, there are a couple good screening questions to ask yourself:
- Have you often been bothered with feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or lack of pleasure in doing things?
If the answer to either of these questions is, “yes,” ask your doctor to look into the possibility of a mood disorder.
Unfortunately, there is a high incidence of depression in people with epilepsy. The prevalence of major depressive disorder in people with epilepsy is approximately 29 percent.
In a recent study, 775 people with epilepsy were compared to 395 people with asthma and 362 healthy people. The results revealed that 26.5 percent of the epilepsy group had severe depressive symptoms, and only 20.2 percent of the asthma group and 5.2 percent of the healthy group had severe depressive symptoms.
Depression is common in children with epilepsy, as well. In one outpatient study of 42 children aged 7 to 18, 26 percent of the children were diagnosed with depression. In another study, 115 adolescents aged 12 to 16 were examined and the results revealed 23 percent of them had symptoms of depression. Often these symptoms go unrecognized.
Children may primarily suffer from the classic symptoms of depression, such as sadness or fatigue. But they may also exhibit other symptoms that are less obviously related to depression. These symptoms include: poor concentration or poor school performance; changes in sleep pattern or appetite; complaints of lack of love from family members; unexplained crying; feelings of anger; unprovoked irritability; and multiple somatic complaints.
It is important to note that depressive symptoms may also affect antiepileptic drug compliance and seizure control. A family history of depression increases the likelihood of this diagnosis.
Although some people with epilepsy may have depressive symptoms that fail to meet the criteria for a major depressive disorder, or a dysthymic disorder, they may still also have poor quality of life and respond positively to mood disorder treatment. Because of the irregular and pleomorphic nature of these symptoms, they may often be overlooked.
Mood changes may also occur up to 72 hours prior to a seizure and last upwards of three days afterwards. In addition, depressive symptoms may increase after a seizure and include suicidal ideation, hence the reason why systematic mood disorder screening of people with epilepsy by doctors is important. It will help ensure that affected patients receive needed treatment.
The intensity of depressive disorders in people with epilepsy may also be amplified. The history of a suicide attempt in one study appeared to be about five times higher than seen in the general population. Not all studies have found an elevated risk of suicide in people with epilepsy,but a pooled sample of reviews confirmed an elevated risk.
Significance of Mood Disorders on Quality of Life
For a person with uncontrolled epilepsy, the single most important factor in determining his or her quality of life is the presence of depression, not seizure frequency.
It is extremely unfortunate, but depression is not often recognized in a routine office visit. The press for time may make seizure frequency the primary focus; however, it is still imperative that attention be paid to the psychological impacts of the condition. It is important that people with epilepsy be their own advocate and speak up if these issues are not raised during the visit. Their quality of life may depend on it.
Causes of Depression in People with Epilepsy
There are many factors that may explain the increased incidences of depression in people with epilepsy. These include neurobiological factors, treatment-induced factors and psychosocial factors.
Neurobiological factors may have, for example, been caused by the following: head injuries; histories of central nervous system illnesses and strokes that may be associated with the onset of epilepsy; and predispositions to depression. It has also been suggested that there are structural and neurotransmitter similarities in the brain’s pathways that are common to both depression and epilepsy.
The most important treatment-induced factors obviously revolve around the use of antiepileptic drugs. Antiepileptic drugs may be responsible for mood changes, both positive and negative. For example, phenobarbital has been known to cause depression. Other antiepileptic drugs may also cause depression, but usually do not. Multiple antiepileptic drugs used together may also contribute to a negative mood state.
It may be difficult to determine whether a medication or an underlying brain problem is to blame for an abnormal mood. When people with epilepsy start new antiepileptic drugs, attention must be paid to mood changes. If mood deterioration is associated with the initiation of an antiepileptic drug, then the new drug may be the cause and a discussion with the treating neurologist is encouraged.
Finally, mood disorders may also be a simple psychological response to having epilepsy. The challenges of living with epilepsy may lead to mood changes, which is a common problem for many people coping with a chronic condition. People with epilepsy may feel frustrated by the unpredictability of seizures, the inability to drive or work, or being singled out by others as “different.” These feelings should be addressed with a health care provider.
The Importance Treating Mood Disorders
It is imperative that people with epilepsy experiencing mood disorders promptly receive effective treatment, especially after considering the relatively high frequency of depression, decreased quality of life and suicide. The most effective approach to recognizing depression in people with epilepsy is searching for easy-to-change causes, such as changes in antiepileptic drugs.
Many types of treatment are available for mood disorders in people with epilepsy, but psychotherapy and medication are the most common. These forms may be used separately or together, but the overriding goal is to eventually eliminate symptoms of depression.
Psychotherapy, or talk therapy, may be very useful, too, especially to rectify depression clearly instigated by prominent psychosocial circumstances. It may also be used in combination with psychopharmacologic intervention. The most common type of medication treatment involves antidepressants, of which there are several kinds.
The most frequently prescribed antidepressants for adults with epilepsy and depression are in the same class as Prozac. Prozac is also used to treat major depressive disorders in children. When antidepressants are used it is important for the patient with epilepsy to be closely monitored. This is to evaluate any potential side effects, such as worsening of depressive symptoms. Counseling for the adult or child may also help, and family therapy may be useful, as well, particularly if anyone else in the family has a mood disorder.
It is important to remember that mood disorder medications may require dose adjustments and may take several weeks to become fully effective. Just like antiepileptic drugs, sometimes more than one antidepressant may need to be tried before getting good results. For most individuals with epilepsy, depressive symptoms usually respond very well to treatment.
It is important that a patient’s depression treatment result in a return to a normal mood state. If he or she is treated with an antidepressant, it’s also important that they take the medication for as long as recommended by a health care professional.
For further descriptions of mood disorder and depression issues, refer to a recently printed publication available via the Epilepsy Foundation. The publication, from which most of the above information was extracted, is entitled, “Epilepsy and Mood Disorders – Information Booklet for People with Epilepsy.”
Editor’s Note: John Barry, M.D., is Stanford University’s director of Neuropsychiatry & Psychotherapy Clinics, as well as an associate professor. He is also a member of the Epilepsy Foundation’s professional advisory board.