Download Depression in epilepsy: recognizing and treating it.

Epilepsy & Mental Health
Paola M. Bailey, Psy.D.
Director of Mood Disorders & Epilepsy Program
Northeast Regional Epilepsy Group
Why is a discussion on mental health relevant
to people with epilepsy?
Epilepsy is a chronic neurologic condition
Depression is one of the most common
complications of chronic illness
CDC estimates that ≈ 1/3 of individuals with a
chronic medical condition experience symptoms of
depression at some point in their life.
Why are chronic conditions, such as
epilepsy, associated with changes in
mood?
1) Chronic conditions can physiologically alter
mood
Changes in neurotransmitters, hormone levels, etc.
In epilepsy, electrical discharges in, or near, the
limbic system (controls certain emotions) can
produce mood changes.
Other explanations for mood changes…
2) Mood changes can be a natural reaction to
receiving a diagnosis.
 Sadness, anger, frustration, etc.
3) Mood symptoms could be due to iatrogenic
effect of certain medications:
 Side- effect of some meds (e.g., phenobarbital)
 High doses
 Multiple AEDs
 Sudden discontinuation
Other explanations for mood changes…
4) Mood changes could be a reaction to life
changes associated with having epilepsy
Lifestyle changes (e.g., work/school)
Limitations on mobility (e.g., loss of license)
Limitations on previously enjoyed activities (e.g., certain
sports)
Loss/reduction in independence
Changes in learning/memory
Sense of lack of control
Changes in self-esteem
Why is it important to address depression
in people with epilepsy?
There is stigma & denial that interferes, but here
are some reasons why you should seek
treatment:
50-60% of patients with epilepsy have depression or
anxiety- it’s more common than you think!
Depression caused by chronic disease can aggravate
the condition.
Depression can cause person to have worse response
to treatment (e.g., meds & compliance).
Depression can intensify and even cause pain.
Why is it important to address mental
health in people with epilepsy?
Depression can limit a person’s ability to interact
with others and increase social isolation.
Depression can increase risk of suicide.
Risk of Suicide in Epilepsy:
People w/epilepsy: risk 5x ↑ than general population
People w/complex partial seizures: risk is 25x ↑
Chronic Epilepsy & Depression
 No known association between depression and:
 Seizure type
 Seizure frequency
 Seizure duration
 Age of seizure onset
 However, patients who do have higher risk of
experiencing depression are:
People with left temporal lobe epilepsy
People with frontal lobe epilepsy
General Facts about Depression
Depression can affect people of all ages, races,
SES, and genders.
Ratio of women: men is 2:1
50% of people with depression do not get
treatment; mostly because they are not
diagnosed.
Of those who do get treatment, > 80% improve!
What exactly is Depression?
Three Types:
Major Depression
Minor Depression (Dysthymia)
Bipolar Depression (Manic-Depression)
Major Depression
 What am I looking for (in myself or others)?
 5> symptoms, over 2 week period:
 Think a drastic change from “usual” state.
 Think degree to which it interferes with your life.
 Depressed mood almost all
day
 Reduced interest in activities
or people
 Weight change (5%/month)
 Insomnia/hypersomnia
 Fatigue
 Motor retardation or
activation
 Guilt or low self-worth
 Difficulties with
concentration
 Suicidal thoughts or acts
Minor Depression (Dysthymia)
Feeling depressed almost every day for at least 2
years (in kids, 1 yr).
Less acute, more chronic.
Having 2> symptoms:
Changes in appetite
Insomnia/hypersomnia
Low self esteem
Fatigue
Concentration problems
Hopelessness
Bipolar Disorder (Manic-Depressive)
 Alternating between period of mania and depression.
 Manic cycles
4> symptoms; lasting 1 week:
 hyperactivity, irritability, agitation, insomnia, hypersexuality, grandiosity,
racing thoughts, pressured speech.
 Intense depressive cycles
Symptoms previously mentioned
 Ratio of mania to depression can vary
Some people more manic, others more depressed
Ictal Depression
 Ictal- physiologic state or event such as a seizure (or
stroke or headache).
 Inter-Ictal Depression:
 Depression that occurs between seizures; not during an active
seizure.
 Peri-Ictal Depression:
 Depression just before or just after (hours or days) a seizure.
 Ictal Depression:
 Depression that co-occurs with seizure.
Epilepsy & Anxiety
Anxiety - Experience of fear or apprehension in
response to anticipated danger/threat.
Around 57% of people with epilepsy have highlevel anxiety.
Like in depression, it can be ictal (during),
interictal (between), peri-ictal (before), or postictal (after).
Epilepsy & Anxiety
Anxiety and types of epilepsy:
Risk of anxiety is ↑ in:
 People with focal rather than generalized
epilepsy
 People with temporal lobe epilepsy
 People with frontal lobe epilepsy
Generalized Anxiety Disorder (GAD)
 Excessive anxiety & worry for 6> months; hard to control
 Symptoms of anxiety:
 Restlessness or feeling keyed up or on edge
 Being easily fatigued
 Difficulty concentrating or mind going blank
 Irritability
 Muscle tensions
 Sleep problems (difficulty falling/staying asleep, or
restless sleep)
 In epilepsy, worry can be fear of future seizures/medical
complications.
Panic Attacks
 A discrete period of intense fear
 Develops abruptly & peaks within 10 minutes:
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Heart pounding
Sweating
Trembling/shaking
Shortness of breath
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Numbness/tingling
 Feeling dizzy, unsteady,
lightheaded, or faint
 Derealization or depersonalization
 Fear of losing control or going
crazy
 Fear of dying
 Chills or hot flashes
Panic Attacks
Often, with panic attacks, the person develops a
fear that it will happen again.
So, although a panic attack if brief (≈ 10 mins), it
can have a more long lasting effect on the
person.
Epilepsy & Panic Attacks:
6x more often than general population.
Phobias
 Phobia
Unreasonable fear/anxiety of being exposed to a particular
thing (e.g., flying, germ, snakes, etc.).
In people with epilepsy, can be fear of becoming ill.
 Social Phobia
Unreasonable fear/anxiety of social situations, especially with
people they don’t know or who they expect might judge them.
In people with epilepsy, can be fear of being judged or mocked
because of condition.
 Agoraphobia
Avoidance or anxiety related to open spaces or any place
outside of one's home or a “safe zone”.
In people with epilepsy, can be fear of leaving home and having
a seizure outside.
What if I recognize these symptoms?
Don’t let shame/embarrasment/stigma prevent
you from getting help.
 Remember, depression & anxiety are quite common
in the general population and in people with epilepsy
Think about the degree of suffering these
symptoms bring you, then remember that >80%
of those treated, improve!
Seek professional diagnosis & treatment.
Suicidal thoughts require immediate attention.
Treatments for Depression & Anxiety
 Medication
Anti-depressant medication:
 Longer time to take effect (2-8 weeks)
 Require you to take them daily
 Some side effects to keep in mind (weight gain, dry mouth, etc.)
 Little risk of addiction
Anti-anxiety medications:
 Most take effect immediately (within 15-20 minutes)
 Can be taken “as needed”
 Side effects can be stronger (drowsiness, lethargy, etc.)
 Risk of dependence, so short-term use is best
Important to check with epileptologist!!
Treatments for Depression & Anxiety
 Psychotherapy (individual or group talk therapy)
Supportive
 Less structured, more about providing support through difficult times
 Short or long-term
Process/Exploration Based
 More in-depth analysis of personality traits, family characteristic, life
patterns, etc.
 Longer in duration
Skills Based
 Teaches specific skills to target specific problems (communication,
anger, etc.)
 Short-term
Treatments for Depression & Anxiety
Family Therapy
Can be conducted mostly with epilepsy patient &
occasionally with family, or always with family.
Can be supportive, process (changes in family unit),
and/or skills based.
Psychoeducation
Education about condition as well as coping strategies.
Treatments for Depression & Anxiety
Biofeedback
Technique that teaches people to use signals from their own
bodies as cues for change (e.g., think thermometer or scale).
Computer monitoring allows for very specific information on
bodily functions that might otherwise not be known to the
person (e.g., heart rate, temp, electrical signals within muscles,
perspiration, etc.).
Person is taught to make internal adjustments that alter these
states and move person into a more relaxed state.
Often used for chronic pain, migraines & panic attacks.
Treatments for Depression & Anxiety
Vagal Nerve Stimulator (VNS)
Vagus nerves run on each side of chest and connect
to brain stem.
Device is implanted next to one nerve which sends
electrical impulses to the brain:
Used to control/prevent certain seizures.
Also used to treat depression.
Treatments for Depression & Anxiety
Electro-Convulsive Therapy (ECT)
Electric currents are passed through the brain which cause a
brief seizure → causes a change in brain chemistry → quickly
reverses symptoms of depression.
It often works when other treatments have been
unsuccessful.
Particularly for severe depression.
Can be used in people with epilepsy (with some debate).
Alternative Treatments
Holistic Herbs & Natural Supplements
St. John’s Wort, Echinacea, Valerian Root , etc.
Must consult with doctor prior to taking any of the
following herbs/supplements because they can interact
with AEDs
What can I do to help myself?
 Exercise:
Yoga, Pilates, non-aerobic physical exercise, weight lifting under
supervision.
30 minutes per day improves mood; if you can’t do 30, do what
you can, any physical activity improves both your physical &
mental health.
 Diet:
Make an effort to eat a balanced and healthy diet, as this too has
an effect on mood
 Increase consumption of fruits, veggies, whole grains, legumes & nuts
 Focus on lean meats, unsaturated fats (plant based)
 Reduce: sugar (anxiety), coffee (anxiety), alcohol (depression)
Consult with your nutritionist for your specific needs
What Can I Do To Help Myself?
 Sleep:
Problems with sleep are not only a symptom of depression
and anxiety, but can also trigger a mood episode!
Try to get on regular schedule; do not nap during day.
Try ear plugs, sound machine, eye mask.
If problem persists, get sleep study and medical treatment.
 Meditation:
Research has shown that meditation can improve symptoms
of depression & prevent relapse in those with histories of
depression.
What Can I Do To Help Myself?
Attend Epilepsy Support Groups & related
activities!
Increase connection to other people who might have
similar struggles/fears/concerns are you, decrease
social isolation, meet inspiring people, get involved
in the community.
For list of support groups in NY & NJ:
www.epilepsylifelinks.com
What Can I Do To Help Myself?
Optimism has been linked with improved
medical & mental health
One way to teach yourself to become more
optimistic is to practice “Gratitude”
 Think about 3 people who have most helped you.
 Call them, write them a letter, write about them.
 Get yourself thinking about how blessed you are to
have them in your life.
What can I do? Work on Stress!
Stress is related to:
↑ in medical problems (elevated blood pressure,
elevated sugar levels, ulcers, etc.)
 ↑ levels of depression, anxiety, sleep problems,
irritability and many other negative emotional changes
Important to monitor & regulate sleep, diet, and
exercise, these are all linked to stress
Try some easy stress reduction exercises…
Stress Reduction Exercises
Deep Breathing (Diaphragmatic breathing)
When nervous/scared, we breathe fast & shallow.
 When calm, we breathe slow & deep.
 So, if you purposefully deepen and slow down your
breath, you “trick” your brain in to thinking you are
calm.
Try it (with caution)!
Stress Reduction Exercises
Deep Muscle Relaxation
Systematic technique for achieving a deep state of
relaxation
Researchers discovered that a muscle could be better
relaxed by first tensing it for a few seconds and then
releasing it
Tensing and releasing various muscle groups in
sequence throughout the body produces a deep state
of relaxation
Try it!
So…
Now we know that depression and anxiety are
frequently experienced by people with epilepsy.
That there are a lot of different types of
depression and anxiety reactions a person can
have.
AND, we also know that there are a large variety
of treatment approaches, from the conventional,
to the more natural/holistic approaches…one
will work best for you!
What should I do if I think I’m suffering
from depression or anxiety?
First, you must obtain a proper diagnosis
 Only by a trained and licensed mental health
professional (psychiatrist, psychologist, or social
worker)
Then, you can obtain proper treatment. And
remember, more than 80% of those treated for
depression and anxiety, get better!
Where do I go for diagnosis/treatment?
Ask your epileptologist/nurse for a referral.
Ask your insurance company for a referral.
Take suicidal thoughts/reports seriously.
Contact the New York State Psychological
Association:
www.nyspa.org and visit “Referral Service” Page
Contact National Institute of Mental Health
(866) 615- NIMH (6464)
References & Resources
 Psychiatric Issues in Epilepsy, Edited by Ettinger, A & Kanner A (2001).
Lippincott, Williams & Wilkins
 National Institute of Mental Health
 1-866-615-NIMH (6464)
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 http://www.nimh.nih.gov/publicat/spdep5122.cfm
American Psychological Association (www.apa.org)
NY State Psychological Association (www.nyspa.org)
Breathing Exercises: Treatments2go
 http://www.youtube.com/watch?v=_7ySGgAFAAo&feature=related
Autogenic training: Subliminal Science
 http://www.youtube.com/watch?v=t05S6O6YWgw
Deep muscle relaxation: Cutgame
 http://www.youtube.com/watch?v=KxQJIiu9tK0&feature=related