Download Diagnosis and Treatment of Mood Disorders in Epilepsy

DIAGNOSIS AND TREATMENT OF MOOD
DISORDERS IN EPILEPSY
Siddhartha S. Nadkarni, M.D.
F.A.C.E.S. Conference
May 5, 2013
WHAT IS MOOD?
•
Emotional State or Frame of Mind
•
Not an Emotion, less specific
•
A Weather
•
Not Temperament or Personality (which are more like a climate)
•
Dysthymia
•
Major Depression
•
Bipolar Disorder
• Mania
• Depression
• Mixed States
• Bipolar I, Bipolar II
HOW TO DIAGNOSE MOOD DISORDERS
DYSTHYMIA
•
Chronic Depression
•
More days than not for at least 2 years
•
In kids can be irritability for at least 1 year
•
Never goes more than 2 months without experiencing:
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
DEPRESSION
•
5 Symptoms for at least 2 weeks:
• Depressed Mood*
• Sleep Disturbance
• Interest Loss (“Anhedonia”)*
• Guilty Ruminations
• Energy loss
• Concentration Loss
• Appetite Changes
• Psychomotor Changes
• Suicidal Thinking
•
* One has to be depressed mood or loss of pleasure
MANIA
•
1 Week of persistently elevated, expansive, or irritable mood (or any duration if
hospitalization required)
•
During this time at least 3 of the following:
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative or pressured speech
• Flight of ideas or racing thoughts
• Distractibility
• Increased goal-directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities that have a high potential for painful
consequences
BIPOLARITY AND DYSTHYMIA
•
Bipolar I is diagnosed by the presence of a manic episode
•
Bipolar II is diagnosed by the presence of depression and hypomania
•
Mixed state is when one meets criteria for both a depressive and manic episode
•
Schizoaffective Disorder is characterized by psychosis between mood episodes
•
Outside post-ictal or prodromal mood states, Depression is far and away the most
common mood disorder in Epilepsy
DEPRESSION AND EPILEPSY
• Up to 80% of Epilepsy patients have depression (50% - 80%).
• Suicide attempts may be 4 times that of a control group with
chronic neurologic illnesses.
• Depression was the only correlating factor in a recent study in
terms of quality of life for a wide range of seizure patients
(Boylan, 2004) including sz
type/frequency/location/medications, etc.
DEPRESSION AND EPILEPSY
• Increased Suicide attempts related to interictal
psychopathology (borderline p.d., psychosis) rather than sz
frequency, medications, psychosocial stressors (Mathews and
Barabas, 1981; Medez et al., 1989)
• Biological Factors contributing to interictal depression:
• Family History of Mood Disorders
• Left Sided Sz focus
• Bilateral Frontal Hypometabolism
DEPRESSION AND EPILEPSY
•
WAY UNDERRECOGNIZED AND UNDERTREATED (BOYLAN, 2004).
•
May be different than “major depression.”
TREATMENTS FOR DEPRESSION IN EPILEPSY
•
Antidepressants
•
Anti-Epileptic Drugs
•
Vagus Nerve Stimulation
•
Cognitive Behavioral Therapy
•
Transcranial Magnetic Stimulation
•
Future Directions and Alternative Treatments
MAJOR NEUROTRANSMITTERS
Type
Major Transmitters
Amines
Acetylcholine
Catecholamines (DA, NE)
Serotonin
Histamine
Amino Acids
Glutamate
GABA (γ-aminobutyric acid)
Glycine
Other Small Molecules
ATP
Neuropeptides
Angiotensin II
β-endorphin
Cholecystokinin
CRF
Enkephalin
Neuropeptide Y
Orexin
Somatostatin
Substance P
Many others
NOREPINEPHRINE
SEROTONIN
ANTIDEPRESSANTS
RISPERDAL
Karen Blair has Schizophrenia. “The magnificent Circus”
SIDE EFFECTS
• All Anti-Epileptic Drugs (AED’s) have side effects.
• In a given patient these effects may be problematic or helpful.
• The Goal of Epilepsy treatment is to obtain seizure freedom
without untoward side effects.
• A note about the PDR.
AED’S
•
Depression
•
Anxiety
• Phenobarbital
• Keppra
• Zonegran
• Lamictal
• Depakote
• Felbatol
• Dilantin
• Keppra
ZYPREXA
“She Likes You”
POSITIVE SIDE EFFECTS
•
Mood Stabilization:
• Tegretol
• Depakote
• Lamictal
•
Antidepressant
• Lamictal
•
Stimulant
• Lamictal
•
Anxiolytic
• N eurontin
• Phenobarbital
SEROQUEL
“What Jack Saw”
Antiepileptic Drug
Barbiturates
Beneficial Effects
Anxiety, Mood stabilizing,
Sleep
Carbamazepine
Aggression, Mania, Mood
stabilizing *
Ethosuximide
Gabapentin
Lamotrigine
Anxiety, Insomnia, Social
phobia*, Mood stabilizing
Mania*, Mood
stabilization*
Levetiracetam
Data not available.
Phenytoin
Mania
Tiagabine
Topiramate
Mania, Mood stabilization
Binge eating, Mania, Mood
stabilization
Valproate
Agitation, Aggression,
Irritability, Mania*, Mood
stabilization*
Mania
Zonisamide
Harmful Effects
Aggression, Impaired
cognition & attention,
Depression, Irritability,
Sexual function and desire
Irritability, Impaired
attention
Aggression, Confusion,
Depression, Insomnia
Irritability/agitation (usually
in children with disabilities)
Insomnia, Irritability
(usually in children with
disabilities)
Anxiety, Depression,
Irritability (all appear more
common in children)
Depression, Impaired
Attention
Depression, Irritability
Depression, Impaired
cognition (word finding,
memory) & attention,
Irritability
Depression
Aggression, Emotional
lability, Irritability
Neuropsychopharmacology, April 2001
•
Open Pilot Study of 60 patients with treatment resistent depression
•
2 weeks single blind recovery (no stimulation) followed by 10 weeks of VNS
•
59 completers because one person improved during recovery period (no stim)
•
Conclusions:
• 30.5% responder rate for HRSD
• 30% responder rate for the MADRS
• 37.3% responder rate for the Clinical Global Impression-Improvement Score
• Of those who had received 7 or more antidepressants, none responded
• 39% of the rest responded
• Those who never had ECT were 3.9 X more likely to respond
• Most Common Side Effect was Hoarseness in 55%
• Good for low to moderate antidepressant resistence
Biological Psychiatry 2005
• 222 patients
• 15% responded in active treatment
• 10% responded in sham arm
• 1% dropped out for non-tolerabilty
• No evidence of short term efficacy
ELECTROCONVULSIVE THERAPY
• ECT is likley the most effective treatment
we have for Depression
• ECT is not contraindicated in Epilepsy
• In fact ECT came into use due to “forced
normalization.”
• ECT can be used to abort Status
Epilepticus
TREATMENT TIPS
• First step is diagnosis. We don’t do as good a job as we should in asking
about these symptoms. You may need to tell us.
• Remove inciting AED’s.
• Antidepressants, may respond to lower doses in this population.
• Antipsychotics as needed or in low doses.
• Stimulants.
• Anti-anxiety medications may treat both seizrues and anxiety but tolerance
and withdrawal are worries.