Epilepsy, suicidal behaviour, and depression: do they share common pathogenic mechanisms?
Explore the source record for details and available documents.
Case-Control Studies↗
Biomedical subjects
Andres M Kanner
Publications and source records attributed to Andres M Kanner.
Rapid detection of major depression in epilepsy: a multicentre study.
BACKGROUND: Depression is a common comorbid disorder in epilepsy but is not routinely assessed in neurology clinics. We aimed to create a rapid yet accurate screening instrument for major depression in people with epilepsy. METHODS: We developed a set of 46 items to identify symptoms of depression that do not overlap with common comorbid cognitive deficits or adverse effects of antiepileptic drugs. This preliminary instrument and several reliable and valid instruments for diagnosis of depression on the basis of criteria from the Diagnostic and Statistical Manual IV, depression symptom severity, health status, and toxic effects of medication were applied to 205 adult outpatients with epilepsy. We used discriminant function analysis to identify the most efficient set of items for classification of major depression, which we termed the neurological disorders depression inventory for epilepsy (NDDI-E). Baseline data for 229 demographically similar patients enrolled in two other clinical studies were used for verification of the original observations. FINDINGS: The discriminant function model for the NDDI-E included six items. Internal consistency reliability of the NDDI-E was 0.85 and test-retest reliability was 0.78. An NDDI-E score of more than 15 had a specificity of 90%, sensitivity of 81%, and positive predictive value of 0.62 for a diagnosis of major depression. Logistic regression showed that the model of association of major depression and the NDDI-E was not affected by adverse effects of antiepileptic medication, whereas models for depression and generic screening instruments were. The severity of depression symptoms and toxic effects of drugs independently correlated with subjective health status, explaining 72% of variance. Results from a separate verification sample also showed optimum sensitivity, specificity, and predictive power at a cut score of more than 15. INTERPRETATION: Major depression in people with epilepsy can be identified by a brief set of symptoms that can be differentiated from common adverse effects of antiepileptic drugs. The NDDI-E could enable rapid detection and improve management of depression in epilepsy in accordance with internationally recognised guidelines.
Adult↗
What should psychiatry residents be taught about neurology?: A survey of psychiatry residency directors.
OBJECTIVES: To improve our ability to teach psychiatry residents during their required 2 months on neurology rotations, we investigated the perceived needs of psychiatry program training directors. METHODS: We contacted the program directors organization of the American Psychiatric Association and disseminated a web-based survey to all program directors. The survey asked questions about the format and content of neurology training desired for psychiatry residents. The survey was sent a second time to increase response rate. RESULTS: Sixty (32%) training directors responded. Overall satisfaction with neurologic education was rated at 3.6 out of 5 (standard deviation +/- 0.96). The specific content areas which elicited the most interest for focused training modules were differential diagnosis and biologic substrates of dementia, evaluation and treatment of drug-related and spontaneous movement disorders, evaluation and management of sleep disorders, cognitive and mood effects of stroke, and inherited disorders. Many program directors commented on perceived weaknesses of inpatient-based exposure to neurology; 78% of responders favored outpatient and consultation settings. CONCLUSIONS: In an era of deliberation about neurobehavioral integration and cross-training of neurologists and psychiatrists, neurologists should strive to provide the best possible multidisciplinary education to psychiatry trainees.
Attitude of Health Personnel↗
Depression and the risk of neurological disorders.
Explore the source record for details and available documents.
Atrophy↗
Mood disorders in the medically ill: scientific review and recommendations.
OBJECTIVE: The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES: Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION: Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS: A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.
Acquired Immunodeficiency Syndrome↗
The use of monotherapy in patients with epilepsy: an appraisal of the new antiepileptic drugs.
The use of antiepileptic drugs (AEDs) in monotherapy is always preferred to a polytherapy regimen because monotherapy facilitates drug compliance, is associated with a lower risk of toxicity, and is less costly. In addition, the yield of polytherapy to render a patient seizure-free when monotherapy regimens did not is relatively low. The available data derived from randomized controlled trials suggest that standard and new AEDs appear to display comparable antiepileptic efficacy but they differ with respect to tolerability and toxicity, which may be related to their pharmacodynamic and pharmacokinetic properties. New AEDs appear to be better tolerated than standard AEDs and to have fewer pharmacokinetic interactions than standard AEDs. In this article, we review the advantages of using AEDs in monotherapy in patients with newly diagnosed and refractory epilepsies, focusing on the individual properties of the drugs that may make them more appropriate in various patient groups.
Age Factors↗
Pharmacotherapy of Mood Disorders in Epilepsy: The Role of Newer Psychotropic Drugs.
Depression in patients with epilepsy (PWE) is a relatively common comorbidity that has a significant negative impact on their quality of life. Therefore, recognition and management of a comorbid depressive disorder is paramount to achieve successful comprehensive treatment in PWE. Depression in epilepsy may mimic primary depressive disorders, but in a significant percentage of depressed PWE, the clinical semiology has an atypical presentation and fails to meed any of the diagnostic criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Despite the relatively high prevalence of depression in epilepsy and its frequent atypical presentation, there has been only one controlled study (in 1979) to establish the safety and efficacy of antidepressant drugs in PWE. Accordingly, clinicians must rely on data from studies of pharmacotherapy of primary depression. These data are adequate to guide the clinician in the basic principles of pharmacotherapy of depression in PWE. Many questions are yet to be answered, including: 1) are the expectations of symptom remission to pharmacotherapy in PWE different in typical and atypical forms of depression, and do they differ from those of patients with primary depression? and 2) are the doses of antidepressant drugs necessary to yield symptom remission different between PWE and those patients with primary mood disorders?
Journal Article↗
Should neurologists be trained to recognize and treat comorbid depression of neurologic disorders? Yes.
Depression is a relatively common psychiatric comorbidity of most neurological disorders, with prevalence rates ranging between 20 and 50% among patients with stroke, multiple sclerosis, epilepsy, Parkinson's disease and dementia. Furthermore, depression is an independent predictor of poor quality of life in these patients and has a negative impact on the response to treatment, course and recovery of neurological deficits. Thus, treatment of depression has become an integral part of the management of these neurologic disorders. This article discusses the rationale for neurologists to be trained in recognizing depressive disorders in neurologic patients and identifies the type of mood disorders in which neurologists can provide pharmacotherapy and those that need to be referred to the care of the psychiatrist.
Animals↗
Screening for major depression in epilepsy with common self-report depression inventories.
PURPOSE: Major depression is a common psychiatric comorbidity in chronic epilepsy that is frequently unrecognized and untreated. A variety of self-report mood inventories are available, but their validity as well as ability to detect major depression in epilepsy remains uncertain. The purpose of this study was to determine the ability of two common depressive symptom inventories to identify major depression in people with epilepsy. METHODS: In total, 174 adult patients with epilepsy underwent standardized psychiatric interview techniques [Mini International Neuropsychiatric Interview (MINI) and Mood Disorders module of the Structured Clinical Interview for DSM-IV Axis I Disorders-Research Version (SCID-I)] to determine the presence of current major depression. Subjects completed two self-report depression inventories [Beck Depression Inventory-II (BDI-II), Center for Epidemiological Study of Depression (CES-D)]. The ability of these self-report measures to identify major depression as identified by the gold standard structured interviews was examined by using diagnostic efficiency statistics. RESULTS: Both the BDI-II and the CES-D exhibited significant ability to identify major depression in epilepsy. All ROC analyses were highly significant (mean area under the curve, 0.92). Mean sensitivity (0.93) and specificity (0.81) were strong, with excellent negative predictive value (0.98) but lower positive predictive value (0.47). CONCLUSIONS: Common self-report depression measures can be used to screen for major depression in clinical settings. Use of these measures will assist in the clinical identification of patients with major depression so that treatment can be initiated.
Adult↗
Clinical assessment of Axis I psychiatric morbidity in chronic epilepsy: a multicenter investigation.
This study characterizes the rate of current Axis I DSM-IV disorders using a brief standardized psychiatric interview procedure, the Mini International Neuropsychiatric Interview (v5.0) (MINI), and determined the validity of MINI diagnoses of current depressive episodes to the research standard (Structured Clinical Interview for DSM-IV Disorders [SCID]). One hundred seventy-four patients with chronic epilepsy from five tertiary medical centers were interviewed using the MINI and the mood disorders module of the SCID. Current Axis I disorders were evident in one-half the sample (49%), with prevalent anxiety (30.4%) and mood (21.8%) disorders. Major depressive episode was the most common individual diagnosis (17.2%). Concordance was high between the MINI and SCID for diagnoses of current depression, especially for major depression. Of those with current major depression, less than one-half were treated with antidepressant medications. Current Axis I DSM-IV diagnoses can be effectively and accurately identified in clinical settings using shorter standardized psychiatric interview techniques. Issues regarding recognition and treatment of psychiatric morbidity in epilepsy are discussed.
Adult↗
Prevalence and clinical characteristics of postictal psychiatric symptoms in partial epilepsy.
OBJECTIVE: S: To identify the prevalence and clinical characteristics of postictal psychiatric (PPS) and cognitive (PCS) symptoms in patients with refractory partial epilepsy and to investigate whether interictal psychiatric and cognitive symptoms worsened in severity during the postictal period. METHODS: Using a 42-item questionnaire, the authors determined the prevalence and clinical characteristics of PPS and PCS that occurred after >50% of seizures in 100 of 114 consecutive patients with refractory partial epilepsy during a 3-month period. The postictal period was defined as the 72 hours that followed a seizure. The prevalence of all interictal psychiatric and cognitive symptoms was identified and the frequency with which they worsened postictally determined. RESULTS: A mean of 2.8 +/- 1.8 PCS (median = 3) and 5.9 +/- 5.3 PPS (median = 5) was identified, which included postictal symptoms of depression (PSD) in 43 patients, anxiety (PSA) in 45, postictal psychotic symptoms (PIP) in 7, hypomanic symptoms in 22, neurovegetative symptoms in 52, and fatigue in 37. Most patients experienced more than one type of PPS. Independently of the occurrence of PPS, 38 patients reported a worsening of interictal psychiatric and cognitive symptoms postictally. A history of depression and anxiety significantly increased the number of PSD, PSA, and PIP. CONCLUSIONS: Postictal psychiatric symptoms are common among patients with refractory partial epilepsy, and the severity of interictal psychiatric and cognitive symptoms commonly worsens during the postictal period.
Adult↗
Is major depression a neurologic disorder with psychiatric symptoms?
In the last decade, multiple investigator groups have identified structural changes of various neuroanatomic structures in patients with idiopathic major depression and bipolar disorders. Using high-resolution MRI of the brain and functional neuroimaging studies (i.e., PET, SPECT), researchers have described decreases in the volume of hippocampal formation, amygdala, entorhinal cortex, various frontal lobe structures, and basal ganglia, in addition to abnormal cerebral blood flow and metabolic activity in these structures as well as in thalamic nuclei. Similar structural and functional changes have been identified in patients with depression associated with a variety of neurologic disorders (i.e., stroke, Parkinson's disease, epilepsy, Alzheimer's dementia). In addition, recent data have shown that depression is a risk factor for the development of several neurologic disorders, including epilepsy, stroke, and Parkinson's disease and bears a negative impact on the course and outcome of most neurologic disorders. This article reviews these data and provides evidence that major depressive and bipolar disorders may in fact be neurologic disorders with psychiatric symptoms.
Major Depressive Disorder↗
Efficacy and tolerability of the new antiepileptic drugs, I: Treatment of new-onset epilepsy: report of the TTA and QSS Subcommittees of the American Academy of Neurology and the American Epilepsy Society.
PURPOSE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs [AEDs; gabapentin (GBP), lamotrigine (LTG), topiramate (TPM), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LEV), and zonisamide (ZNS), reviewed in the order in which these agents received approval by the U.S. Food and Drug Administration] in the treatment of children and adults with newly diagnosed partial and generalized epilepsies. METHODS: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane Library for relevant articles from 1987 until September 2002, with selected manual searches up to 2003. RESULTS: Evidence exists, either from comparative or dose-controlled trials, that GBP, LTG, TPM, and OXC have efficacy as monotherapy in newly diagnosed adolescents and adults with either partial or mixed seizure disorders. Evidence also shows that LTG is effective for newly diagnosed absence seizures in children. Evidence for effectiveness of the new AEDs in newly diagnosed patients with other generalized epilepsy syndromes is lacking. CONCLUSIONS: The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes for which more evidence is necessary.
Acetates↗
Efficacy and tolerability of the new antiepileptic drugs, II: Treatment of refractory epilepsy: report of the TTA and QSS Subcommittees of the American Academy of Neurology and the American Epilepsy Society.
PURPOSE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) [gabapentin (GBP), lamotrigine (LTG), topiramate (TPM), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LEV), and zonisamide (ZNS)] in the treatment of children and adults with refractory partial and generalized epilepsies. METHODS: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane Library for relevant articles from 1987 to March 2003. RESULTS: All of the new AEDs were found to be appropriate for adjunctive treatment of refractory partial seizures in adults. GBP can be effective for the treatment of mixed seizure disorders, and GBP, LTG, OXC, and TPM for the treatment of refractory partial seizures in children. Limited evidence suggests that LTG and TPM also are effective for adjunctive treatment of idiopathic generalized epilepsy in adults and children, as well as treatment of the Lennox-Gastaut syndrome. CONCLUSIONS: The choice of AED depends on seizure and/or syndrome type, patient age, concomitant medications, and AED tolerability, safety, and efficacy. The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with refractory epilepsy and identify those seizure types and syndromes for which more evidence is necessary.
Acetates↗
Recognition of the various expressions of anxiety, psychosis, and aggression in epilepsy.
Anxiety, psychosis, and aggressive behavior are among the frequent comorbid psychiatric disorders identified in patients with epilepsy. Often the clinical manifestations of these disorders vary according to their temporal relation relative to seizure occurrence. Thus, postictal symptoms of anxiety or psychosis differ in severity, duration, and response to treatment with interictal symptomatology. Psychiatric symptomatology in epilepsy can appear concurrently with the seizure disorder and improve or remit on the abolition of epileptic activity. We refer to these as paraictal psychiatric phenomena. Such is the case of aggressive disturbances associated with gelastic seizures caused by hypothalamic hamartomas. In this article, three case studies are presented to illustrate the importance of distinguishing psychiatric symptoms of anxiety, psychosis, and aggression, with respect to their temporal relation with seizure occurrence.
Adolescent↗
Thalamic Dysfunction in Idiopathic Generalized Epilepsy: New Findings of Old News.
Explore the source record for details and available documents.
Journal Article↗
Diagnosis and management of depression and psychosis in children and adolescents with epilepsy.
The neurologic dysfunction underlying epilepsy can predispose patients to psychiatric disorders, and the incidence of both depression and psychosis is increased in people with epilepsy. Depressive disorders are the most frequently recognized psychiatric comorbidities in people with epilepsy, but depression in children can be particularly difficult to recognize. Clinicians need to inquire about not only classic symptoms of depression such as anhedonia but also less obvious symptoms such as unprovoked irritability, unsubstantiated complaints of lack of love from family members, somatic complaints, and problems with concentration and poor school performance. The diagnosis of depressive disorders in children with epilepsy and mental retardation is even more difficult. Physicians need to be alert for the presence of iatrogenic depression, which may result from antiepileptic drugs or epilepsy surgery. People with epilepsy are also at increased risk for psychosis, which can be interictal, postictal, or (rarely) an expression of ictal activity. This psychosis can be related to seizure remission (ie, alternative psychosis) or iatrogenic (eg, related to antiepileptic drugs or following temporal lobectomy). Although both antidepressants and antipsychotic drugs have the potential to lower the seizure threshold and increase seizures, careful drug selection, dosing, and slow titration can minimize this risk, allowing treatment to proceed.
Adolescent↗
Structural MRI changes of the brain in depression.
For many years, investigators have been trying to identify the neuroanatomical structures responsible for the development of neuropsychiatric disorders, specifically depression and schizophreniform disorders. The available data were based on observations made in neurological patients who developed a psychiatric comorbid disorder following the neurologic insult. With the advances in high-resolution magnetic resonance imaging and functional neuroimaging studies, we have witnessed in the last decade a wealth of new data that identify structural neuroimaging changes in mesial temporal structures, prefrontal cortex and basal ganglia in major depressive disorders. The purpose of this article is to briefly review the published data on neuroanatomical structural changes associated with major depressive and bipolar disorders.
Atrophy↗