Forced normalization
In the 16th century, Cardenus (Whitwell 1936) wrote about a case of melancholia alternating with epilepsy, describing what is possibly the first case of forced normalization associated with epilepsy. The term forced normalization was coined by Heinrich Landolt (Landolt 1953) and defines a phenomenon characterized by the fact that with the occurrence of psychotic states, the EEG becomes normal or more normal compared to previous recordings.

Although forced normalization clinically usually manifests as a schizophrenia-like psychosis, prepsychotic dysphoria and depression have also been reported (Wolf 1984). Several studies have also reported a decrease in seizure frequency prior to the onset of depressive illness (Dongier 1959/60, Flor-Henry 1969).

A decrease in the seizure frequency and thus forced normalization can be brought about by (Robertson 1998):

  * 1) a spontaneous reduction in seizures,
  * 2) antiepileptic drugs,
  * 3) temporal lobectomy.

The phenomenon of forced normalization forms an interesting interface between neurology and psychiatry, with various theories being suggested to explain the same. While (Wolf et al. (1991) suggested the condition to be a form of active but restricted subcortical seizure activity, various others have postulated that amygdaloid and limbic kindling might play a role in the development of this phenomenon (Krishnamoorthy, 1998). The roles of the glutamate and the GABA receptors in the mechanisms of epilepsy and psychosis also suggest the possibility of the involvement of various neurotransmitters in forced normalization (Krishnamoorthy 1999). One of the most recent hypotheses put forward to explain the same, digresses towards a more physiological view involving dysfunctions of the ion channels, and suggests that the phenomenon of forced normalization could be a unique kind of channelopathy (Krishnamoorthy 2002).

AEDs and depression
Anti-epileptic drugs may cause significant psychiatric side effects. Kanner (Kanner et al. 2000) studied 100 patients who were treated for depression in epilepsy. In almost a third of these patients, the depression was considered iatrogenic, provoked by AEDs. The AEDs, which have been commonly reported as depressogenic, are vigabatrin (10%), tiagabine (5%), topiramate (15%) and phenobarbitone (Trimble 1998). Levetiracetam therapy was associated with depression in 2.5% individuals; this was dose-dependent and was also related to a past history of febrile seizures and status epilepticus (Mula et al. 2003).

Laterality hypothesis
In the late 1960s, Flor-Henry (Flor-Henry 1969) postulated that affective disorders were more common in patients with right-sided temporal lobe epilepsy. Many investigators have subsequently reported mixed and overall equally balanced results, favouring neither the right nor the left hemisphere. Modern laterality hypotheses relate to the connectivity of the mesial temporal lobes; left temporal epilepsy may lead to frontal lobe dysfunction (hypofrontality) and clinical depression (Schmitz 2002). Evidence from FDG-PET (Bromfield 1992) and HMPAO-SPECT (Schmitz et al. 1997) studies also suggest a difference in the psychopathology of depression in left-sided TLE as compared to right-sided TLE. Victoroff (Victoroff et al. 1994), suggested that in individuals with left-sided epileptogenicity, there is a progressive vulnerability to depressive “decompensation”. This “laterality hypothesis” has, however been challenged by Quiske (Quiske et al. 2004), who noted a similar preponderance of depressive symptoms in both right and left-sided pathologies. Depression in left-sided epilepsy has been hypothesized to be a consequence of seizure activity. This has been confirmed (as above) by Reuber (Reuber et al. 2004), who found that following left-sided lobectomy, only patients who became seizure-free improved with respect to mood. Patients with left-sided epilepsies who did not become seizure-free and patients with right-sided TLE however, did not improve.

Endocrine and metabolic factors
The ictus is known to be associated with a wide range of changes in the levels of norepinephrin, tryptophan and 5HIAA, all of which have been implicated in theories regarding the development of depression (Meldrum 1991).

Psychological factors
Epilepsy is associated with repeated and unpredictable episodes of loss of consciousness. This unpredictability and uncontrollability has been compared with Seligman’s concept of “learned helplessness”, which occurs when patients are exposed to adverse experiences on a random basis (Abramson et al. 1978, Hermann 1979, DeVellis 1980). Another concept used to explain depression in patients with epilepsy and depression is the “burden of normality” that describes psychiatric decompensation in a person who is cured from a chronic illness (Schmitz 2002). This may happen when a person loses illness-associated privileges and is forced to meet the everyday challenges of a healthy person. The occurrence, as well as the anticipation of occurrence of seizure, can also act as a serious impediment in the well-being of the individual, thus adding to the psychological burden of the individual.

_{Author(s) : R Seethalakshmi, Ennapadam S Krishnamoorthy , The Institute of Neurological Sciences, Voluntary Health Services, Taramani, Chennai, India.}

Summary : 1) Depression is a common and important accompaniment of epilepsy. 2) Depression in epilepsy is phenomenologically different from the usual forms of depression and it is essential that treating physicians assess for these varied forms as well. 3) Depression in epilepsy may be managed more effectively if the relationship to the ictus is better understood. 4) Other factors such as stressful life events, related or unrelated to epilepsy, may contribute to the depressive symptoms. 5) Antiepileptic drugs, particularly GABAergic agents such as vigabatrin, tiagabine, topiramate and phenobarbitone are depressogenic in nature. 6) The newer antidepressants, SSRIs such as sertraline, citalopram and paroxetine do not lower seizure threshold and can be safely used to treat depression in epileptic individuals. Fluoxetine may be avoided because of its longer half-life.

Keywords : epilepsy, depression, classification, etiology, treatment, SSRI