Treatment of psychiatric disorders in epilepsy is largely opinion-led, with little evidence from systematic randomized control trials (Krishnamoorthy 2003).

Pre-ictal and ictal depression do not usually require treatment; an improvement in seizure frequency reduces the occurrence of these forms of depression (Lambert 1999) Medications such as benzodiazepines e.g. clobazam, and behavioural methods such as progressive muscular relaxation, biofeedback, and yoga may abort or prevent the development of the attack. The general guidelines for management of depression in epilepsy include the following points.

Antidepressants
Management of depression in epilepsy with antidepressants involves three major issues:

  * a) effect of antidepressants on seizure threshold,
  * b) antidepressant-anticonvulsant interactions,
  * c) efficacy of antidepressants in this category of patient.

Chronic inhibition resulting in psychiatric disorders requires pharmacological intervention directed against this. The presence of dysphoric disorders in patients with epilepsy indicates the presence of marked inhibition. The proconvulsant nature of antidepressants appears to serve as effective antagonists to excessive inhibition. Patients with primary generalized seizures tend to have lower seizure thresholds, and antidepressants must be used with caution in these patients. Within certain concentration ranges, raised levels of extracellular serotonin have been shown to have converse anticonvulsant properties in animal studies (Clinckers et al. 2004).

Virtually all non-MAOI antidepressants, including the newer antidepressants such as citalopram, paroxetine, reboxetine and sertraline lower the seizure threshold in varying degrees (Trimble 1978b, Edwards 1985). Robenstein (Robenstein et al. 1993) suggested that SSRIs are less seizurogenic as compared to TCAs. Antidepressants and anti-epileptic drugs can affect each other’s levels, with anti-epileptic drugs usually reducing antidepressant levels and antidepressants increasing anti-epileptic drug levels (Robertson 1998a, Robertson 1998b). (Davis and Glassman 1989) in a recent review found that 65% patients on imipramine improved as compared with only 30% on placebo. (Trimble and Robertson 1985), in a placebo-controlled double-blind study however, showed that there were no significant differences between either active drug and placebo in the first six weeks of treatment.

Psychological therapies
Several models of cognitive behavior therapy, ranging from more generic applications to more specific models based on original research, have been applied in epilepsy. In a recent meta-analysis of psychological therapies in epilepsy however, Ramaratnam (Ramaratnam et al. 2001) concluded that, “in view of the methodological deficiencies and limited number of patients studied, we have found no reliable evidence to support the use of treatments and further trials are needed”.

The brief form of psychotherapy, group psychotherapy, patient support groups, relaxation therapy, and EEG biofeedback have all been shown to be effective.

Electroconvulsive therapy
Despite a few sporadic reports of spontaneous seizures after ECT (Devinsky 1983, Grogan et al. 1995), major studies have found the incidence of spontaneous seizures following ECTs to be lower than the incidence of epilepsy in the general population (Blumenthal 1955, Blackwood et al. 1980). ECT may be life-saving in some patients with depression, particularly severe or psychotic depression not responding to antidepressants. The efficacy of the ECT may, however, be reduced by anti-epileptic drugs. Weiner and Coffey (1993) recommend that, with the exception of patients at high risk for status epilepticus or with recent generalized tonic-clonic seizures, AEDs should be omitted the morning before each ECT treatment.

Novel treatments such as vagal nerve stimulation have recently been shown to have a positive effect on both epilepsy and co-morbid depression (Harden et al. 2000, Elger et al. 2000).

Finally, transcultural issues need to be addressed, and treatment approaches have to be tailored to meet the individual needs of the patient. Krishnamoorthy (2003), in a recent review, pointed out that while western patients and wealthier Asian patients welcome psychological explanations, patients from the lower socioeconomic groups in these settings may find these less acceptable. It is important that patients must be treated until complete resolution, as residual symptoms can impede the patient’s quality of life

Epileptic Disorders. Volume 9, Number 1, 1-10, March 2007, Review article
John Libbey Eurotext
Author(s) : R Seethalakshmi, Ennapadam S Krishnamoorthy