Beruflich Dokumente
Kultur Dokumente
Cynthia Harden, MD
Laura Ponticello, RN
Comprehensive Epilepsy Center Department of Neurology and Neuroscience
AM. Biol Psychiatry. 2003;54:388-398. 2Ettinger A, et al. Neurology. 2004;63:1008-1014. 3Wrench J, et al. Epilepsia. 2004;45:534-543.4Weissman MM, et al. J Clin Psychiatry. 1986;47(suppl 6)11-17. 5 Blum D, et al. In: Program and abstracts of the 54th Annual Meeting of the AAN; April 13-20, 2002. 6Kessler RC, et al. Arch Gen Psychiatry. 1994;51:8-19, 7Ettinger AB, et al Neurology. 2005;65:535-40.
1Kanner
Pharmacoresistant Epilepsy Controlled Epilepsy Gen. Population (Annual) Gen. Population (Lifetime)
40
30
20
10
0
Population
AM. Biol Psychiatry. 2003;54:388-398. 2Ettinger A, et al. Neurology. 2004;63:1008-1014. 3Wrench J, et al. Epilepsia. 2004;45:534-543. 4Waraich P, et al. Can J Psychiatry. 2004;49:124-138. 5Boylan LS, et al. Neurology. 2004;62:258-261.
1Kanner
100
QOLIE-89 Total Score
80 60 40 20 0
r = -0.73 P<0.001
10
15
20
25
30
35
40
General Population
% of Population
20 15 10
19% 14%
5%
5
1%
Ideation1,2
Behavior/Attempts
1Boylan 2Jones
LS, et al. Neurology. 2004;62:258-261. JE, et al. Epilepsy Behav. 2003;4:S31-S38. Publishers; 1997:2141-2151.
Risk Factors for Depression in Women with Epilepsy (Beghi et al., 2004)
Any depression, or moderate to severe depression*
Concurrent disability Treatment for associated conditions (neurologic, endocrine, cardiovascular, orthopedic)* Seizures in past 6 months* Being a housewife or unemployed*
Lack of adequate clinical response after 2 well-delivered treatments at adequate dose and duration from 2 different classes of treatment1
ME, Rush AJ. In: Bloom FE, Kupfer DF, eds. Psychopharmacology: The Fourth Generation of Progress. New York, NY: Raven Press, Ltd.; 1995:1082-1097.
1Thase
If no to both, major depression is unlikely May inquire about intermittent symptoms proximal to seizures in PWE to assess atypical manifestation of depression. If yes to either, proceed with the follow-up clinical interview or administer screening instrument
Adapted in part from: Whooley MA, Simon GE. N Engl J Med. 2000;343:1942-1950.
Sleep disturbance
Psychomotor problems Lack of energy
Poor concentration
Excessive guilt
Adapted in part from: Whooley MA, Simon GE. N Engl J Med. 2000;343:1942-1950. American Psychiatric Association. DSM-IV-TR. R.R American Psychiatric Association: Washington, DC; 2000.
Reliability*
.94 .92 .86 .843 .46-.974 .825 .90
CES-D7
20
5-7
.85-.90*
*Internal Consistency, Interrater Reliability 1Arnau, et al. Health Psychology. 2001;20:112-119. 2Rush, et al. Soc Bio Psych. 2003;54:573-583. 3Dugan W, et al. Psychooncology. 1998;7:483-493. 4Bagby RM, et al. Am J Psychiatry. 2004;161:2163-2177. 5Maier W, et al. J Psychiatr Res. 1988;22:3-12. 6Hellerstein DJ, et al. J Affective Disorders. 2002;71:85-96. 7Vahle VJ, et al. Arch Phys Med Rehabil. 2000;84:S53-S62.
Includes only items assessing DSM-IV criterion Scores 9 symptom domains High internal consistency though less than that of the IDS Excellent interrater reliability Acceptable discriminant validity
QIDS-SR less sensitive to residual symptoms than the IDS-SR
Rush AJ, et al. Biol Psychiatry. 2003;54:573-583.
Psychometric Overview
High interrater reliability Excellent internal consistency and sensitivity Total scores correlate well with depressive subtypes of various intensity-mild depressive symptoms rather than major depression
1Victoroff
JI, et al. Arch Neurol. 1994;51:155-163. 2Perini GI, et al. J Neurol Neurosurg Psychiatry. 1996;61:601-605. 3Gilliam F, et al. Epilepsia. 2000;41(suppl 7):54. Abstract 1.193. 4Bromfield EB, et al. Arch Neurol. 1992;49:617-623. 5Mayberg HS, et al. Ann Neurol. 1990;28:57-64. 6Eison MS. J Clin Psychopharmacol. 1990;10(suppl 3):26S-30S. 7Kanner A. Epilepsy Behav. 2003;4:S11-S19. 8Quiske A, et al. Epilepsy Res. 2000;39:121-125.
Amygdala
Prefrontal cortex
Depression
Decreased 5HT-1A
CBZ, VPA, or LTG: reintroduction of that AED or another mood-stabilizing agent may be sufficient
Did the depressive episode follow the introduction or dose increment of an AED with negative psychotropic properties?
LEV, PB, PRM, TGB, TPM, or VGB: lower dose or discontinue that AED
If culprit agent provides best seizure control, counteract negative psychotropic effects with an antidepressant
Kanner AM, et al. Epilepsy Behav. 2003;4:S11-S19. Kanner AM, et al. Epilepsy Behav. 2000;1:37-51.
Do depressive symptoms have a temporal relationship with the occurrence of seizure frequency?
Postictal depression usually responds poorly to antidepressant therapy; consider an optimal prophylactic AED
Kanner AM, et al. Epilepsy Behav. 2003;4:S11-S19. Kanner AM, et al. Epilepsy Behav. 2000;1:37-51.
Electroconvulsive Therapy
Not contraindicated in seizure disorders
Kanner AM, et al. Epilepsy Behav. 2000;1:37-51.
paroxetine (Paxil)
amitriptyline* (Elavil) desipramine* (Norpramin)/nortriptyline*(Pamelor) mirtazapine (Remeron) phenelzine (Nardil)/ tranylcypromine (Parnate) trazodone (Desyrel)/nefazodone (Serzone)
* TCA , SSRI, NE/5HT modulator, MAOI, Serotonin modulator.
0.1
0.06 0.05-0.1 (unknown) 0.04 Rare (unknown) Rare (unknown)
0.5 at 250 mg/day 1.66 at >250 mg/day 0.6 at >200 mg/day 0.3 0.26 0.2
from Harden CL, Goldstein MA. CNS Drugs. 2002;16:291-302. 2American Psychiatric Association. http://www.psych.org/psych_ pract/treatg/pg/ Practice%20Guidelines8904/MajorDepressiveDisorder_2e.pdf.
Mood reported as better or much better by 44% of Registry patients after 1 year of VNS Therapy3
1Elger 2Harden
G, et al. Epilepsy Res. 2000;42:203-210. CL, et al. Epilepsy Behav. 2000;1:93-99 3Data on file. Cyberonics, Inc.
ECT
Patients with severe functional impairment and/or treatment resistant depression Psychiatrists are reluctant to use in patients with pharmacoresistant epilepsy
Summary
Depression is a common comorbidity with epilepsy, especially for women, and compromises quality of life!
Clinicians should screen patients for depression at the least with two simple questions and initiate a plan for further evaluation and treatment if depression is suspected!
Case 1
Woman in her early 40s with intractable partial epilepsy since age 14
Nocturnal and diurnal convulsive seizures Multiple medication failures of all available AEDs mostly due to non-serious side effects; now back to old standbys phenytoin and phenobarbital No risk factors for epilepsy Video-EEG shows interictal independent temporal spikes, left more frequent than right; no seizures recorded MRI shows cerebellar atrophy
Case 1, contd
Assessment of seizure frequency and severity compromised during office visits by tearfulness, excessive sensitivity during discussions and tangential ideation Social status: recent divorce and subsequent financial and insurance issues, two small children at home, low educational level, not employed Coping with all issues is marginal as per patient report Is it likely that she is depressed? (yes or no by response buttons)
What we did
Added Celexa 10 mg per day