Depression in Children and Adolescents with Epilepsy
EpilepsyUSA July/August 2007
Depression in Children and Adolescents with Epilepsyby Jay Salpekar, M.D., special to epilepsyUSA
One of the most common psychiatric comorbidities in pediatric epilepsy is mood disorder, specifically depression. Depression is present in approximately one quarter of children and adolescents with epilepsy, and is reported to be even more common in adults. Some studies report depression as present in as many as 60 percent of adults with uncontrolled or other complicated forms of epilepsy. Given the frequency of depression in adults, it stands to reason that depression may be significantly underreported in children.
This is unfortunate, as depression can be extremely dangerous, and in some cases even more debilitating than seizures. Depression can even be life threatening as suicidal ideas and even attempts may be insidious and ultimately catastrophic. (Recent studies have shown that up to 20 percent of children with epilepsy have thought about suicide.) Depression can be subtle and difficult to identify. Many clinicians are not experienced in identifying depression. As mentioned in the article regarding psychiatric comorbidity (page 13), mental health care may be difficult to find for many families. Even epilepsy specialists who are well intentioned in addressing comorbid depression may be unsure on how to proceed.
Depression has historically been regarded as solely an artifact of the stress of chronic epilepsy or as a medication side effect. Many clinicians have an attitude that depression may be an expected development given the stress of having seizures and suffering the consequent drastic adjustments in lifestyle. However, modern understanding of depression has shown it is a medical condition based upon brain dysfunction. That is, depression is not merely the result of psychological stress or social circumstances. Physicians now recognize that many types of depression result from a neurochemical disorder of the brain that goes beyond the stress of having a chronic disease, and prompt treatment is required.
Children and adolescents who are depressed may not state that they feel sad or depressed. Children may be very irritable or have little tolerance for frustration. A child who is cranky or is significantly unsettled by even minor frustrations may be exhibiting depressive symptoms. What might be especially confusing for parents is that depressed children might not have the energy or desire to go out, but might actually appear to enjoy themselves once they are in a social situation. Children or adolescents may isolate themselves from peers or reject overtures from others and can become hypersensitive to rejection. Often basic functions like regular appetite or sleep schedule may be impaired. Children may also describe a decrease in energy, a feeling of being tired all the time or complain of vague aches or pains like headaches or stomach upset.
Eventually a child might feel helpless regarding their condition or hopeless about the outlook for the future. At worst, a child may describe not wanting to be alive, or even contemplate suicide. One key feature of clinical depression is that these feelings are not consistent with reality. A child with depression might have negative thoughts and feelings regardless of the parental encouragement, the adolescent’s apparent educational and social successes, and a good prognosis or stability of his or her epilepsy.
The most important thing for parents to do is to observe children for a significant change in their routine. Whereas any child may have bad days or even an extended period of feeling “down,” depression is more sustained—symptoms are often present for a matter of weeks or more. A child who gradually rejects activities he usually enjoyed or has a significant change in functional level, may have depression. Parents should be bold enough to ask, even about difficult subjects such as suicide. A child will still have such thoughts whether anyone asks them or not, so it is important to face up to the possibility. Asking a child about symptoms of depression can be challenging, and does require a sensitive approach. A line of questioning that gradually addresses depressive symptoms may be the best strategy. A parent or clinician can start with simple questions and progress based upon how the child responds. An example of such a line of progressive questions is listed below:
• Are you finding things that you like to do?
• How often do you feel happy?
• Do you think you are as happy as most of your friends?
• Do you often feel like nothing will turn out good for you?
• Do you feel like you don’t even want to be alive?
A child or adolescent who describes symptoms of depression may require professional help, especially if they are having difficulty functioning at school or at other activities in which they are engaged. Many children will improve with talk therapy from a psychologist, social worker or a children’s or adolescent’s psychiatrist. Social groups are also important, especially if it is possible to facilitate interaction with other children with epilepsy.
If these efforts are ineffective or if suicidal ideas are present, then serious consideration should be given to treatment with medication. Sophisticated studies regarding medication treatment for children and adolescents with depression are uncommon, but some do show significant improvement. The most common antidepressants used for children and adolescents are SSRIs (Serotonin Selective Reuptake Inhibitors). SSRIs are a mainstay of depression treatment and, with careful usage, can yield tremendous improvement. The approaches to treating depression in children with epilepsy are similar to those for children without epilepsy.
Depression is, unfortunately, common in children and adolescents with epilepsy. However, the good news is that depression is very effectively treated so long as it is identified. Identifying and treating depression may be one of the most important aspects of care for children and adolescents with epilepsy.