Mood Disorders Online Chat Transcript (September 19, 2006)

Introduction

Dr. Frank Gilliam: Good evening everyone. My name is Frank Gilliam, and I have been an epilepsy physician for 15 years. Our group's research in the concerns of persons with epilepsy (what I call "patient oriented research") has led us to emphasize several common problems in addition to the obvious issue of seizure control. We, along with other international research groups, have shown that depression and anxiety are commonly associated with epilepsy. Depression may be present in 2 out of every 5 people with recurrent seizures. Depression appears to be less common in people whose seizures are completely controlled, suggesting a relationship between depression and seizures.

Our current research indicates that the brain problems associated with a lower seizure threshold may be more important that "life stresses" in causing depression. This is important to realize, because it means that depression may not simply be a reaction to the stresses of living with epilepsy, but may be due to the same brain problems that cause the seizures. Depression is certainly NOT the fault of the person, and is not due to laziness or a "weak constitution." Although we are aggressively investigating the best ways to treat depression in epilepsy, there is not definite evidence to support specific recommendations at this point. Certain antidepressants, such as Buproprion (Wellbutrin), may lower the threshold, and should probably be avoided if possible. Current recommendations are to use a serotonin reuptake inhibitor (SSRI) or a form of cognitive/behavior therapy as the initial treatment for depression in epilepsy. I look forward to our interaction tonight.

All the best,

Frank Gilliam

Catherine Kane: Welcome, everyone! On behalf of the Epilepsy Foundation, I would like to thank everyone here for joining us. It is obvious that this important topic is of great interest, and we are pleased you could take time out of your schedule to join the discussion.We are fortunate that tonight's expert, Dr. Frank Gilliam, has been able to join us early this evening.

Epilepsy & Personality

Lori: I've heard some people refer to an "epileptic personality". Do you have any research on this?

Frank Gilliam: Dr Geshwind did a great deal of research in this area over 30 years ago, but I do not believe that it is useful... personalities are so complex, and vary so much between people, that I believe picking out negative things to attribute to "epilepsy" is not helpful.

Guest Two: I have no history of Epilepsy in my family, except me. However, on both sides I have severe depression. Can depression and epilepsy be connected in this way?

Frank Gilliam: There is no direct evidence for this yet, but I have seen many families that had both epilepsy and/or depression in different family members. My personal belief is that we will identify a familial relationship through further research, but we do not yet know.

Antiepileptic Medications: Do They Affect Mood?

Tracy: Can being on Dilantin or any anticonvulsants affect your moods after long term use?

Frank Gilliam: Most antiepileptic medications can cause mood or anxiety problems in certain situations. Valproate (Depakote) and Lamotrigine (Lamictal) are approved by the FDA for the treatment of bipolar disorder, but even they can cause mood or anxiety problems in some people. One thing I would like to emphasize tonight is that if a new symptom occurs after beginning a new medication or changing the dose, it is probably due to the medication.

Guest One: One question that I would like to see addressed is the relationship between thyroid hormones (which strongly affect one's mood among other things) and many, if not most, seizure medications.

Frank Gilliam: Medications that stimulate the liver to metabolize more rapidly (Dilantin, Tegretol, Phenobarbital) can change level of thyroid and other hormones. If symptoms of these changes occur (i.e., any new problems) you should discuss the possibility of changing medications with your physician.

Lori: Can medications after a long period of time affect your mood? In other words, can one develop any sort of dependency? I've noticed that if I miss my Dilantin and Depakote dosage I'm not always myself.

Frank Gilliam: In general, there is no dependency with the antiseizure or antidepressant medications. However, I usually recommend a slow wean from any drug to prevent withdrawal symptoms (which are usually irritability, nervousness, etc).

Merrick Bartlett: Is it possible that an AED's side effects can change over time? For example, could hormonal changes make a difference even after having good experiences with one certain AED?

Frank Gilliam: Yes, adverse effects can change over time, but this is uncommon on stable doses during a stable hormonal period of life. Menopause, renal and liver changes after age 55, and other factors are a different story, though; we should be aware that medication effects will probably change during these times.

Edward P. McMorrow: What antidepressant medication would be best with an already taken "cocktail" of Keppra, Tegretol, and Lamictal?

Frank Gilliam: In my opinion there is no "best" SSRI.

Barb: I have a question. I have a bad temper and am very irritable. Does that have to do with my seizure meds? Also, could depression have something to do with the medications? I take Keppra and Trileptal, but I also have asthma and allergies which I take medications for too.

Frank Gilliam: Levetiracetam (Keppra) may have higher rates of irritability and agitation than some other drugs. It is a potent drug for seizures, but should be used carefully in people with irritability.

Ephy: has there been much research regarding how seizure medications interact with other meds?

Frank Gilliam: Fortunately, most SSRIs have minimal interaction with seizure meds, but there are exceptions so please discuss with your doctor.

Tina: We thought my daughter had ADD, but I feel her irritability is related to the Keppra. I would never stop her taking it, but I would like to add an anti-depressant instead of Adderall, which is not effective with her moods. Is this too much for an 11 year old?

Frank Gilliam: In my opinion, it is worth treating an antiseizure medication side effect with another drug in certain circumstaces.

Antidepression Medications & Mood

Linda L. Mellish: What exactly does an SSRI do to decrease depression?

Frank Gilliam: SSRI block the re-entry of the neurotransmitter serotonin back into the cell, so more is available to do its job at the receptor site.

Linda L. Mellish: So are you saying, then, that because the seizures occur due to the mis-fire or over-fire of the neurotransmitters, that this affects depression in people with epilepsy?

Frank Gilliam: This may in fact be the case for some people, but certainly not all people, with epilepsy.

Anna: Is it possible to avoid further medicine after depression is identified?

Frank Gilliam: There are several forms of therapy that are usually provided by a psychologist (cannot prescribe drugs) in collaboration with a psychiatrist (can prescribe). The most commonly used is cognitive-behavior therapy. This can be highly effective, and is recommended by the American Psychiatric Association as an alternative treatment option if the physician or patient does not want an SSRI.

Carol Staats: In your medical opinion, could taking Seroquel, Zoloft and Verapamil increase seizure probability?

Frank Gilliam: Possible, but not common in my experience. I want to be very careful with this issue, though. In some patients Seroquel or Zoloft could change seizures. I am about to complete a large randomized comparison of Zoloft and cognitive behavior therapy, so I hope to have more detailed information soon. My current practice is to use SSRIs as necessary to treat the depression.

Therapy

Linda L. Mellish: What type of cognitive behavior therapy? I mean what happens in those sessions to decrease seizure? Or are we gearing that more toward assisting the accompanying depression?

Frank Gilliam: The sessions are targeted to treat the depression, not the seizures. It is possible that improving depression will improve seizures, but this is not yet known.

Catherine Kane: We are very encouraged to see all of the questions you are sending in.

Epilepsy & Depression

Robert: My depression got so bad in the last year and a half that I even considered taking my life 22-3 times when in fact each time I checked myself in at the hospital for treatment. Is this common for Epileptics? I am asking you this because never in my entire life have I ever been that depressed before. I have a very supportive family etc. very close family. I am now out of harms way!

Frank Gilliam: Unfortunately, the proportion of deaths due to suicide in persons with epilepsy is 10 times greater than the general population.

Sylvia: Do most neurologists automatically screen for depression, considering the high rate of depression among epileptics?

Frank Gilliam: No! The Epilepsy Foundation has developed a Web page to allow persons to take a screening test themselves and take to there doctor... very progressive.

Catherine Kane: The Epilepsy Foundation's tool, which was developed under Dr. Gilliam's guidance.

Danny: I heard that after a patient has had a VNS for a few years it could start to work on his/her depression like ECT after being in ater a few years. Is that true?

Frank Gilliam: The FDA recently approved VNS for depression that has not responded to medications. We are still studying it for depression in epilepsy. A very large European study is underway that should give us guidance within the next three years.

Maxwell: I have epilepsy. Is it normal to be depressed?

Frank Gilliam: I went back to some earlier questions to be fair...Let me be clear, although depression may be predictable in many persons with epilepsy, it is not normal and should not be tolerated by the medical community. Depression in epilepsy should be treated as the potentially disabling disorder that it is.

Maxwell: I told my doctor about headaches and dizziness. He asked if I was depressed, I said no and then he blew me off. Is it depression?

Frank Gilliam: It could still be depression. Many people with epilepsy and depression do not experience "depressed" or sad feelings, but rather loss of interest and enjoyment of common activities. The diagnosis of depression can be based on EITHER. This may be particularly important in temporal lobe epilepsy.

Lorie Ricks: Can multiple life issues overshadow epilepsy symptoms giving a false impression that it is the medication when the moods are a reflection of circumstances faced?

Frank Gilliam: My belief, after 15 years of practice and also emerging research data, is that the life circumstances may contribute to, but do not cause, depression.

Linda L. Mellish: What type of "brain problems" is your research finding that would suggest a causality between depression and epilepsy?

Frank Gilliam: Injury to the hippocampus in the temporal lobe, increased activation of areas of the prefrontal lobe, and changes in serotonin binding to receptors outside of the seizure onset zone. These are probably specific to the type of epilepsy.

Merrick Bartlett: Are there some types of epilepsy more prone to depression than others?

Frank Gilliam: I thought so several years ago, that is that temporal lobe epilepsy was a greater risk and absence epilepsy was less, but emerging evidence suggests that this may not be true.

Donna Palski & Ryan Carson: Is easy irritability a good indication of depression?

Frank Gilliam: In my opinion, in the setting of epilepsy, it may be a major or primary symptom.

Robert: Can epilepsy without depression cause behavior traits mimicking depression?

Frank Gilliam: Yes, especially medication side effects. The NDDIE on the Epilepsy Foundation website is an attempt to get around this problem.

Guest 4: I fear that if I had a diagnosis of depression, my doctors would treat me differently--possibly chalk up any problems I have to the depression. How can a patient receive treatment for depression, yet not lose credibility or dignity?

Frank Gilliam: This is a main purpose of our research to: to educate physicians to UNDERSTAND depression in epilepsy and empower persons with epilepsy to advocate for themselves. I understand the difficulty of your situation, but we must ask the medical community to show respect the dignity of all patients...especially with depression!!! I really wish you the best in this.

Linda L. Mellish: I hear what guest4 is saying -- so many times I've asked questions of my son's physician and received no response; or even worse you become the "you know what" mom because you're trying to be an advocate for your child.

Frank Gilliam: Please continue to advocate...hopefully the neurology community will catch up with you.

Guest 5: Is it normal to feel crazy and disoriented after a seizure and severe crying spells

Frank Gilliam: Yes, but usually not more than an hour or so. If your "postictal" period lasts longer then you should emphasize this to your MD. Not that lasting an hour is OK, it is just more common.

Epilepsy Surgery & Mood Disorders

Pat Hair: I have Epilepsy in the right temporal lobe and am under pre-surgical evaluation. Could epilepsy surgery help ease depression?

Frank Gilliam: It is premature to include depression in the decission for surgery, but our group and other groups have published significant improvement in mood after epilepsy surgery. However, 10% of people may have worsening of mood after surgery.

Cindy H.: I deal more with anxiety and depression since brain surgery, is this common?

Frank Gilliam: It is not common, but is known to occur in a small proportion of patients. It should be treated.

Cindy H.: The good news is I have been seizure free for 4 years since the surgery, and only take 200mg Lamictal

Frank Gilliam: Wonderful!

Epilepsy, Mood Disorders & Specific Populations

Sylvia: Do your studies show that women suffer more from depression due to PMS and hormonal issues?

Frank Gilliam: No...very interesting question. Although depression is twice as common in women than men in the general population, it is equal in persons with epilepsy. On the other-hand...PMS and hormones may effect seizures or depression in some women with epilepsy.

Bill: How do you differentiate the teenage deal with real depression?

Frank Gilliam: Very tough question...If you feel that mood or behavior is interfering with school or extracurricular activities, I would recommend an evaluation by an adolescent psychiatrist. Although this is a volatile time of life, it is also a time that we do not want to be affected by depression.

Catherine Kane: Be sure to visit the Mood Disorders section of our website for more information.

Conclusion

Guest: Just a comment - I feel that this type of dialogue is so important to everyone touched by epilepsy - family, friends, co-workers

Frank Gilliam: Thank you...I am writing and thinking as fast as I can...the positive comment will keep me going!

Catherine Kane: As you all can see, our expert is very enthusiastic about the topic. We appreciate your patience as he utilizes not only his medical and subject matter skills, but also his typing skills, to respond. :)

Douglas: Is there a website or office to contact you or Mrs. Kane another time maybe to propose another event?

Catherine Kane: Douglas, this is a great question. We are already looking into future events. Please contact Erika Mabry, Program Manager, at emabry@efa.org with your suggestions and input.

Linda L. Mellish: You can tell by the number of people typing that we all appreciate your time, Dr. Gilliam; we are thirsty for knowledge for ourselves, our children.

Catherine Kane: Well stated!

Bill: Not a question, but a comment: Dr. Gilliam, I heard you speak in 2000 at U.C. Davis in Sacramento. You were the only hopeful person who I heard that day, shortly after my 23 years old son was diagnosed with epilepsy. I'll never forget you. I'm so grateful to have heard you speak. From the bottom of my heart, thank you.

Catherine Kane: Thanks for the compliment, Bill. I'm sure even an accomplished doctor like Dr. Gilliam appreciates positive feedback like this. We hope your son is doing well!

Catherine Kane: I'm sure some of you are also watching the time and realizing that this evening's chat is coming to a close. I want to re-emphasize that we will be collecting all of the questions submitted this evening and forwarding them to Dr. Gilliam for inclusion in the transcript if his schedule permits.We are already looking into scheduling another event, as well.

Catherine Kane: Also, we hope you will consider visiting and joining our online support group, called eCommunities. This online discussion forum is active 24/7, and it is a welcoming community where you can discuss your feelings with other people who may have similar experiences.

Catherine Kane: We would like to express our deep appreciation to Dr. Gilliam for volunteering his time to discuss this very important subject. His dedication and enthusiasm are easily seen in his responses here. We would also like to thank Cyberonics, Inc., for their sponsorship of this online chat. And most importantly, we want to thank you, our members and supporters, for your interest and participation. For more information, send an email to Erika Mabry at emabry@efa.org.

Linda L. Mellish: Thank you, Dr. Gilliam for listening and responding.

Frank Gilliam: Thanks to you all. I wish each of you the best until our next chat.