Online Chat Transcript: Mood Disorders and Epilepsy

Posted: November 5, 2002

Does epilepsy impact your mood? Or could depression or anxiety be a side effect of the epilepsy meds? This chat offered some answers to these questions and some coping strategies for depression, anxiety and other mood disorders.

John Barry, M.D. is an assistant professor of Psychiatry and Neurology at Stanford University Medical Center. He presently runs the neuropsychiatry clinic and the individual psychotherapy clinic for the residents. His main interest is in the interface between neurology and psychiatry especially related to people with epilepsy.

Peggy Friel has been employed for more than 20 years as a social worker with people with epilepsy. For the past 10 years, she has been employed at the Comprehensive Epilepsy Center at Swedish Medical Center in Seattle, Washington.

Admin Hello and welcome to tonight's event with Dr. John Barry and Peggy Friel. Please take a moment to read their biographies on the top half of your screen and feel free to ask questions at any time by typing /ask followed by your question. We'll also be posting a transcript of this event in the next day or two... Tonight we're taking a mix of live questions from you, the audience, as well as questions submitted from users through our website. We won't get to everyone's questions tonight, but we should be able to provide a good overview of the subject. Of course, if you have specific questions about your experience or that of a family member, please bring it up with your doctor. We'll get to people's specific questions in a moment... but I was wondering if each of you could begin with a quick overview of the issues associated with epilepsy and mood disorders.

Dr. Barry I think the major issues that are extremely important for people to recognize is that depression is frequently associated with epilepsy. The rates vary between 11 and 60 percent depending on what criteria you use. The average, using diagnostic techniques that have been well verified, range around 29 percent for a Major Depressive Disorder (MDD). The depressions associated with epilepsy are also often severe and associated with an increased suicide rate. In addition, depressions in people with epilepsy are frequently missed and in nearly 50 percent of cases, not treated. Depression in people with epilepsy can be associated with AEDs use, either because of possible toxicity of the medication or because of the effects of the medication on seizure frequency itself. It's therefore important for people with epilepsy who are put on an AED to pay attention to the new onset of a mood disorder. It's also imperative that if this does occur that a discussion with your doctor ensue -- either a neurologist or a general practitioner, and that the causes of the depression are investigated and appropriate interventions are taken. These interventions may take many forms -- the first may be an investigation of any medical cause. In addition, many psycho-social issues also manifest in the course of attempting to deal with a chronic medical illness. These factors need to be analyzed as well.

Peggy Friel Epilepsy often causes problems for the person with the disorder and their loved ones. The person with epilepsy may mourn the loss of independence and resent the restrictions on their activities. They may dread having a seizure because of embarrassment or possible injury. Family members can be torn between wanting to respect the person's independence and the urge to keep them safe from harm. Epilepsy can affect employment, driving, income and social relationships.

Dr. Barry There are several types of psycho-social interventions that may be extremely useful. They would include individual, couples, family and group intervention. If the depression continues, and it's important that we define what we mean by depression -- depression that requires treatment would be a consistent feeling of sadness associated with difficulty sleeping, decrease in appetite, difficulty concentrating, low energy as well as feelings of hopelessness, worthlessness and sometimes feeling that life isn't worth living. Some of these features of depression can be associated with the side effects of medication. However, one feature of depression that does not seem to result as frequently from medication is an inability to enjoy life, called anhedonia. If present, the presence of a depression needs to be investigated. If these symptoms are persistent and severe and are not affected by psycho-social intervention, then anti-depressant medications are possibly indicated. Anti-depressants can be very effective treatments for depression in people with epilepsy. They all, however, have the potential of decreasing the seizure threshold to some degree. Some anti-depressants decrease the threshold to an unacceptable level and therefore should be avoided. There are others, however, that seem to be relatively safe in people with epilepsy. However, even these can increase the seizure frequency and vigilance is required.

cbacon In treating complex partial seizures and depression, which anti-depressant is most likely NOT to lower the seizure threshold? Also, are there different concerns when treating younger patients?
Dr. Barry All of the anti-depressants decrease the threshold some. However, the serotonin reuptake (SSRIs) inhibitors are probably the safest. For example: sertraline was found in one study reviewing its safety in 100 patients, to be safe and effective. However, the medication did have to be discontinued in one patient because of a definite increase in seizure frequency. In young adults and children, the effectiveness of the SSRIs, which are felt to be fairly safe in people with epilepsy, have only a small amount of literature to document their effectiveness. We just don't have as much information in young adults about the effectiveness and side effects of these medications. The presumption, however, is that the same principals would apply, but further research is needed.
Peggy Friel Epilepsy can present special challenges to young people as it impacts mastering the normal developmental tasks of childhood. Seizures and medication can have a negative effect on behavior, energy level, and ability to listen, concentrate and learn. When children want to make friends and have activities outside the home, they may feel limited by seizures. Parents have the difficult job of balancing the need for safety with the need for increasing independence. For example, epilepsy can complicate issues during adolescence such as driving, experimenting with alcohol, dating, obtaining first employment, and moving away from home.

Criselda Someone told me not to take St. John's Wort if I'm having seizures, is this right? If so, what would happen if I did?
Dr. Barry First, the question is... are these medications effective? For depression, for example, there are some studies that have found St. John's Wort to be effective for mild-to-moderate depression. Other studies that have shown it to be ineffective. There's also a concern about interactions between AED's (especially phenytoin, carbamazepine and phenobarbital) and St. John's Wort. That makes its use potentially complicated in people with epilepsy. I think that there are other alternatives that have been tested where interactions are clearer and effectiveness better documented. I would recommend using medications that are known rather than take chances with medications (and remember that herbals are drugs) that we do not know well.
Peggy Friel The recent Epilepsy Foundation National Conference included a symposium on alternative therapies. A tape of this presentation is available for purchase through the Epilepsy Foundation.

TB Are mood changes directly proportional to doses? Which drugs, if any, most commonly affect mood in a positive way? Which drugs most commonly affect mood in a negative way?
Dr. Barry AEDs can affect mood both positively and negatively. The medication that we're mostly concerned about affecting mood adversely would be phenobarbital. Other AED may also cause negative mood effects -- the best rule of thumb to use is temporal relationship. In other words, if an AED is started and a depression occurs within several weeks after its introduction, then the drug itself might be implicated as causing it. It's also important to note that some AED's do have positive mood effects, the extent of which is unclear at the present time. However, medications like lamotrigine had, in the original studies validating its effect on seizure frequency in people with epilepsy, effects on both seizure control and also a positive mood effect. This resulted in both improved sense of well-being and resultant quality of life. Phenobarbital can cause depression. It can cause irritability and can cause behavioral disturbance, which is often seen in children. One particular study, for example, in a phenobarbital group, the rate of depression was 40 percent with suicidal ideation in 47 percent. Depression decreased when the medication was changed to carbamazepine.

Jimbo Hey Peggy. Under what circumstances would a person contact a social worker? How do I find one in my area?
Peggy Friel A social worker can be helpful by providing emotional support and counseling and by assisting with practical matters. Counseling can address such issues as mood disorders, marital and family relationships, dealing with a disability and the loss and grief from changed life circumstances. A social worker can help locate community resources to deal with issues such as job loss, the need for medical coverage or sheltered living. A social worker might help a child deal with epilepsy at school by educating school personnel and providing information to the parents about accommodations. A social worker can work with the family to assist the child to feel comfortable discussing issues about epilepsy with peers. Social workers may organize support groups where parents and children can meet other people who are facing similar issues. You can obtain a referral to a social worker in your area from the National Association of Social Workers. The website is www.naswdc.org.

mary1 Carbamazepine is Tegretol; Oxcarbazepine is trileptal (right?)
Dr. Barry Yes, that's correct. Carbamazepine has been used for people with bipolar disorder and can be quite effective and Trileptal may be effective as well for people with bipolar disorder but has not been investigated as extensively.

Frank Do these anti-depression drugs cause any loss of memory as AED's do?
Dr. Barry AED's can cause cognitive side effects with some medications, such as topiramate (topamax) where significant cognitive side effects can result, especially if the dose is rapidly increased. Many of the AED's also have cognitive side effects and the same caveat that was mentioned before in reference to mood disorders is applicable here as well. In other words, if, at the start of an AED you start to have significant cognitive complaints, it might be related to the initiation of the medication. Examples of cognitive complaints would include inability to think clearly, losing their train of thought, memory disturbance. If that happens, a change of medication, if possible, might be indicated. Some families of antidepressants can cause memory side-effects. For example, tricyclic antidepressants may have significant anticholinergic effects that may result in memory dysfunction. Others, like the SSRIs, have much fewer complaints regarding memory disturbance.

Jillbob My sister had surgery at Beth Israel Hospital in Boston to relieve seizures resulting from left temporal lobe epilepsy. That was two years ago. Now she thinks the government is after her and that a conspiracy involving her family, the government and the internet is after her. Is this from the surgery?
Dr. Barry It sounds like your sister developed a psychotic disorder after her surgery. This reaction has been described in literature after temporal lobe surgery. It's unclear whether it's from the surgery itself or possibly from the control of the seizures that she was experiencing. For reasons that are unclear to us, sometimes people with epilepsy that have their seizures under good control can develop psychosis and depression. Under those circumstances, it's important to treat the target symptoms and most often that can be done effectively with psychotropic medication.

Wendy My name is Wendy, I am 32 years of age. I am a single parent and currently disabled. I have many illnesses going on but some how think they may all be connected. I am on so much medication to treat these different problems and wondering if this could contribute to my present concern. I was diagnosed with arthritis and neuropathy in my TMJ. I have had a total of four surgeries bilaterally. The doctor wanted to put an artificial joint in on the left side, I declined. I now drive to UCLA once a month and they inject morphine into my joints, once every few months they will add steroids. This does not get me out of pain, it only makes it manageable. They also have me on 3600 mg of Neurontin q.d. As a result of my jaw condition I now battle with migraines. When I have one I have to inject myself with DHE, this med seems to be working. I have suffered from endometriosis for 12 years which resulted in a hysterectomy. The doctor screwed up my surgery, I have had two repair surgeries since and have two more to go. I also suffer from insomnia in which I take Ambien every night. This is just a peek at my medical history and I feel this some how contributes to seizures that I started having 1 1/2 years ago. These are full body convulsions, but I am aware of what is happening during these episodes. I would at times have up to 5 a day, I did stop breathing on 2 occasions. They ran every test imaginable and then some. My heart was checked, I had an EEG, I had an MRI, CT scan, and the standard blood tests. I was accused of being a street drug user (which I have never done illegal drugs in my life). I have seen a neurologist, psychiatrist, and many other doctors. My final diagnosis was severe panic attacks and prescribed Xanax. I do not buy it. I have not had a "seizure/panic attack" in about 4 months, but I feel it is now manifesting itself in a different way now. The only way I can describe it is like having mini seizures. I visited the neurologist today and he is ordering an EEG. I think he is missing something, what I don't know. He does not seem real concerned and kind of dismissed the issue. I however am very concerned and want an acceptable answer. I don't buy the panic attack theory. I have had panic attacks in the past and should know the difference.
Peggy Friel If your seizure-like episodes return it would be helpful to determine if these are epileptic seizures or non-epileptic psychological episodes. An epileptic seizure is caused by abnormal electrical discharges in the brain while non-epileptic seizures are psychological in origin. It is important to get an accurate diagnosis because the treatments are different. Hospitalization at an epilepsy center for continuous EEG monitoring which records one of your episodes, can help diagnose your condition.
Some psychological non-epileptic seizures do not feel like panic attacks -- the stress and pain caused by enduring complicated medical conditions can sometimes predispose people to non-epileptic seizures.
Dr. Barry People who experience non-epileptic seizures often have histories of intermittent chronic depression and trauma in their background. I would agree with Peggy, however, that the diagnosis needs to be clarified.

Sueb Are the cognitive side effects by AED's usually permanent?
Dr. Barry No. They're a side effect of the medication. Therefore, changing the dose or changing the medication would probably change the cognitive side effect.

Denise How do mood disorders coincide with EEG's? Are they detectable?
Dr. Barry Not at the present time. There are certainly functional central nervous system changes that take place in the brain as a result of depression. For example, the frontal lobes of the brain do not work as well in people with depression -- including those with epilepsy. Some of these changes can be detected using other tests, like functional brain imaging. That may explain why cognitive and memory complaints are very common in people with depression.

marylyn Can the abrupt discontinuation of Prozac trigger a seizure?
Dr. Barry Prozac is a medication that stays in your system for up to 5 or 6 weeks. Therefore, although I don't recommend that any antidepressant be discontinued abruptly, especially if it's working, physical withdrawal types of side effects should not take place with the abrupt discontinuation of Prozac. In contrast, medications like paroxetine (paxil), and sertraline (zoloft), can have some physical withdrawal effects if discontinued abruptly. However, a seizure disorder should not be made worse by their abrupt discontinuation.

Admin Well... I'm afraid our time here has come to an end for the evening. Do you have any closing thoughts?

Peggy Friel Mood disorders in people with epilepsy are often unrecognized and so go untreated leading to unnecessary suffering. I encourage people with epilepsy who are experiencing mood disorders to seek help from their neurologists and the mental health services in their communities.

Dr. Barry I would reiterate all the above and just close by saying that mood disorders in people with epilepsy can be treated effectively. There is hope. Also, the effective treatment of mood disorders can possibly help control seizures as well.

Admin Well... thanks for coming out tonight. Of course, we'll be posting a transcript of this event shortly. And for those of you who did not get your questions answered, we're going to get them to either our guests or the Epilepsy Foundation's Information and Referral department.

Have yourself a good evening.