Mood Disorders

Epilepsy Foundation » Programs » Mood Disorders » Mood Disorders: Ask the Expert (December 2005/January 2006) 

Ask the Experts: 'About Mood Disorders' with John Barry, M.D.

John Barry, MD

Dr. John Barry is Assistant Professor at the Stanford University Medical Center. Barry is a psychiatrist who is dedicated to people with epilepsy, and how epilepsy is related to mood disorders. He serves on the Epilepsy Foundation's Board of Directors and Professional Advisory Board. Barry also co-chairs the Foundation's Mood Disorders Initiative.
(Photo courtesy: Stanford University)

Earlier this year, we asked our epilepsyfoundation.org readers to submit questions to John Barry, MD. The questions with his responses appear below:

Epilepsy's Relation to Mood Disorders

Epilepsy affects my mood and makes me feel as though I need antidepressants. I've found that since my brain has to work extra hard, this causes my mind to get fatigued. In return, can depression be a side affect or result of epilepsy?

Dr. Barry: It has been recognized for years that patients with epilepsy are more likely to develop depression, which may occur in more than 50 percent of patients. Depression is the most frequent psychiatric co-morbidity (unrelated, but commonly noted condition or disorder) in people with epilepsy with anxiety disorders more prevalent in some studies. Patients with complex partial seizures are particularly susceptible to depression.

Seizures or their etiology (cause or origin of a disorder) appear to predispose patients to develop depression. The lack of predictability of seizures and the stigma associated with epilepsy may also contribute to feelings of depression. The risk of psychiatric hospitalization for patients with epilepsy and depression is higher than for nonepileptic patients with depression.

Risks for depression include neurobiological (e.g., head injury, central nervous system infection, stroke), psychosocial (e.g., inability to drive, effect of seizures on interpersonal relationships, stigma, work), and iatrogenic (e.g. adverse effects of AEDs and other medical treatment). Specific features of epilepsy that appear to be associated with an increased risk of depression include auras of psychiatric symptoms, late onset of seizures, and multiple seizure types. Partial seizures and seizures of left temporal lobe origin have also been reported as risk factors, but these observations require confirmation.

Depression is the most common psychiatric complication following epilepsy surgery, and temporal lobectomy may result in de novo depression and suicide attempts. A history of depression may also be a poor prognostic factor for success of temporal lobectomy.

AEDs may be associated with negative behavioral effects, particularly the barbiturates (phenobarbital and primidone). The exacerbation or de novo (new) appearance of depressive symptoms should prompt an investigation of any negative side effects from a newly added or increased AED. Carbamazepine, gabapentin, topiramate, lamotrigine and levetiracetam may have negative behavioral effects in children with developmental delay. AEDs, however, may also have positive effects on mood (e.g., lamotrigine).

Depression contributes to the risk of suicide in patients with epilepsy, particularly in patients with complex partial seizures originating in the temporal lobe. Suicide is more common in patients with refractory epilepsy and patients who are psychotic. Among the AEDs, barbiturates have the strongest association with suicide and should be avoided, when possible, in people with epilepsy at risk of depression.

My mom has epilepsy and she has been very, very moody. It's not the normal type of moodiness you would see, either. She is happy one second, mad the next and then back to happy... things like that. Is that normal or should I try to get her to a doctor for help?

Dr. Barry: I think that you should get help with a full evaluation. It sounds as though your mother could use an evaluation and perhaps psychotherapy and/or psychopharmacological intervention! Her mood variability could be part of a mood disorder like Bipolar Affective Disorder (BAD).

My sister was diagnosed with epilepsy at age 10, and has had an eating disorder since age 14. Before the onset of her eating disorder, she always had a ton of friends and was never teased or bullied for having epilepsy. Is it possible that the epilepsy and depression/eating disorder are related?

Dr. Barry: Epilepsy and depression have a relationship. Eating disorders are also associated with depression. Whether there is an independent association with epilepsy is unclear.

Can you explain the relationship between subictal activity and Interical Dysphoric Disorder? Also, how it is treated?

Dr. Barry: D. Blumer has emphasized the pleomorphic pattern of mood complaints in epilepsy and coined the term "interictal dysphoric disorder" (IDD). The symptoms have an intermittent course and can be categorized into depressive-somatoform and affective symptoms. The depressive- somatoform symptoms include (i) depressive mood, (ii) anergia, (iii) pain, and (iv) insomnia. The affective symptoms include (i) irritability, (ii) euphoric mood, (iii) fear, and (iv) anxiety. Unfortunately, there are no direct comparisons in the literature evaluating depression in a PWE using standard diagnostic techniques with those yielding a diagnosis of IDD. It is possible that a spectrum exists with a chronic dysthymic state characterized by the features of the IDD that may intermittently exacerbate and at that time meet criteria for MDD. The IDD is treated in a similarly to MDD with psychotherapy and medication (refer to Barry JJ. Epilepsia 44(Suppl 4)30-40.2003).

My seizures began while I was working in the dental field. As a result, I stopped working for a year, started taking medication and eventually reduced my seizures. In December 2005, I went back to school. Three days afterward, while in bed, I felt my seizures return at 4 a.m. Could going back to school be too much stress for me or my brain?

Dr. Barry: I certainly think that it may be a stress and certainly stress can be associated with an increase in seizure activity. That said, however, you have to live your life and school is potentially a big part of that. I would get a referral to a mental health professional who could recommend a course of treatment for the stress.

My son has epilepsy. He has no health insurance, thus he cannot receive the care he needs. He suffers chronic depression, auras and grand mal seizures. He has lost jobs and has become a recluse. I would like to know what funding is available to get him the proper care he needs and get him on track. He feels a sense of hopelessness. Where can he get the support and medical care he needs? He needs test updates, possible change of medication and emotional support. What is the best program for a holistic support system and how can he get funding for it?

Dr. Barry: Contact your local Epilepsy Foundation affiliate for programs in your area and local support. You can find the affiliate nearest you by visiting www.epilepsyfoundation.org and selecting Your Community.

Also, on the Epilepsy Foundation's website, the Answer Place has information that addresses health insurance and employment issues.

My daughter has been doing a lot of hand wringing and teeth grinding, and recently it has escalated. She now clenches her jaw so tightly that she shakes and bites through her skin atop her hands, and she'll also bite through her lips. It is so intense that she crosses her eyes, sweats and shakes and no one seems to know what is wrong? Any ideas? This has been going on for about six months and has slowly increased to this bleeding point. She has CP, EP and developmental delay. She cannot speak and her cognitive ability is that of a 9 month old child. These are causing her to have mini-seizures and we are very concerned parents.

Dr. Barry: I would want to be sure that these are not seizure-related and discuss this with your neurologist. From the psychological point of view, often people with poor verbal abilities express their psychological distress somatically. I would thoroughly check for any psychosocial issues that might be bothering your daughter and change the situation if possible.

If something doesn't go the way I want it to I tend to get depressed immediately. I would describe myself as "moody." Is this part of the epilepsy, even though mine is controlled?

Dr. Barry: Epilepsy can certainly affect one's mood and level of irritability. However, I would suggest that you see a counselor who is familiar with epilepsy, if possible, and have him or her evaluate you and your psychosocial situation.

My son has been seeing a therapist for what we think is anxiety. He was diagnosed with epilepsy at age 3. Is this anxiety related to him having epilepsy or from dramatic events related to having seizures and their effects on him physically?

Dr. Barry: Unfortunately this is a difficult question to answer. The answer is probably that both are right. What the contribution is from each weight of each factor is on each person is is probably very individualized.

My son has Smith-Magenis Syndrome with left frontal seizure activity. How does frontal lobe seizure activity affect behavior? How does it differ from temporal lobe seizure activity? Are there any natural, homeopathic substances to be taken that will help reduce the excitability and irritability of the brain?

Dr. Barry: Seizures of frontal origin may have excessive movements of the arms and legs, associated with bizarre vocalizations with the person appearing to be awake and responsive. I would refer you to publications by Steven Schachter, M.D., regarding herbal products. (Editor's Note: See Dr. Schachter's article on our site.)

My 17 year old son, who is mentally challenged, has become increasingly aggressive when he does not win a game. Could a young person's epilepsy induce aggressive feelings? What resources would you suggest where we could investigate this issue further?

Dr. Barry: Epilepsy can be associated with irritability which might lead to poor frustration tolerance and aggression. I would suggest seeing a psychiatrist who could evaluate the psychosocial situation and help clarify the problem and suggest either medication or a psychotherapeutic intervention.

Does having epilepsy cause deep anxiety or increased stress levels in one's mental state after a seizure? I have been told that my attitude changes quite noticeably.

Dr. Barry: Patients may experience alterations in mood during a seizure (ictal), which may include manic or depressive symptoms. Changes in mood may occur days before (prodromal) or after a seizure (postictal). Postictal depression may last a day or more and may be accompanied by suicidal ideation. Periictal mania is rare.

How does epilepsy display itself in mood alterations? What are the different types of mood disorders associated with the condition?

Dr. Barry: The most common mood disorders in people with epilepsy are major depressive disorder and dysthymia. The lifetime-to-date prevalence of major depressive disorder in people with epilepsy ranges from approximately 8 to 48 percent, with a mean of 29 percent. A comparison of 775 people with epilepsy from the community to 395 people with asthma and 362 healthy controls using the Center for Epidemiologic Studies Depression (CES-D) Scale revealed that 36.5 percent of the epilepsy group had positive findings, compared to only 27.8 percent of the asthma group and 11.8 percent of controls.

Some patients with epilepsy may have depressive symptoms that fail to meet the criteria of major depressive or dysthymic disorder, but may still respond to treatment. Because of the intermittent and pleomorphic nature of these symptoms, they may often be overlooked. Mood changes may also occur peri-ictally, with a deterioration in mood occurring up to 72 hours prior to a seizure and lasting up to 3 days postictally or more. Depressive symptoms may increase postictally and include suicidal ideation. Systematic screening of people with epilepsy for mood disorders will help insure that affected patients receive needed treatment.

People with a Dysthymic Disorder have symptoms that are similar to those of major depressive disorder and include changes in appetite, sleep, decreased energy or fatigue, low self-esteem, poor concentration or difficulty in decision-making and feelings of hopelessness. Symptoms are persistent and present for most of the day more days than not for 2 years or more. The patient does not have major depressive disorder or bipolar spectrum disorder, and symptoms do not occur only during psychosis or are substance induced.

The data regarding the incidence of Bipolar Affective Disorder are limited, but it appears that there may be an increased frequency in patients with epilepsy. In one study, 8.1 percent of epilepsy patients met criteria for bipolar spectrum disorder (subtypes of BAD) using the Mood Disorder Questionnaire (MDQ), which was 6.6 times higher than healthy controls and 1.6-2.2 times higher than people with migraine, asthma, or diabetes. In a retrospective study of patients with temporal lobe epilepsy seen on a consult service, 5/25 (20 percent) met criteria for bipolar affective disorder. AEDs may rarely induce hypomania (i.e., zonisamide).

My daughter has complex partial seizures. She recently moved back home after being away for six months. She has been without health insurance since the summer of 2003 and I have been paying for her medication. As she continues to have seizures, she needs a full workup. She needs a form of medical assistance to get it. How can I go about getting this, as well as help with the cost of her medications?

Dr. Barry: Contact your local Epilepsy Foundation affiliate for resources in your area and local support. 

Issues with Medications

Does epilepsy impact your moods? Does epilepsy or the medications for the epilepsy, stress and depress me? Sometimes I look at old wooden homes, or things that remind me of my past farm life, and feel that funny, nauseated aura that comes before the partial complex seizure.

Dr. Barry: Yes, epilepsy can be associated with depression and the medication used to treat epilepsy can be associated with both negative and positive psychotropic effects. Many people with epilepsy do note an increase in their seizure frequency with stress and depression.

My daughter has had uncontrolled epilepsy for four years. Her physician does not want to continue her Prozac and has increased her dose of Lamictal. When she takes this medication she becomes withdrawn and cries a lot without the antidepressant. He is afraid that this medication will increase the likelihood of her later committing suicide. Is the medication the cause of her depression and anxiety, or is it something else?

Dr. Barry: If depression is associated with starting a drug it may be due to that drug. If there is no alternative and switching to another drug is impossible than treating the depression it with an antidepressant is reasonable. Caution is always needed, however, after starting any medication and antidepressants are no different. Close observation is needed but the lack of treatment for a depressive disorder is also dangerous and can adversely affect overall quality of life.

Generally, there is more danger of suicide from not treating a depression than the potential side effects of antidepressant drug treatment intervention.

I was diagnosed with epilepsy at age 13. I was on Tegretol for a long time and finally started managing my epilepsy drug free. The Tegretol was causing cloudiness of thought and mood swings. I have been off my medication for five years now, but the mood swings have returned. They get so bad that I cannot control them. Are mood swings normal with epilepsy? I also have no healthcare benefits and a restricted income. Can you point me in the direction of some agencies that help people in my situation? My mood swings get so bad I sometimes get scared for what might happen.

Dr. Barry: Since you are now having mood swings once again, it might be that they were not caused by Carbamazepine, however the medication didn't control it either. I think that it would be important for you to see a psychiatrist for an evaluation. Mood swings can be seen in people with epilepsy. Whether it is caused by the disease or associated with it is unclear. I n addition, I would also consult with a neurologist about your seizures since the return of mood swings may be associated with seizure activity even without your apparent awareness.

People without funds may be seen in a government sponsored mental health clinic. I would start by calling one in your area and I suggest that you do it soon! .

My brother recently had his medication dosage increased, and he takes about 200 milligrams of Topamax and 1500 milligrams of Keppra to help control his seizures. Lately we've noticed he at times is very easily agitated and becomes very angry, to the point of concern for physical violence. He yells loudly, and he repeats himself. Could this be a side effect of the increased dosage? Any suggestions as to questions we could ask his neurologist? Could the head trauma he once suffered be the cause of this?

Dr. Barry: When a medication is started and a mood change is noted subsequently it is certainly reasonable to consider the medication as a possible cause. I would bring this up with your neurologist ASAP.

I took Depakote for years, beginning at age 19. Then, about a year ago, I changed to Zonagran. I have had no grand mal or petit mal seizures over the years. It took me some time to adjust to Zonagran, but there don't appear to be any side effects. About five years ago I was diagnosed with depression and I am now taking Zoloft every day. As a result, my mood shifts sometimes. I have crying episodes every once in a while, and sometimes I feel sad. Are the emotions I am having initiated by my epilepsy, or by the Depakote I took over the years?

Dr. Barry: My rule of thumb is that when you start a medication watch for any changes in your overall mood , since it may be due to the drug. This is applicable for AEDs certainly as well. . You have been taking the Depakote for many years and presumably have not had any side-effects from it and developed the depression before the Zonegran was added. I doubt it is the medication. The depressive symptoms that you are having now could be from mild epilepsy and its psychosocial effects on you or may be due to other things including a lessening of the effects of Zoloft. You also mentioned mood shifts and I would want to know more about that as well. I would check with a health care professional and be evaluated again.

I'm sometimes very depressed after seizures. Sometimes I'll talk to people and just start crying. I asked my neurologist about this and he said the temporal lobe is involved with emotions, so it's not unexpected. Sometimes I'll unconsciously say things that make people mad. I take four antiepileptic medications, and I can't tell if it's a side effect.

Dr. Barry: It may be that you are having postictal (after a seizure) depression. Mood changes associated with seizure activity is common and postictal mood changes can be serious. Although we do not have much data on this, if the seizures cannot be stopped by a medication change and they are not associated with a medication change, then treating it with an antidepressant would be reasonable.

My daughter takes Trileptal and when the dosage was increased she had restless sleep patterns with talking and walking in her sleep. The doctor feels the drugs haven't reached therapeutic levels and she may have an underlying mood disorder. I see no evidence of a mood disorder. She has been diagnosed with left onset with rapid generalization. Her seizures, though, seem more like body tics. She is aware of them and doesn't loose consciousness. What type of epilepsy might this be, and should I see a psychiatrist as her doctor suggests?

Dr. Barry: It sounds as though you have a series of questions that should be directed to your neurologist. I would start with her/him first. One important point here, make sure that when you go to your doctors office you have your questions in hand and make sure that they are answered and that you understand what is being said before you leave. If questions come up afterward, call and get them answered.

Can the drugs Zonegran and Tegretol-XR, particularly when taken in high doses, cause depression or anxiety in a person with epilepsy?

Dr. Barry: All AEDs can be associated with negative psychotropic effects. A change in medication may be indicated.

I was diagnosed with epilepsy at 16 and am now 23. Some time ago, I had a few focal seizures and have since been on Carbatrol. I haven't had a seizure since. In my opinion, I had seizures due to stress – my parents were divorcing. I have been thinking about coming off or at least lowering my medication since I haven't had a seizure in a long time. Does this sound like a good idea?

Dr. Barry I think that this question should be answered by your neurologist. There may be many factors here that need to be taken into consideration but I would not decrease your medication without the input of your neurologist.

Are there any antiepileptic medications that may produce hallucinogenic or psychotic side effects?

Dr. Barry: Psychosis has been seen as a side-effect in several AEDs. Some researchers in the area have noted that as an unusual association of having "normalized" EEGs in some PWE, psychotic symptoms can be seen. This is a rare phenomenon however and debated in the literature.

Have you heard of any cases where Trileptal and Depakote combination therapy caused problems?

Dr. Barry: If you are referring to psychological problems, I don't think that the combination has any unique side-effects but certainly drug-drug interactions can be found and the points made above are useful here as well. Note that any time polypharmacy is used more potential additive side-effects may result.

I'm taking daily doses of 400 milligrams of Dilantin and 100 milligrams of Lamictal. Would these levels of prescribed medications be considered high or low doses?

Dr. Barry: Serum drug levels can be done to determine the answer to this question. The phenytoin dosage may be high and the lamotrigine dose may be low.

My daughter has had seizures since age 3. Now at age 14, she mostly has partial complex seizures with status epilepticus occurring about every six weeks. The seizures she has during school have been labeled non-epileptic seizures, as they cannot be captured by ambulatory EEG. I recently witnessed an event and agree that it was not a "real seizure." We have been seeing a psychiatric counselor for about six weeks. I know the process is slow, but the events continue in the meantime. Any suggestions on how to proceed with treatment? Can these events be caused by the medication she's on: Dilantin and Zonegran?

Dr. Barry: Ambulatory EEG may not be sensitive enough to determine if these are in fact nonepileptic and yes medications can be causative if that is the case. Epileptic and nonepileptic seizures can co exist in one person. The later should be addressed by looking at psychosocial issues and depression as possibly causative.

I had a seizure last week after 4 ½ years of being controlled. I am now terribly scared they will start again. I need to work and be able to drive my family places. I take 200 milligrams of Tegretol three times daily. What do I do?

Dr. Barry: Discuss this issue with your neurologist and psychiatric help may be useful as well. . Serum levels of the medication may be done to help give you confidence that your drug levels are adequate. and another AED could be switched or added to it.

I took Dilantin for a year and noticed that the higher the dosage, the higher the frequency and severity of depression, anxiety and even paranoia. I recently reduced my dosage and feel much better. Could the Dilantin have caused these problems?

Dr. Barry: Yes. AEDs can have many side-effects including the ones that you describe.

I've taken Dilantin daily for the last 17 years and recently was diagnosed with Attention Deficit Hyperactivity Disorder. I have such a hard time concentrating that I want to try one of the drugs for this. Are there any known links between head injuries, ADHD and epilepsy, or the drugs used to treat them?

Dr. Barry: Yes. However, it may be useful to look at the phenytoin as a possible cause for your attention problems. I would suggest speaking to your neurologist about a potential switch to another medication with less of a possible side effect of a cognitional dysfunction.

Editor's Note: Some of the information presented above has been taken from the Epilepsy Foundation's Mood Disorder fact sheets. For a copy of the fact sheets contact emabry@efa.org or visit the Answer Place.

This edition of "Ask the Experts" was made possible in part by an educational grant from Cyberonics, Inc.