Establishing a depression screening protocol for young epilepsy patients is feasible and effective and helps fill an unmet need, new research shows.
“We’re trying to make other clinics aware that screening is feasible; it’s easy to do, even in a large volume clinic,” study investigator and pediatric psychologist Hillary Thomas, PhD, UT Southwestern Medical Center, Children’s Health System, Dallas, told Medscape Medical News.
Screening for depression among patients with epilepsy was included in recently updated quality measures for epilepsy care, published by the American Academy of Neurology.
“Screening is greatly needed in this population as teens and children with epilepsy have a higher risk for developing depressive symptoms,” she said.
Thomas and her co-investigators found that about 16% of teens attending their epilepsy clinic required some type of behavioral health intervention.
This finding, she said, highlights the need for a behavioral health protocol within an epilepsy clinic.
The study was presented here at the American Epilepsy Society (AES) 2018 Annual Meeting.
Depression Highly Prevalent
Based on various research studies, the prevalence of depression in children with epilepsy ranges from 5% to 38%. This is about two to three times higher than the general population, said Thomas.
Epilepsy itself is one factor that boosts depression risk. Taking antiepileptic drugs (AEDs) may also increase depression risk.
“We know that many AEDs can have depression or mood effects as a side effect, and so we worry sometimes that our treatment could be causing or worsening depression,” study coauthor Susan T. Arnold, MD, professor, pediatrics, neurology and neurotherapeutics, and director of the Comprehensive Epilepsy Center at UT Southwestern, told Medscape Medical News.
There’s a “fair amount of evidence” that some factors that increase the risk for epilepsy also raise the risk for depression, said Arnold. Abnormalities in certain neurotransmitters or structural abnormalities in the brain can increase this risk.
Screening kids helps identify those who are vulnerable, “which is so easy for us to overlook otherwise,” said Arnold.
To screen for depression, the clinicians used the adolescent version of the 9-item Patient Health Questionnaire (PHQ-9). This assessment tool includes questions about impairment and about suicidal ideation.
In general, a score of 0 to 9 on this scale indicates mild depression, 10 to 20 moderate depression, and more than 20 means severe depression.
The clinic has developed a protocol for responding to the varying levels of depressive symptoms.
“If they’re in that mild to minimal range of depressive symptoms, we don’t necessarily do anything specific in clinic, but we do educate regularly” and keep families up to date on monitoring, said Thomas.
For young patients in the moderate to severe range of depression, providers will speak to families and the clinic will connect them to behavioral health resources, she said.
A “gold standard” for treating depression is cognitive behavioral therapy, which helps patients identify negative thought patterns and change their behavior to improve mood. Some patients need a referral to a psychiatrist for medical management.
“We know for sure that those two interventions work for depression in general, but there is not a lot of research to show how effective they are in a pediatric epilepsy population,” said Thomas.
If a child indicates any suicidal ideation, regardless of the level of depressive symptoms, a pediatric psychologist or clinical social worker is paged.
“We then provide further risk assessment and create safety plans for families,” said Thomas.
For the study, researchers included 394 children aged 15 to 18 years who completed the PHQ-9 between June 2017 and May 2018.
The study found that 64% of subjects had minimal depressive symptoms, 20% had mild symptoms, and 9% had moderate or severe symptoms. About 7% had suicidal ideation and 16% required the behavioral health protocol.
Children should ideally be screened at every clinic visit, but at minimum once per year, said Arnold. Most kids come to the clinic every 6 months so it’s done at that time.
Staff at the clinic were a “a little reluctant” at first to start doing depression screening, said Arnold.
“One of the concerns initially was how we were going to get through our very busy day and provide care for the child’s epilepsy if we’re sidetracking ourselves to care for depression.”
But staff were “positively surprised” at how smooth and nondisruptive the introduction was.
“Although we do sometimes need to call a social worker or psychologist down to clinic, it’s not that often; most of the time, children are not in a crisis situation. In retrospect, we wish we had started the screening sooner,” Arnold said.
Thomas and Arnold said they want to show other epilepsy experts that introducing depression screening wasn’t disruptive.
“It didn’t complicate the clinic visit that much and we found ways of organizing our ability to refer to local mental health services when needed, and ways of building this information into our clinic workflow,” said Arnold.
The clinic has about 8000 visits a year from children with epilepsy.
“With such a large population, we feel that the information we’re collecting is something that is very valuable to share with other clinics,” said Arnold.
Clinic patients now fill out questionnaires using paper forms, but the aim is to introduce an online format that patients can complete on iPads when they come in.
Commenting on the findings for Medscape Medical News, Amy Brooks-Kayal, MD, codirector of the Translational Epilepsy Research Program, Ponzio Family Chair in Pediatric Neurology, and chief of pediatric neurology, Children’s Hospital Colorado in Aurora, said the study finding that 16% of the population needed some type of behavioral health intervention was informative.
“It highlights the importance of screening for emotional and behavioral comorbidities in adolescents with epilepsy. It also underlines the need for having a behavioral health protocol in place to manage the patients identified as needing intervention,” she said.
SOURCE: Medscape by P. Anderson
Arnold, Thomas, and Brooks-Kayal have disclosed no relevant financial relationships.
American Epilepsy Society (AES) 2018 Annual Meeting: Abstract 1.388 . Presented December 1, 2018.
For people with treatment-resistant depression, adding vagus nerve stimulation to medication can drastically improve their quality of life, concludes a new study.
People with severe depression may benefit from the neurostimulation technique ‘vagus nerve stimulation.’
The National Institute of Mental Health suggest that over 16 million people in the United States have had at least one episode of major depression in the past year.
Of these, more than 10 million adults report that the condition severely impaired their quality of life.
There are a variety of treatments available for depression, including therapy, medication, and making changes to one’s lifestyle. However, for some, these therapies are not enough to relieve the symptoms and improve quality of life.
Some with treatment-resistant depression turn to neurostimulation. One type of neurostimulation is vagus nerve stimulation (VNS).
In VNS, a device is fitted in the patient’s chest or neck, under the skin. These devices send pulses of electrical stimulation to the vagus nerve, which starts in the brain, goes through the neck, and ends in the chest and abdomen.
However, does VNS really improve the quality of life of those who opt for it? A new study, just published in The Journal of Clinical Psychiatry, aims to answer this question.
The researchers were led by Dr. Charles R. Conway, a professor of psychiatry at Washington University in St. Louis, MO.
Source: By A. Sandoiu/fact checked by J. Collier for MedicalNewsToday.com
Research at Royal Holloway University of London, has suggested a link between patients with epilepsy and patients with bipolar disorder, through investigating a medicine used to treat both disorders.
Valproic acid has been used successfully for many years to treat people with a diagnosis of either epilepsy or bipolar disorder, but there has never been a clear understanding of how it works for these two different conditions. Unfortunately, the drug also has severe side effects, increasing the chance of causing birth defects, if taken by pregnant women.
Professor Robin Williams, Head of the Centre for Biomedical Sciences in Royal Holloway’s School of Biological Sciences, and his students have carried out extensive research to discover how the drug works. Their work has been published in the journal Disease Models & Mechanisms.
Robin said: “To enable us to understand how the drug works in both conditions, we carried out tests using a simple amoeba as a research model. Using this model we were able to identify a single protein affected by valproic acid. This protein has previously been associated with both conditions, however, our research has been the first to suggest that it may be the key linking the treatment of both disorders”.
“Now that we understand how valproic acid works, we have been able to design potential new drugs that would be effective in treating both conditions, without causing birth defects.”
“Successfully developing these new drugs would be potentially life changing for women who want to have children, but depend on valproic acid to manage their condition”.
The next step for Robin and his colleagues is to find a partner organisation who will support the development of these new compounds. Development of these new drugs could lead to safer and more effective treatments for patients with epilepsy and bipolar disorder.
The initial research has been funded by NC3Rs.
In the UK, there are around 500,000 people who have epilepsy and around 2.4 million who have bipolar disorder.
Children with a chronic physical illness have a substantially elevated prevalence of psychiatric illness. The odds of having a mental health disorder were 62% higher among children with vs without a chronic physical condition, even after adjusting for sociodemographic variables and access to health care, according to results from a study published in 2016.1 The risk for psychopathology is even greater among children who have chronic central nervous system (CNS) disorders.
In children with epilepsy, various studies have reported a prevalence of mental health problems ranging from 16% to 77%, and a 3-fold to 9-fold risk compared with controls.2 In a recent study of children and adolescents age 10 to 19 years who had epilepsy, the most commonly observed comorbid psychiatric disorders were attention-deficit/hyperactivity disorder (ADHD) and anxiety, and 26.8% of those with a psychiatric diagnosis demonstrated executive dysfunction. Independent risk factors for this comorbidity were executive dysfunction, male gender, and early seizure onset.3 Other research has also revealed higher rates of depression and autism-spectrum disorder in this population.4
Cognitive and linguistic deficits have been cited as risk factors for psychiatric comorbidity in pediatric epilepsy, along with family factors such as parenting style and quality of the parent-child relationship.2 Although some research findings show a link between antiepileptic drugs (AEDs) and psychopathology in this patient group, results have been largely inconclusive.5
Psychiatric comorbidity has a significant impact on quality of life and psychosocial outcomes in this population, underscoring the importance of adequate screening and treatment measures.2 To elucidate the unique considerations involved in caring for these patients, Neurology Advisor spoke with Janelle L. Wagner, PhD, licensed clinical psychologist, research associate professor of nursing and pediatrics, and faculty member of the Comprehensive Epilepsy Center at the Medical University of South Carolina; and David W. Dunn, MD, the Arthur B. Richter professor of child psychiatry, professor of psychiatry and neurology, and director of the child and adolescent psychiatry section at Indiana University School of Medicine.
Neurology Advisor: How might the presence of epilepsy influence treatment of psychiatric comorbidities?
Dr Wagner: Up to 50% of persons with epilepsy also experience cognitive/neurodevelopmental and/or psychiatric comorbidities, and we are learning more about the bidirectional relationship between epilepsy and these psychiatric comorbidities, including neuroanatomic and neurotransmitter overlap, and providing support for epilepsy as a spectrum disorder.6 Epilepsy healthcare providers are being encouraged to screen for and potentially initiate medication management for these psychiatric symptoms in persons with epilepsy.
Studies support the use of selective serotonin reuptake inhibitors (SSRIs) to treat depression and anxiety and stimulants to treat ADHD in persons with epilepsy, and guidelines have been published for use of these medications in these patients.7 There is also a growing body of literature to support the use of behavioral health interventions such as cognitive behavioral therapy to alleviate depression, and in many cases, these interventions focus on evidence-based therapeutic strategies that have been adapted to fit epilepsy and the challenges it poses to individuals and their families.8
Dr Dunn: One of the first steps in treatment of psychiatric problems in people with epilepsy is to check on seizure control and AEDs. Frequent seizures can have a negative impact on attention, and nocturnal seizures may leave a patient feeling tired the following day. AEDs may have adverse effects that could contribute to ADHD, anxiety, or depression.
Most psychiatric medications are safe, but care should be taken in choosing psychotropic medication, and the response should be monitored. Stimulants such as methylphenidate or amphetamines can be used by people with epilepsy and ADHD without the risk of loss of seizure control. Antidepressants may be used without an increase in seizure frequency with certain exceptions — bupropion and the tricyclic antidepressants may lower seizure threshold and should be used with caution. Clomipramine may also lower seizure threshold. Of the antipsychotics, clozapine is most likely to cause seizures. Olanzapine and quetiapine have a lesser effect on increasing seizure number. [As] psychotropic medications may interact with AEDs, blood levels of AEDs should be checked after starting, changing doses, or discontinuing psychotropic medication.
Neurology Advisor: What is known about the influence of AEDs on psychiatric comorbidities?
Dr Wagner: Given the potential shared mechanisms between epilepsy and psychiatric disorders, it is not surprising that AEDs may influence psychiatric symptoms. For example, in a pediatric study, psychiatric or behavioral adverse effects to AEDs were more likely to develop in youth with medically refractory epilepsy and/or a history of psychiatric diagnosis.9 Similarly, higher hyperactivity/impulsivity in children with new-onset epilepsy at baseline predicted greater behavioral adverse effects to AEDs at 1 month post-AED initiation.10 In an adult study, Kanner and colleagues showed that comorbid depressive and anxiety symptoms can worsen the severity of adverse effects associated with AEDs.11 These studies raise an important consideration — the onset of psychiatric symptoms.
Dr Dunn: AEDs are also known mood stabilizers, and some AEDs are used to treat bipolar disorder. As with all medications, there are potential adverse effects of AEDs. The older drug phenobarbital has caused inattention, hyperactivity, and depression. Newer AEDs such as perampanel and brivaracetam can cause irritability. Behavioral adverse effects are less common with other second- and third-generation AEDs, but after starting an AED, the physician should monitor for anxiety, depression, inattention, or irritability.
Neurology Advisor: How might clinicians discern AED-related psychiatric comorbidities vs those unrelated to AEDs, and in either case, what is the optimal approach for treating these issues?
Dr Wagner: To tease apart AED-related psychiatric comorbidities and those unrelated to AEDs, clinicians must conduct baseline psychiatric screening prior to AED initiation and continue screening throughout the course of AED treatment. If significant psychiatric symptoms are present prior to AED initiation, clinicians are encouraged to treat those symptoms as comorbid as they move forward with AED initiation. If screening at baseline does not occur, these comorbid psychiatric symptoms may be confused with AED adverse effects, resulting in unnecessary changes to the AED regimen. It is important to note that these patients are at risk for worsening psychiatric symptoms with AED treatment.
If psychiatric symptoms are not present at baseline but present following AED initiation, these symptoms are likely adverse side effects to the AED and clinicians should consider dosing changes or alternative treatment options — such as a different seizure medication or diet — for seizures. In this case, it is very important to have a discussion with the patient and family about the severity of the psychiatric AED adverse effects and the alternative treatment options, as many patients report psychiatric symptoms as more burdensome than seizures themselves.12 If patients experience greater psychiatric symptoms, they are also at risk for poor adherence to their prescribed AED regimen.13
Dr Dunn: It can be difficult to decide if emotional and behavioral problems are due to seizures, AEDs, intrinsic emotional reactions of the person with epilepsy, or a response to the negative reaction of family or people in the community. In general, if the psychiatric problem seems to follow introduction of a new AED or an increase in AED dose, consider that psychiatric problems may be an adverse effect of AED. It may require stopping the AED to see if problems resolve.
Neurology Advisor: What should be next steps in this area, in terms of research or otherwise?
Dr Wagner: As part of comprehensive epilepsy management, clinicians should consider treating both seizures and psychiatric symptoms, or at the least, screening for psychiatric symptoms and referring to a mental health professional if warranted. Screening for psychiatric symptoms is necessary at baseline, prior to AED initiation, and throughout the course of AED treatment.
Next steps for research include continued examination of shared mechanisms for epilepsy and psychiatric disorders, nonpharmacologic interventions for psychiatric disorders, and standardized assessment of AED adverse effects in routine epilepsy care.
Dr Dunn: We need to know who is at most risk for adverse effects from AEDs. Factors that might be important are the past history of the individual or a family history of emotional or behavioral problems. Pharmacogenomics research is assessing drug metabolism for clues to potential adverse effects or variable response to medications. The hope is to develop precision medication for the individual. There is still much research to be done.
Source: By Tori Rodriguez, MA, LPC for Neurology Advisor
Suryavanshi MS, Yang Y. Clinical and economic burden of mental disorders among children with chronic physical conditions, United States, 2008–2013. Prev Chronic Dis. 2016;13:150535.
Plioplys S, Dunn DW, Caplan R. 10-year research update review: psychiatric problems in children with epilepsy. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1389-1402.
Alfstad KÅ, Torgersen H, Van Roy B, et al. Psychiatric comorbidity in children and youth with epilepsy: an association with executive dysfunction?Epilepsy Behav. 2016; 56:88-94.
Bolton PF, Carcani-Rathwell I, Hutton J, Goode S, Howlin P, Rutter M. Epilepsy in autism: features and correlates.Br J Psychiatry. 2011;198(4):289-294.
Caplan R. Psychopathology in pediatric epilepsy: role of antiepileptic drugs. Front Neurol. 2012;3:163.
Jensen FE. Epilepsy as a spectrum disorder: implications from novel clinical and basic science research. Epilepsia. 2011;52(Suppl 1):1-6.
Kerr MP, Mensah S, Besag F, et al; International League of Epilepsy (ILAE) Commission on the Neuropsychiatric Aspects of Epilepsy. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy.Epilepsia. 2011;52(11):2133-2138.
Michaelis R, Tang V, Wagner JL, et al. Cochrane systematic review and meta-analysis of the impact of psychological treatments for people with epilepsy on health-related quality of life. Epilepsia. 2018;59(2):315-332.
Chen B, Detyniecki K, Choi H, et al. Psychiatric and behavioral side effects of anti-epileptic drugs in adolescents and children with epilepsy. Eur J Paediatr Neurol. 2017;21(3):441-449.
Guilfoyle SM, Follansbee-Junger K, Smith AW, et al. Antiepileptic drug behavioral side effects and baseline hyperactivity in children and adolescents with new onset epilepsy. Epilepsia. 2018;59(1):146-154.
Kanner AM, Barry JJ, Gilliam F, Hermann B, Meador KJ. Depressive and anxiety disorders in epilepsy: do they differ in their potential to worsen common antiepileptic drug-related adverse events. Epilepsia. 2012;53(6):1104-1108.
Cramer JA, Blum D, Reed M, Fanning K; Epilepsy Impact Project. The influence of comorbid depression on seizure severity. Epilepsia. 2003;44(12):1578-1584.
Ettinger AB, Good MB, Manjunath R, Faught RE, Bancroft T. The relationship of depression to antiepileptic drug adherence and quality of life in epilepsy. Epilepsy Behav. 2014;36:138-143.
Depression can cause debilitating fatigue and make the simplest activities, such as getting out of bed, too difficult to manage.
According to a 2018 report, fatigue affects over 90 percent of people with major depressive disorder.
In this article, learn about the link between depression and fatigue, as well as how to cope.