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Mood Disorders in Epilepsy

Online Health Chat with Dr. Tatiana Falcone

April 15, 2011


Introduction

Cleveland_Clinic_Host: Depression is the most common mood disorder in patients with epilepsy. It is a chronic illness that affects their quality of living - even after they become seizure-free.

Depression usually starts in adolescence. Characteristics of depression in children and adolescents include:

  • Emotional symptoms, such as irritability, anger, sadness, and feelings of rejection
  • Behavioral symptoms, such as social isolation, regression, reckless behavior, loss of interest in social activities, and substance abuse
  • Cognitive symptoms, such as poor self-esteem, feelings of worthlessness, guilt, feelings of not being loved, problems concentrating, declines in school performance, and recurrent thoughts of death or suicide
  • Physical symptoms, such as headaches, fatigue, and problems with appetite, sleep, or weight

Depression is frequently under-recognized and under-treated. Untreated depression has many negative consequences in the lives of patients with epilepsy and their families. There is a bi-directional relationship between depression and epilepsy. Patients with poor control of their seizures are at a higher risk of becoming depressed, and severely depressed patients are at a higher risk of having more seizures. Effective treatment of depression improves quality of life in patients with epilepsy.

Dr. Tatiana Falcone received her medical degree from the Universidad Pontificia Bolivariana in Medellin, Colombia, and completed her residency and internship at Cleveland Clinic. Dr. Falcone’s specialty interests include: anxiety and mood disorders, epilepsy and behavior, psychiatric issues in epilepsy, psycho-oncology, psychosis, and schizophrenia.

To make an appointment with Tatiana Falcone, MD, or any of the specialists in the Epilepsy Center at Cleveland Clinic, please call 216.636.5860, or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/epilepsy.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Tatiana Falcone. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.


Mood Disorders and Epilepsy

Peyton: In people with epilepsy, are mood disorders more common in men or women?

Dr__Tatiana_Falcone: It depends on age. In children, depression is equal in boys and girls. In adolescents and older individuals, depression is more frequent in women.

Peyton: What is the average age for the onset of depression/mood disorders in patients with epilepsy?

Dr__Tatiana_Falcone: Adolescence is when we start seeing symptoms of depression in patients with epilepsy.

alexandra95: I am a 14-year-old girl with epilepsy, and I think I am suffering from some kind of depression. I will suddenly feel the need to just fall to the floor and cry for no reason. Is this normal or is it just my own little thing?

Dr__Tatiana_Falcone: Alexandra, I think it will be very important to talk to your parents and your doctor about how you feel. I don't think this is your little thing, and I think it will be good for you to ask for some professional help.

alexandra95: If I am cured of my epilepsy will I become a whole new person, emotionally? I sometimes suddenly get so depressed I just want to fall to the floor and cry. Is this normal?

Dr__Tatiana_Falcone: If you were cured of your epilepsy, your quality of life might be improved. Emotionally, we sometimes see the mood symptoms persist. The good news is there is treatment for it, and we know the more engaged you are in your life, the less likely these symptoms will worsen. There are some resources that can help, such as participating in support groups. Check with your local chapter of the Epilepsy Foundation to see what groups are available in your area, or ask your specialist if they know of a local support group. Symptoms can be hard to cope with, and some patients experience severe bouts of depression (i.e., "fall to the floor and cry"). If these symptoms persist for more than two weeks, see a psychologist or a psychiatrist; they can help. The extra-support always helps. Sometimes, depending on where the seizures are coming from, we see patients experience (shortly after having a seizure) severe depressive symptoms. It may be helpful to change scenery, change the situation at that moment, or do something else (even if you don't feel like it). Changing the scenery will certainly help. If you are feeling lonely, call a family member or a friend to be there with you.

abackus:Can you please explain how mood can have an effect on seizures.

Dr__Tatiana_Falcone: It is a two-way street, and sometimes when patients are more anxious and more depressed, you can see more seizures occurring. Sometimes we see mood symptoms appear first, then the seizures. Sometimes patients become seizure-free and in the next year they develop depression. This is certainly not always the case, but it occurs in some patients, depending on where the epilepsy is coming from. We have seen most of these cases in patients who have temporal lobe epilepsy.


Depression after Epilepsy

abackus: I've had epilepsy since age 3. At age 17, I had epilepsy surgery that was very successful. I am now 20 years old and seizure-free. I've been reducing my seizure medications over the last several months and will be medication-free by the end of May. Over the years, I have experienced many of the symptoms of a mood disorder, but have never been diagnosed with any disorder. At times, a particular symptom may have been attributed to the seizure medication I was taking at the time. Now that freedom from medication is so close, I hesitate to consider new medications to treat a possible mood disorder. Can you discuss any natural remedies or alternative therapies?

Dr__Tatiana_Falcone: Congratulations on finally getting off the antiepileptic drugs (AEDs)! This is great news. I am very happy for you. Yes, it is very frequent to see mood symptoms associated with epilepsy. Also, sometimes we see mood symptoms when medication levels are changing. If the mood symptoms persist for more than two weeks, I encourage you to see a psychiatrist or a psychologist. In the case of epilepsy, there are currently no studies of alternative treatments that have shown effectiveness in clinical trials. So, there is no evidence that in the co-morbidity of epilepsy and depression, alternative treatments are effective. I have seen many studies from Germany on mood disorders and some different alternative treatments that seem encouraging. However, none of these studies included patients with medical conditions such us epilepsy. My recommendation is that if you have symptoms for more than two weeks, consult the appropriate provider. Depression has a huge impact on the quality of life, and getting treatment certainly will improve your quality of life. Treatment could be medication or it could also be psychotherapy.

Peyton: I’ve had epilepsy for more than 17 years, underwent surgery twice, with meningitis as a complication. For me, improving my physical health and eating sensibly held off any depression. I now feel much better about myself and it shows in my epilepsy and attitude. I haven’t had a seizure in years when I was having several each night during sleep. Is it common for someone to work themselves out of depression or am I just odd?

Dr__Tatiana_Falcone: Well, I am glad to hear that you are doing better. We believe improving your activities of daily living will improve your mood (like having a good night sleep, exercising for at least 30 minutes five times a week, eating right). Also, we know that the natural course of the depression might last up to nine months when left untreated.


Epilepsy Medication

caglel: My 9-year-old son has refractory epilepsy, Doose syndrome, and has been on many different AEDs over the past few years. Would you please comment on the impact of AEDs and different combos that might exacerbate depression or behavior problems? For example, we suspected depression last year, and later weaned him off Felbatol® (felbamate) because it did not seem to help, then we saw a huge improvement in his mood.

Dr__Tatiana_Falcone: Thank you for your question. There is a lot of co-morbidity between depression and epilepsy, and sometimes it might be related to the medication, but sometimes it might also be related to the epilepsy (i.e., number of seizures, quality of life, impact on daily living). We know some of the AEDs might in some cases help and in some cases worsen depression symptoms. If the depression is related to the AED, the patient should be feeling better after the medication is out of his or her system in one to three weeks, depending on the medication. In some cases, it is hard to stop the AED if it is working. Sometimes, we add an antidepressant to help with the treatment, or if the depression is mild, we refer the patient for psychotherapy. Cognitive behavioral therapy is the most evidence-based technique to help patients with depression and epilepsy.

johnboy77: Does Keppra® (levetiracetam) have any permanent or life-threatening side effects?

Dr__Tatiana_Falcone: Any medication, starting with acetaminophen, can have life-threatening side effects. Keppra® is one of the medications that has more behavioral side effects (mood issues,aggression, and in some cases psychosis).

Working closely with your neurologist/epileptologist to have lab tests done on a regular basis helps prevent some of these side effects. Also, if you see notice any symptoms, contact your doctor as soon as they appear.

johnboy77: Could Keppra® be the cause of my child being behind in school?

Dr__Tatiana_Falcone: Some of the medications can have a cognitive impact. In most cases, it is more the number of seizures that have the most impact on school performance.

lilkitkat80: Have you had a lot of feedback about the side effects of generic epilepsy medication versus the name brand? It's lamotrigine (Lamictal®) manufactured by Teva Pharmaceutical Industries that has bad side effects for me.

Dr__Tatiana_Falcone: We see that generic medications for epilepsy sometimes are different than brand name medications, and we see the effects on the number of seizures increasing when the patient goes from the brand name to the generic. Is not the same with all of the medications. Consult with your neurologist if you have seen any change in the number of seizures.

amandasloan: I am new here and hope it is OK to just jump in. My 8-year-old daughter is taking Keppra®. She started having seizures in Sept 2010 and started Keppra® in October 2010. I noticed a change in her behavior/mood and discussed it with her neurologist, who suggested B6. She said it has been shown to improve behavior issues caused by Keppra® in some patients. I have noticed it has helped some, but she is still very defiant and moody (more so than a typical 8-year-old). I am not sure at what point I should be more concerned that it might be an issue of an actual depression diagnosis.

Dr__Tatiana_Falcone: We see a lot of behavioral side effects with Keppra®. If the behavior/mood is affecting her quality of life, I suggest you see a therapist or a psychiatrist. Also, discuss this with your neurologist to see if Keppra® is the best medication choice for your child. Is it controlling the seizures well? If it isn’t, then maybe looking for another medication might help. However, if is effective for the seizures, adding therapy or a medication for the behavior problems might help.


Seizures

KellyA: Often, the physical effects of seizures themselves and the side effects of AEDs are unpleasant, to say the least. How do we distinguish these from the 'physical complaints' of depression?

Dr__Tatiana_Falcone: In this case, we look more for the mood symptoms, such as sadness, hopelessness, helplessness, decreased engagement in regular activities, and social isolation.

rzienty: Does the severity of epilepsy have an impact on the level of depression? Do different types of seizures have different effects?

Dr__Tatiana_Falcone: It depends where the seizure is coming from. We see that patients with more seizures might their epilepsy will have a greater impact on their quality of life.

spider: I have had epilepsy for almost 35 years. What evidence is there on long-term effects (potential harm or lack thereof) to the brain for people who continue having seizures? I currently have grand mal seizures approximately once per year and remain on at least four medications and have a VNS device.

Dr__Tatiana_Falcone: We know there is some evidence of brain effects, especially when the seizures last more than 30 minutes, and also with the grand mal seizures.


Behavior Issues

sonshine3: My 14-year-old son has a brain injury and subsequently has epilepsy. Aggression has been a problem in the past, although he takes Lamictal® as a mood stabilizer and he takes Tenex® (guanfacine) to help with the side effects of aggression associated with Vimpat® (lacosamide). How do I differentiate adolescent/teen behaviors due to puberty/hormones that need discipline and guidance verses depression that needs treatment/counseling? Since he functions as an 8 to 10-year-old academically and socially, and has other social limitations, some of the emotional issues may stem from lack of social interaction and isolation from "non-disabled" peers. How do I identify the differences?

Dr__Tatiana_Falcone: It is difficult to differentiate which behaviors are related to the epilepsy, which behaviors are related to the hormones, and which behaviors are secondary side effects of the medications. The important question is how much these behaviors are different from his peers and how much these behaviors are affecting his every day social interaction.

Tenex® is a good medication to help with aggression. I believe a social skills group might also be very beneficial.

To differentiate if some of these behaviors are related to the epilepsy, you can create a calendar and track the seizures and the behaviors, and see if the day he is having more seizures he is also having more problems with his behaviors.

Behavior therapy is also a great tool to help with aggressive behavior.


Depression Symptoms

agoodwin: What are typical symptoms of depression in young children? I have a 7-year-old son who has myoclonic astatic generalized epilepsy. I worry that I'm missing the signs of depression, as he is still too young to really tell me verbally how he feels.

Dr__Tatiana_Falcone: Good point. In young children, we see more behavior symptoms, more tantrums, less engagement, more isolation. They don't want to do the regular activities they used to love, and they have problems at school. If you see the symptoms persist for more than two weeks, see a psychologist or a psychiatrist.


Co-morbidities

sofiesmom: My 12-year-old is on medication for seizures. She has always shown some OCD behaviors; for example, having to leave the house at the same time every day, eating the same thing for breakfast or lunch and not switching up. Should I worry? She also takes Zoloft® (sertraline) 75 mg.

Dr__Tatiana_Falcone: You are already receiving treatment for this. Sertraline is a good medication to help with these symptoms. These are frequent in patients with epilepsy. I believe therapy is really helpful. The combination of therapy and medication is the best. Cognitive behavioral therapy (CBT) is the type of therapy that has shown the most evidence for the treatment of OCD.

There is a great book -- "The Boy Who Couldn't Stop Washing: The Experience and Treatment of Obsessive-Compulsive Disorder" by Judith L. Rapoport -- that I think that is a great resource. Also try the American Academy of Child and Adolescent Psychiatry to look for the facts for families. Go to www.aacap.org and check OCD.

Mommabearof3: My 9-year-old son was recently diagnosed with variant benign Rolandic epilepsy. Prior to this, he had been diagnosed with numerous psychiatric issues (ADHD, ODD, bipolar). He also has behavior issues, and had been on many psychiatric medications, which seemed to worsen his behavior. He was hospitalized, and I requested a neuro consult, which lead to finding the seizures. He's since had a 48-hour EEG, which confirmed the diagnoses. He has absence seizures and complex partial seizures, even quite frequently during the day, never a grand mal. He is on AEDs. Is it possible this has been the issue all along? His behavior issues started at age 3. I'm curious if the psych meds caused the epilepsy or if that was likely the problem all along. And if so, how had he not had a grand mal seizure since the psych meds lower the seizure threshold?

Dr__Tatiana_Falcone: We frequently see patients who have psychiatric issues first. ADHD, ODD, mood disorders, and later in life develop the seizures. I doubt that the psych medications caused the epilepsy. Yes, some of the psych medications can decrease the seizure threshold, but it is unlikely that caused the epilepsy. It might trigger one seizure, but not epilepsy. It will be hard to know if he didn't have an EEG at the beginning of the symptoms.

agoodwin: I know that many times there is co-morbidity for epilepsy and other disorders. We suspect our son has ADD. Can you tell me how well drugs like Ritalin® (methylphenidate) or even the ketogenic diet work with kids who have epilepsy? Many times my 7-year-old will get aggressive right before having a myoclonic seizure. Do you have any thoughts on ways to reduce this behavior?

Dr__Tatiana_Falcone: Medications (stimulants) are very effective in helping with ADD. Stimulants do decrease the seizure threshold. It is important to try to do behavior therapy first. If this didn't help, then stimulants might be indicated.


Antidepressants

BriMarie243: I'm 23 and have had epilepsy since I was 8. I've had depression of various degrees for as long as i can remember. I've tried three different medications for depression, I've talked to my neurologist, a psychologist, and a psychiatrist and nothing seems to help. Do you have any advice?

Dr__Tatiana_Falcone: I am sorry to hear that. Sometimes it is hard to cure some of the symptoms of depression. Combination therapy might help.

Maybe doing psychotherapy and medication at the same time will help, and there are some antidepressants that we consider second line to help when the depression is not improving, such as Effexor® (venlafaxine) or Cymbalta® (duloxetine), or even adding a second medication to your antidepressant could also help (such as a mood stabilizer).

msfin: My daughter has partial complex seizures and depression. She was put on fluoxetine (Prozac®), but that seems to make things worse. Are there certain antidepressants that work best for people with partial complex seizures?

Dr__Tatiana_Falcone: There are no differences in effectiveness with the SSRI's, but that doesn't mean that other medications in the same family might not be more effective for her. Sometimes, we see some antidepressant don't work for some patients and work great for others. There are many other medications that could be effective, consult with your psychiatrist about other medication choices, such as Lexapro® (escitalopram oxalate) or Zoloft®.


General Questions

socialworker: What suggestions do you have to ensure that neurologists and psychiatrists work together concerning medication interactions, specifically for those who are not being seen at an epilepsy center that have both professionals working in the same facility.

Dr__Tatiana_Falcone: That is a hard question, especially when the two providers don't work at the same institution. We believe that it is very important that all the physicians involved in prescribing medication know the interactions of the medications prescribed. Here at Cleveland Clinic, we have a system to share our clinical information in a privileged manner. It is called Dr. Connect. This way, we are able to keep all the providers informed about the medication changes. Asking the psychiatrist and the neurologist to communicate after the appointment will help, or -- as in the medical home model -- asking all the specialists to communicate to the pediatrician or PCP all the changes and making sure that all the physicians are aware of all the medication changes, since both the AED can have effects on the mood and the mood can have effects on the seizures.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Falcone is now over. Thank you again Dr. Falcone for taking the time to answer our questions today about Mood Disorders in Epilepsy.

Dr__Tatiana_Falcone: Thank you very much for your time and participation. If you are in the Cleveland area please check with us about Project Cope.


More Information

To make an appointment with Tatiana Falcone, MD, or any of the specialists in the Epilepsy Center at Cleveland Clinic, please call 216.636.5860, or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/epilepsy.

You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult

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This chat occurred on April 15, 2011

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