Epilepsy & Mental Health

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: August 15, 2025
Expiration Date: August 14, 2026

Estimated Time of Completion: 30 minutes

Epilepsy and Mental Health
Anna Shapiro-Krew, MD

Description
Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience
Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director
Andreas Alexopoulos, MD, MPH
Epilepsy Center

Additional Planner/Reviewer
Cindy Willis, DNP

Faculty
Anna Shapiro-Krew, MD
Center for Adult Behavioral Health

Host
Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Epilepsy and Mental Health
Anna Shapiro-Krew, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

Glen H Stevens, DO

DynaMed Consulting

All other individuals have indicated no relationship which, in the context of their involvement, could be perceived as a potential conflict of interest.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast August 15, 2025 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Epilepsy affects millions worldwide, but for many, the seizures are only part of the story. Anxiety, depression and other psychiatric conditions often walk hand-in-hand with neurological disorders, complicating diagnosis, treatment, and quality of life. In today's episode, we'll explore how clinicians are navigating this complex landscape, the latest research shaping integrated care, and what it means to truly treat the whole person.

I'm your host, Glen Stevens, neurologist, neuro-oncologist, in Cleveland Clinic's Neurological Institute. And joining me for today's conversation is Anna Shapiro-Krew, MD. Dr. Shapiro-Krew is the director of Epilepsy Psychiatry at Cleveland Clinic's Neurological Institute. Anna, welcome to Neuro Pathways.

Anna Shapiro-Krew, MD: Thank you for having me. I'm so happy to be here.

Glen Stevens, DO, PhD: So, Anna, let's first start with you introducing yourself to our listeners. Where'd you train? What do you do? At the Cleveland Clinic,

Anna Shapiro-Krew, MD: I trained here at the clinic. I did my residency in adult psychiatry and then a fellowship and consultation liaison, psychiatry, which if you're not familiar with what that is, you're in the majority. It was previously psychosomatic medicine and really focused on the interplay of somatic illness and psychiatric disease.

And so, using that as a basis, now I work and I'm embedded primarily in the epilepsy department and look at that intersection of epilepsy and psychiatric disease.

Glen Stevens, DO, PhD: Very good. So to start off, tell us what the common psychiatric comorbidities are that present in patients with epilepsy.

Anna Shapiro-Krew, MD: Far and away we're seeing the majority struggling with depression and anxiety syndromes. The literature indicates that between 25 to 50% of patients with epilepsy struggle with a form of an anxiety disorder and up to 62% of patients with epilepsy, unbelievably high numbers there.

Glen Stevens, DO, PhD: So, I'm sure you'll get into the why there's a link here in just a little bit. But in the diagnostic process, when should we start screening patients that have epilepsy and potential psychiatric-related comorbidities?

Anna Shapiro-Krew, MD: Honestly, right away. We see a lot of anxiety and depression with initial diagnosis, but the risk continues with chronic disease, and in particular, patients who are diagnosed in childhood or early adulthood. It's something we can't really forget about, especially because the risk of suicide in this population is two to five times greater than the general population.

We estimate that about 22% of patients have suicidal thoughts when struggling with epilepsy. So this is not something that we can ever really forget about and we should be screening them immediately for symptoms of anxiety and depression.

Glen Stevens, DO, PhD: And in the real world, do you have an idea of how many people are being screened with epilepsy patients or is this something that's kind of on the back burner and we don't deal with that?

Anna Shapiro-Krew, MD: It's sort of hard to say. In the real world, my hope is that they are being screened. And we know at least for our ambulatory patients, they are getting screened by kind of classic screening techniques. The PHQ-9, which is the patient health questionnaire, which is the gold standard for diagnosis of depression, they're getting that before every epileptic appointment.

They're also getting the GAD or the generalized anxiety disorder questionnaire before every appointment. Is it the perfect screen? Not necessarily because it's just a clicking survey they do right before, but I will say at least at the clinic, there's a huge understanding of the importance of screening for depression and anxiety. And I think our clinicians are really comfortable talking to patients about depression and anxiety and the importance of mental health.

Glen Stevens, DO, PhD: Yeah, I certainly remember back in the day when we started doing the PHQ-9 and Dr. Schurmeier was over in the cancer center at that time, and she would sit in a room. I guess the issue is, and I'm always still really surprised, curious, are people in the community doing the screening testing? And I'm just not sure, because it takes time. Right?

Anna Shapiro-Krew, MD: Exactly. And they're not as fortunate as we are, because we have a very similar setup, Dr. Stevens, that you did. Frankly, if someone screens high, the epileptologist just either grabs me in person or calls me on the phone, and I can see those patients immediately. But in the community, those resources might not be there. And so I don't know what the screening is.

Glen Stevens, DO, PhD: And for us, it was good because we had a social worker, and the social worker would come immediately and see the patient and then make a decision. Sometimes patients would go, "Well, I didn't mean to check that," or those types of things. And then you get concern, is it really a problem or not a problem? And do they just not want to face the difficulties that are there, but we would get the social worker involved and let the social worker sort of help.

So I guess that's an option for people that are listening to this that don't have some of the same types of things. If they're at least hooked into a social worker group, they could then maybe have a patient interact with the social worker and then have the social worker help with making the decision of should they be seeing a psychiatrist?

Anna Shapiro-Krew, MD: Absolutely. There's definitely that option. And then I think I'd be remiss if I didn't mention the importance of really epilepsy support groups, because a lot of times those support groups can do the things that our clinicians can't do, which is encourage in a peer-to-peer way to get mental health care.

So there's a great support group in the greater Cleveland area called Empowering Epilepsy, and the founder discusses mental health, promotes mental health and will encourage people to seek mental health services if needed. And sometimes that peer-to-peer support is also a great way to get patients hooked into acknowledging how their mental health may be struggling with their chronic disease.

Glen Stevens, DO, PhD: Yeah, we have a brain tumor support group as well. And of course during the COVID pandemic, it sort of affected everything and threw a bit of a wrench into everything. But I think you're right about that, and I'm glad you put that name out there because these things are important and people need to know that there are places to look and services available to them.

Anna Shapiro-Krew, MD: Absolutely.

Glen Stevens, DO, PhD: So, you mentioned this a little bit in passing, but the difference between pediatric versus adult epilepsy patients. Why don't you go through that a little bit?

Anna Shapiro-Krew, MD: It's a little bit difficult or trickier I should say, when we're talking about the treatment of depression and anxiety in the pediatric population. I think mostly because in pediatric psychiatry, there's this very kind of looming black box warning regarding the utilization of selective serotonin reuptake inhibitors, serotonin, norepinephrine reuptake inhibitors in children and young adults because of the risk of worsening suicidal ideation.

Does that mean that we can't use them? Absolutely not. It just means that we monitor very, very closely. I have some patients who are young adults and who have struggled with suicidal ideation, and I've consulted with my colleagues in pediatric and epilepsy psychiatry, especially if I am worried about worsening suicidal ideation. And that just close follow up is really the key.

We also augment more with psychotherapy then, and it really should be stated that psychotherapy is so important, especially when you're worried that pharmacological treatments aren't going to cut the mustard, if you will.

But again, and I mentioned this before, we can't just ignore the depression and anxiety in our pediatric population because we find that patients who are diagnosed with epilepsy in childhood, in adolescence, they're at the highest risk for suicidal ideation. They're going to live with this disease for the rest of their life. And how will they cope with that?

They're also at risk for nonadherence and kind of rebelling against the being a patient. And so again, it's so important that we are collaborating with the epileptologist as a psychiatric provider as well as psychology to promote psychotherapy and coping skills.

Glen Stevens, DO, PhD: And I'm sure in young people you get social isolation with people that are having seizures because they don't want their peers looking at them and seeing them seizing. There's driving issues, alcohol-related effects and epilepsy. So certainly complicated even more for younger people you can certainly tell.

Anna Shapiro-Krew, MD: And Dr. Stevens, social isolation is one of the primary concerns that we see in the epileptic population. It contributes to a lot of the depression and anxiety, which again, and I feel like I keep plugging these peer support groups, but it's so essential because that social isolation, while super important in young adults and adolescents, continues throughout our lifespan with the epileptic patients.

And addressing that has been actually shown to be one of the most effective ways to reduce scores on the PHQ-9, GAD-7.

Glen Stevens, DO, PhD: And as I get older, all they keep talking about is, "You need to have a social network and that'll help you in aging." So, if it's good when you're old, it's good when you're young, right?

Anna Shapiro-Krew, MD: It's good all the time.

Glen Stevens, DO, PhD: And good all the time. So that then begs the question of course, is there a link between why there's so much psychiatric pathology in epilepsy patients? What's the theory?

Anna Shapiro-Krew, MD: It really goes back to this idea of neuroinflammation. Back in the day, honestly, even when I was in training, this was sort of still kind of new. We had a lot of theories about monoamine transmission causing psychiatric disease, GABA, glutamate, all that stuff. That's still very valid. But what we kind of think is happening is that there's a neuroinflammatory process that's somewhat bi-directional in severe neurologic diseases that can cause psychiatric comorbidities.

And studies have shown us that in fact, the predominant or precursor symptom before patients actually develop symptoms of a severe neurological disease like epilepsy or Parkinson's, tends to actually be depression or anxiety. And it's sort of this inflammatory response in the brain to something severe neurologic is happening. And what we see is that patients who have uncontrolled depression or anxiety symptoms tend to have worsening seizure symptoms and vice versa.

Glen Stevens, DO, PhD: And just to go a little bit more into the neuroinflammatory, are most people drinking the Kool-Aid on this theory or is this controversial in the field at this point?

Anna Shapiro-Krew, MD: Most people are pretty much drinking the Kool-Aid. I mean, we do know that there are changes in hippocampal amygdalal volumes in depression and anxiety/epilepsy. We can see that being an effect. We do know that patients, especially with temporal lobe epilepsy, which gets a lot of flack frankly, because it's the most common epileptic form that there is, and because that temporal lobe is where our limbic system lives, so it's our emotional, like, base camp, all of those sort of combine.

We also do see that there are changes in the abilities for cells to pick up serotonin. We do see less serotonin transmission, less norepinephrine, but really that neuroinflammation is what we think is really connecting the two disease processes.

Glen Stevens, DO, PhD: From my understanding is that cytokines are released, interleukin-VI, tumor necrosis factor, these types of things, that then affect the neurotransmitters, the dopamine, the norepinephrine, the serotonin, which then cause them to be low-

Anna Shapiro-Krew, MD: Yes.

Glen Stevens, DO, PhD: ... which then precipitate the mood-related problems. Right?

Anna Shapiro-Krew, MD: Exactly. Plus-

Glen Stevens, DO, PhD: Is that correct? Yeah.

Anna Shapiro-Krew, MD: Yeah. Plus the cytokines also create stimulation of NMDAR, which promotes more neuroexcitation because we see more glutamate transmission, that can lead to cellular apoptosis. And then we also see just overall lower amounts of GABA, so less neuroinhibition to kind of cool things down. And you can see why with more neuroexcitation from glutamate transmission, you'd be at higher risk for an electrical seizure too, because those, for lack of a better word, those brain cells are now super excited and ready to get charged up.

Glen Stevens, DO, PhD: So, are the anti-seizure medications we're using just Band-Aids for the epilepsy part? I mean, I guess we have to look at treatments to treat the inflammation. So-

Anna Shapiro-Krew, MD: Yeah-

Glen Stevens, DO, PhD: ... where's the field going with this? Or-

Anna Shapiro-Krew, MD: ... and that's a great question and thought. And what's really interesting is, if you look at some of the pharmacomechanisms of action, some of the anti-epileptics, a lot of them do have anti-neuroinflammatory properties. So for example, I'm going to use frankly my favorite anti-epileptic, which is valproic acid.

And you shouldn't probably pick favorites of your medications, but I think it's a beautiful medication.

Glen Stevens, DO, PhD: Well, as a psychiatrist you would like that.

Anna Shapiro-Krew, MD: Oh yeah. As a psychiatrist, I know that it's probably not great for the medical self-esteem to pick a favorite, but valproic acid beautiful drug. And what's really cool about it is that it actually has anti-inflammatory properties. It's been shown to do things like it can reduce the amount of glutamate that's created. It can increase the amount of GABA produced. It has anti-IL-6 factors to it.

In fact, if you look at some genetic studies, what you see is that cells exposed to some sort of viral stimulation, for example, will have this increase in genetic expression of IL-6, but then those same cells exposed to valproic acid will have a decrease in that expression. So, it can help with that. It's been shown to do things like increase serotonin via the kynurenine pathway.

These anti-epileptics do have the ability to actually reduce that neuroinflammation, some of them. Similarly, some of our antidepressants can do that as well. Perhaps not to the extreme scale that we needed to to address the severity of disease. But our thought is that the SSRIs, SNRIs, these medications may have untapped or unrecognized anti-inflammatory properties.

Glen Stevens, DO, PhD: Well, there was a study that came out a number of years ago from the European group, the brain tumor neuro-oncology group, where they use a fair bit more valproic acid than they did in the US as their anti-seizure medication. And they were looking at some of their clinical trials and showed what they thought was increased survival in individuals that were on the valproic acid, because it affects some of the second messaging pathways for tumor development.

But then they did a larger study where they looked at it specifically and they didn't feel that there was a clear benefit of it, unfortunately, which we would've liked to have seen at that time. But again, I think historically in the tumor field, it's been used with people that have behavior, mood-related issues, and seizures to treat both at the same time. I guess we'll say.

Anna Shapiro-Krew, MD: Yes. Yes.

Glen Stevens, DO, PhD: The use, you mentioned the SSRIs and the SNRIs to treat the neuroinflammation, benefits there for both or no, or?

Anna Shapiro-Krew, MD: We think so. We think so, but the data's not totally there. Interestingly, during COVID, during sort of the height of it, there were some studies that indicated that the SSRIs, particularly fluvoxamine, had anti-inflammatory properties and actually reduced the release of cytokines. And so there was a really small study in the literature that came out, and I mean super teeny tiny, like an end of, I want to say, like, 8 to 10, that showed exposure to fluvoxamine actually reduced the severity of COVID-19 symptoms.

But on higher scales, we weren't as impressed with the results. However, it does sort of lead us to hypothesize that these could have anti-inflammatory properties. Frankly, you could argue the same with the TCAs and the MAOIs, but I would avoid those in the utilization or the treatment of patients with epilepsy because they have been associated with worsening seizure burden. Unless you're working with someone who's really, really comfortable with TCAs and MAOIs.

Glen Stevens, DO, PhD: So, when you're over in the epilepsy center, you probably look after a lot of mesiotemporal sclerosis and the temporal lobe being affected. Do you see a correlation with behavioral changes, mesiotemporal versus extratemporal? Is it different? The comorbidity is different or not necessarily?

Anna Shapiro-Krew, MD: I'm sort of trying to hedge a little bit because yes and no. So, the majority of patients I do see, a lot of it is mesiotemporal, or some sort of temporal lobe epilepsy condition. And so, I do see a predominance of depression and anxiety in those folks. Your frontal lobe epilepsies, I tend to see more disinhibition, some association with maybe more mood lability.

I very rarely see anything occipital. I would say just sort of the meat of it, the primary mood symptoms are going to be mesiotemporal.

Glen Stevens, DO, PhD: Okay. So, there's a condition where people can have, I think it's more so mesiotemporal resections, where they can develop a psychosis post-operatively. Talk to me about that a little bit.

Anna Shapiro-Krew, MD: This is absolutely one of my favorite topics because I find it so fascinating, and to really get into it. Dr. Stevens, we probably have to go back a little bit historically. For a very long time, the field believed that psychosis and epileptic seizures were diametrically opposed.

Really, the belief was that dopamine acts as an anti-epileptic, and so that patients who were psychotic had this excess of dopamine and therefore can never really have seizures. This was popularized by the epileptologist Laszlo von Meduna, who actually popularized electroconvulsive therapies.

The concept was sort of further taken by epileptologist Hendrick Landolt, into a concept called force normalization, which basically states that once seizures are controlled, patients are at risk of becoming psychotic because again, the seizures are controlled, there's thought to be this excess of dopamine, they're not seizing, but now they're going to be psychotic.

We know now that that's not necessarily true, and there's actually higher rates of psychosis in the epileptic population than the general population. About 7.5% of patients with epilepsy will struggle with some form of psychosis. 6% look more look more postictal psychosis, e., which is psychotic symptoms right after an ictal event or the epileptic episode.

About 2%-ish will have interictal psychosis, which is the psychotic symptomatology between seizure episodes. But that between can really mean anything from a couple of days, a couple of weeks, to years and years and years and years. And frankly, unchecked interictal psychosis in my experience, begins to look like a primary psychotic disorder like schizophrenia, and I treat them similarly.

At Cleveland Clinic, we are the largest epilepsy brain surgery center in the world. And because of that, we're really lucky. We have this huge database of patients who have had brain surgeries here. And so what we've been doing is we've pulled off patients who developed kind of this de novo psychotic symptomatology, and we're currently analyzing it to see what do these patients have in common that they're developing these new onset psychotic symptoms after having surgery?

And while we're still reviewing that, frankly, the majority of them are actually having seizures, they failed somehow the epilepsy surgery, and it might be kind of like subtle seizures that we might be seeing manifesting in these psychotic symptomatology. Really, that in itself is fascinating to me because it once again shuts down this idea of forced normalization, but it'll take a little bit more data analysis for us to really be sure of what's going on.

Glen Stevens, DO, PhD: Well, it'll be interesting if it's variable between the dominant or the non-dominant temporal lobe as well.

Anna Shapiro-Krew, MD: Mm-hmm. Oh, I couldn't agree more. I think that'll be very interesting. And what we're seeing too is we're still seeing some activity, at least that's what I'm sort of analyzing, is there's still some activity in that lobe that's had the surgery, and we're still seeing then these symptoms come out.

Glen Stevens, DO, PhD: So, I think I've very clearly learned that if you have an epilepsy program, you should have a psychiatrist in your epilepsy program.

Anna Shapiro-Krew, MD: It's definitely, I think, important. And I think what I'm really lucky with here is that our epilepsy department has been so welcoming and encouraging, and they wanted psychiatry to be present, and they've been so great about it. I work with two bright nurse practitioners who are interested in both epilepsy and psychiatry, and the epileptologists want to learn about psychiatric disease and they want to teach about epilepsy.

They had me participate in a 12-week EEG reading course so that we can almost speak the same language so I can understand what this epileptic disease process is like. And that's been so beneficial. So, the collaboration is just phenomenal. We're really lucky here.

Glen Stevens, DO, PhD: If a group does not have access to embedded psychiatric care, either inpatient or outpatient, what options do they have? How can they meet the needs of their patients?

Anna Shapiro-Krew, MD: I think keeping themselves educated on treatment options, being comfortable with utilization of antidepressants, anxiolytics, and then of course, we've talked about a lot of those peer support groups can be very helpful in helping patients find and learn about different options for treating their mental health.

So, what I really love about those peer support groups is that they'll identify, "You seem depressed, you seem anxious. This is a good provider that we know of that we'd like you to check out." And so it's sort of additional support in addition to their epileptologist.

Glen Stevens, DO, PhD: So as we're getting towards the end here, any interesting research coming out or studies that you want to talk about?

Anna Shapiro-Krew, MD: I think what's really interesting is the literature is starting to look at things very collaboratively. One of my absolutely favorite things to read about and discuss right now is the utilization of frankly, old, unused antidepressants. Now they're coming out and saying, "Wait, this actually might be a good antiepileptic."

So for example, we've been looking at building a fenfluramine clinic. Fenfluramine initially was designed as an antidepressant and then became an appetite inhibitor, and now is being modified again for its use as an anti-epileptic. And so, finding anti-epileptics that can also serve as mood stabilizers/antidepressants seems pretty cool to me.

We also see that in things like neuromodulators, like vagal nerve stimulators, which have been approved by the FDA for the treatment of depression, but we're looking at it now for what anxiety disorders can the VNS be helpful for? Previously, here at the clinic, we did studies in deep brain stimulators and their utilization in obsessive compulsive disorder.

So really, I think the research is this moving target, and what we're finding is we can kill multiple birds with one stone, which in my mind is very, very, very cool.

Glen Stevens, DO, PhD: I was doing some reading on COX-2 inhibitors. I think they're looking at them for potentially affecting the cytokines. The COX-2 inhibitors are interesting because we were looking at doing a very large nationwide trial with the COX-2 inhibitor a number of years ago because meningiomas over-express COX-2.

And the thought was that, "Because it's outside the blood-brain barrier, the drugs would get to it. It's a very slow growing tumor, so this is a drug that you could give that would hopefully have low side-effects and could be taken for a long period of time."

And then data came out concerning about its effect on the cardiovascular system. So then, the nationwide trial sort of shut down. So it's interesting to sort of see in this field and area that there's some potential interest of using it. The same with rapamycin. I've read some with rapamycin, which is an mTOR inhibitor on the same thing.

And again, it's a drug we've used for many years for treating certain type of tumor that over-expresses mTOR and the epileptologist will also use it because this very specific genetic disorder, the epilepsy can be controlled using the rapamycin as it goes through.

So as you mentioned, you like some of the old drugs. It seems like some of the old drugs are becoming popular again, becomes full circle, right?

Anna Shapiro-Krew, MD: It's like fashion and medicine are the same. What's old is new again.

Glen Stevens, DO, PhD: So, I think we're up against the clock here. Final takeaways, things that we haven't discussed that would be important?

Anna Shapiro-Krew, MD: I mean, I think the biggest takeaway is that mental health matters, especially in chronic illness. It's a cliche statement. It's something that every psychiatrist will say, but it's incredibly true. When we're not addressing the mental health of our patients, we're actually setting them up for failure. Not only are they at higher risk for a higher morbidity, a higher mortality, but their disease process is worsening.

And so, addressing mental health, it can only be helpful. The literature shows that if you treat depression and anxiety, epileptic seizure frequency goes down and seizure threshold goes up.

Glen Stevens, DO, PhD: Yeah, I appreciate your being here and talking about this because I'm sure there are people listening to the podcasts that are going, "I have patients in my practice with epilepsy, and I haven't been doing a good job of really evaluating their mental state and comorbidities."

So I think this will stimulate some people to maybe we need to look at other aspects of the patient's care and management. So I do appreciate that. Well, Anna, thank you very much for joining us today. I appreciate it. Look forward to having you back again in the future.

Anna Shapiro-Krew, MD: Thank you so much. It's been my pleasure being here. Absolutely.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts.

And for further learning, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, that's consultqd.clevelandclinic.org/neuro, or follow the Cleveland Clinic Neurological Institute on LinkedIn. And thank you for listening.