mula.qxp 11/1/08 04:04 Page 58
Epilepsy
Depression in Epilepsy – Mechanisms and Therapeutic Approaches
a report by
Marco Mula
1,2
and Bettina Schmitz
3
1. Department of Neurology, Amedeo Avogadro University, Novara; 2. Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology,
University of Pisa; 3. Universitätsmedizin-Charité, Department of Neurology, Campus Virchow-Klinikum, Seizure Clinic, Berlin
It has been known for a long time that there are associations between that depression occurred in 4% of seizure-free patients and in 10% of
epilepsy and depression, and there are several reasons why the two patients suffering less than one seizure a month, but at a rate of 21%
disorders may be closely linked. Epilepsy is a chronic disorder that brings in patients with higher seizure frequency. O’Donoghue et al.
7
noted
about social restrictions and discrimination. As with any chronic disorder, that patients with epilepsy and continuing seizures were significantly
epilepsy may be expected to be linked to demoralisation and a negative more likely to suffer from depression than those in remission
perspective on life. Furthermore, patients with epilepsy run the (33 versus 6%).
unpredictable risk of becoming unconscious. This can mean that they fall
and hurt themselves and/or suffer social embarrassment. Recent research, There are a number of studies from selected patient groups that noted
while reinforcing this association, has also pointed out a biological an even higher frequency of depression in these populations. Victoroff
contribution to the association based on neuroanatomical and et al.
8
evaluated 60 patients with intractable complex partial seizures
neurochemical principles.
1
Associations between antiepileptic drug using a structured clinical interview from the Diagnostic and Statistical
prescription and depression have been another focus of attention.
2
Manual of Mental Disorders 3rd Edition (DSM-IIIR), and observed that
58% had a lifetime diagnosis of depressive disorders. Jones et al.
9
Epilepsy and Depression – A Bi-directional Relationship examined 199 patients from five epilepsy centres, again using a
Assessing the prevalence of depression from selected clinical samples of structured clinical interview, the Mini International Neurophychiatric
patients with epilepsy shows a bias towards the more severely affected Interview (MINI), and noted that 34% met diagnostic criteria for a
subjects. A better understanding of co-morbid psychopathology comes mood or anxiety disorder and 19% met criteria for major depression.
from community studies. Edeh and Toone
3
carried out a general practice Ring et al.
10
examined 60 patients awaiting temporal lobe epilepsy
study in the UK and reported that 22% of unselected patients with surgery, and reported at pre-operative assessment that a major
epilepsy were diagnosed as having a depressive disorder. A Canadian depressive disorder was present in 21%. Taken together, these data
Community Health Survey (CCHS) examined 253 people with epilepsy suggest that epilepsy and depression are frequently linked, and that
using a rating scale to identify a history of depression. The authors noted the association is more common than in some other chronic medical
a 22% lifetime prevalence of depression that was much higher than the conditions. Moreover, this relationship seems to be stronger in those
12% prevalence rate reported in the general population.
4
with higher seizure frequencies and with continuing seizures. Thus,
the presence of depression can be said to be even higher in selected
More recently, Ettinger et al.
5
assessed depression in 775 subjects with populations, in particular in patients with difficult-to-treat or drug-
epilepsy and compared the prevalence rates with those of patients resistant seizures.
with asthma and with healthy controls. In this study a rating scale
assessment was also used (the Center For Epidemiological A verified finding is the association between depressive symptoms and
Studies – Depression Scale [CESD]). Symptoms of depression were quality of life (QOL) in people with epilepsy. Gilliam et al.
11
noted
significantly more frequent in the epilepsy group (36.5%) compared with depression to be the most important predictor of QOL, being a more
those with asthma (27.8%) and controls (11.8%). powerful predictor than the actual seizure frequency. Perrine et al.
12
and
Boylan et al.
13
have reported similar findings.
Several studies have noted a correlation between depression and
seizure frequency. In an epidemiological study, Jacoby et al.
6
noted An interesting finding is that the relationship between epilepsy and
depression is not necessarily unidirectional. Patients with co-morbidity do
not always present with the seizure disorder before the emergence of the
Marco Mula works in the Department of Neurology at Amedeo University in Novara and in
the Department of Psychiatry, Neurology, Pharmacology and Biotechnology at the University
depression. In fact, it has been noted in epidemiological studies that
of Pisa. His research interests include the psychopharmacological treatment of epilepsy, the
having a prior mood disorder can be associated with an increased risk of
cognitive and psychiatric effects of antiepileptic drugs and the biological basis of behavioural
problems that can accompany epilepsy. Dr Mula is a member of the scientific committee of
epilepsy.
14,15
There may be a number of reasons for this, including the use
the European Federation of Neuropsychiatry (EFNP) and has been a member of the scientific of proconvulsive antidepressants and the development of epilepsy
and executive committee of the International Neuropsychiatric Association (INA). He is Editor
following suicidal attempts, drug abuse or some other trauma (e.g. head
of Brain and Mind Matters, the newsletter of the INA, and a reviewer for a number of
international journals, including Brain, Epilepsia and the Journal of Neurology Neurosurgery
trauma). However, these findings may reflect on an underlying common
and Psychiatry. He gained his degree in medicine and his MD from the Amedeo Avogadro
pathogenesis, which may relate to an as yet unknown genetic factor or a
University School of Medicine, Novara, specialising in neurology. He completed a PhD in
psychiatry at the University of Pisa.
link with neuro-transmitter function. Certain transmitters, such as
serotonine, glutamate and γ-amino butyric acid (GABA), are known to
E:
marcomula@yahoo.it
play a role in both epilepsy and depression.
58 © TOUCH BRIEFINGS 2007
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