Scott Hirsch, MD


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Depression and Anxiety in People with Epilepsy

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  • Scott Hirsch, MD Depression and Anxiety in People with Epilepsy
  • Scott Hirsch, MD

    1. 1. Depression and Anxiety in People with Epilepsy Scott E. Hirsch, MD NYU-Langone Medical Center 5/15/11
    2. 2. <ul><li>No financial support from pharmaceutical companies. </li></ul><ul><li>Information obtained from best available evidence from: </li></ul><ul><ul><li>Medical Literature </li></ul></ul><ul><ul><li>Clinical Experience </li></ul></ul>Disclosures
    3. 3. Epilepsy <ul><li>The management of patients with epilepsy is focused on: </li></ul><ul><li>Controlling seizures </li></ul><ul><li>Avoiding treatment side effects </li></ul><ul><li>Maintaining quality of life. </li></ul>
    4. 4. Epilepsy and Quality of Life <ul><li>If seizure free, people with epilepsy enjoy a quality of life similar to the general population. </li></ul><ul><li>One third of people with epilepsy continue to have seizures despite treatment. </li></ul><ul><li>Because people with recurring seizures may have lower quality of life, every effort must be made to restore quality of life. </li></ul>
    5. 5. Possible Consequences of Epilepsy <ul><li>May be unable to legally drive. </li></ul><ul><li>May have memory problems or cognitive issues. </li></ul><ul><li>May be exposed to stigma or feel embarrassment. </li></ul><ul><li>May have restricted independence. </li></ul><ul><li>Medication dependence. </li></ul><ul><li>Employment problems. </li></ul><ul><li>These quality of life issues are important! </li></ul>
    6. 6. Adjustment Disorder <ul><li>When coping and problem-solving strategies fail, depressed mood and anxiety symptoms may result. </li></ul><ul><li>This isn’t necessarily a “disorder,” but rather acknowledgement that the person is having trouble adjusting to a life change or a new stressor. </li></ul><ul><li>Bolstering social support, attending support groups, and learning new coping skills often helps adjustment and leads to resolution of symptoms. </li></ul>
    7. 7. Feeling sad sometimes is normal <ul><li>Feeling sad, “blue,” or “down” is part of our normal human experience. </li></ul><ul><li>Appropriate when we experience tragedy, loss, or receive bad news. </li></ul><ul><li>When these feelings persist for more than 2 weeks and also interfere with daily functioning, then we think about “Major Depression.” </li></ul>
    8. 8. Epilepsy and Depression <ul><li>Depressed mood is NOT normal in people with epilepsy. </li></ul><ul><li>Depression can be part of a complex partial seizure. </li></ul><ul><li>Depression can also be pre-ictal or post-ictal. </li></ul><ul><li>Untreated depression is associated with more difficulty achieving seizure freedom. </li></ul>
    9. 9. Depression <ul><li>Depression is under-recognized; occurs in up to 43% of people with epilepsy. </li></ul><ul><li>Depression is a significant factor adversely affecting quality of life. </li></ul><ul><li>Risk factors for depression: </li></ul><ul><ul><li>Epilepsy-related disability </li></ul></ul><ul><ul><li>Unemployment </li></ul></ul><ul><ul><li>Activity restriction/Loss of Independence </li></ul></ul><ul><ul><li>Impaired social support </li></ul></ul><ul><ul><li>Stigma associated with Epilepsy </li></ul></ul>
    10. 10. What causes Depression in Epilepsy? <ul><li>Psychological factors: </li></ul><ul><ul><li>difficulty coping with stressors, such as recurrent seizures </li></ul></ul><ul><ul><li>real or perceived losses </li></ul></ul><ul><ul><li>life experiences that set the stage for later depression </li></ul></ul><ul><li>Biological factors: </li></ul><ul><ul><li>prior history of mental illness </li></ul></ul><ul><ul><li>family history of mental illness </li></ul></ul><ul><ul><li>some seizure types </li></ul></ul><ul><li>Social factors: </li></ul><ul><ul><li>social isolation </li></ul></ul><ul><ul><li>financial issues </li></ul></ul><ul><ul><li>limits on independence </li></ul></ul>
    11. 11. Depression <ul><li>Important to treat in both children and adults. </li></ul><ul><li>Treating depression improves quality of life in people with epilepsy. </li></ul>
    12. 12. Criteria for Major Depression <ul><li>Over a 2 week period, most of the day, nearly every day: </li></ul><ul><ul><li>Depressed Mood </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>Loss of pleasure AND… </li></ul></ul><ul><li>4 or more of the following nearly every day: </li></ul><ul><li>Significant change in appetite or weight </li></ul><ul><li>Trouble falling asleep, staying asleep, waking early/late </li></ul><ul><li>Observable slowness of thought and movement </li></ul><ul><li>Fatigue or loss of energy </li></ul><ul><li>Feelings of worthlessness or excessive guilt </li></ul><ul><li>Difficulty thinking or concentrating </li></ul><ul><li>Recurring thoughts of death or suicide </li></ul>
    13. 13. Feeling down vs. Major Depression <ul><li>Nearly all of the symptoms outlined for Major Depression can be part of our normal experiences. </li></ul><ul><li>BUT… it’s not normal to experience 5 of the 9 possible symptoms together persistently over 2 weeks. </li></ul><ul><li>Major Depression is NOT just a reaction to having Epilepsy. </li></ul><ul><li>Major Depression cannot be willed or wished away. </li></ul><ul><li>When left untreated, Major Depression is associated with worse outcomes. </li></ul>
    14. 14. Children and Adolescents <ul><li>Depression may present with different symptoms than in adults: </li></ul><ul><ul><li>Irritable mood </li></ul></ul><ul><ul><li>Disruptive behavior </li></ul></ul><ul><ul><li>Negative thoughts about themselves </li></ul></ul><ul><ul><li>Decline in academic performance </li></ul></ul><ul><ul><li>Agitation </li></ul></ul><ul><ul><li>Intense worry or phobias </li></ul></ul><ul><ul><li>Regressive behaviors, including separation anxiety </li></ul></ul>
    15. 15. STAR*D: Efficacy of Treatment for Depression <ul><li>Sequenced Treatment Alternatives to Relieve Depression. </li></ul><ul><li>Nationwide public health clinical trial funded by the NIH. </li></ul><ul><li>NOT funded by pharmaceutical companies! </li></ul><ul><li>Largest and longest study to evaluate depression treatment. </li></ul><ul><li>Randomized, Double blinded study. </li></ul><ul><li>2,876 participants, ages 18-75 in Level 1. </li></ul><ul><li>Fewer participants in subsequent levels by design. </li></ul><ul><li>Standardized rating system and treatment. </li></ul>
    16. 16. STAR D* Study Design <ul><li>Level 1: Celexa (an SSRI) for 12-14 weeks </li></ul><ul><li>a. Symptom free -> 12 month follow-up </li></ul><ul><li>b. Symptoms persist or intolerable side effects -> Level 2 </li></ul><ul><li>Level 2: Participant given option of switching to Talk therapy, a different medication or adding talk therapy or a new medication </li></ul><ul><li>a. Symptom free -> 12 month follow-up </li></ul><ul><li>b. Symptoms persist or intolerable side effects -> Level 3 </li></ul><ul><li>Level 3: Participant given option of switching or adding different medication a. Symptom free -> 12 month follow-up </li></ul><ul><li>b. Symptoms persist or intolerable side effects -> Level 4 </li></ul><ul><li>Level 4: All medications discontinued </li></ul><ul><li>Randomly switched to 4 th line medication </li></ul>
    17. 17. STAR D* Conclusions <ul><li>50% of participants had remission after 2 treatments </li></ul><ul><li>75% of participants had remission after 4 treatments </li></ul><ul><li>May need to try more than one treatment for remission </li></ul>
    18. 18. Anxiety <ul><li>Anxiety is a common, normal emotion </li></ul><ul><ul><li>Jitters </li></ul></ul><ul><ul><li>Butterflies in the stomach </li></ul></ul><ul><ul><li>Fear </li></ul></ul><ul><ul><li>Nervousness </li></ul></ul><ul><ul><li>Worry </li></ul></ul><ul><ul><li>Tension </li></ul></ul><ul><ul><li>Trepidation </li></ul></ul><ul><ul><li>Panic </li></ul></ul><ul><li>Anxiety isn’t all bad </li></ul><ul><ul><li>Sharpens our senses </li></ul></ul><ul><ul><li>Helps us know something is wrong </li></ul></ul>
    19. 19. Anxiety and Epilepsy <ul><li>In people with epilepsy, Anxiety becomes a way of life. </li></ul><ul><ul><li>Worry about having a life-threatening seizure. </li></ul></ul><ul><ul><li>Worry about having a seizure in public. </li></ul></ul><ul><ul><li>Worry about being socially rejected </li></ul></ul><ul><ul><li>Fear or worry might be an aura or seizure. </li></ul></ul><ul><li>When anxiety interferes with social, academic, occupational, or home functioning, treatment is recommended. </li></ul>
    20. 20. Anxiety <ul><li>When persistent, Anxiety becomes a problem. </li></ul><ul><li>1 in 4 people develop an Anxiety Disorder over their lifetime: </li></ul><ul><ul><li>Generalized Anxiety Disorder </li></ul></ul><ul><ul><li>Panic Disorder </li></ul></ul><ul><ul><li>Agoraphobia </li></ul></ul><ul><ul><li>Social Anxiety Disorder </li></ul></ul><ul><ul><li>Obsessive-Compulsive Disorder </li></ul></ul><ul><ul><li>Post-Traumatic Stress Disorder </li></ul></ul>
    21. 21. Barriers in treating Depression and Anxiety <ul><li>People do not recognize or believe they need treatment. </li></ul><ul><li>People think current mood or anxiety problems are related to a temporary situation. </li></ul><ul><li>People do not want to consider taking another medicine. </li></ul><ul><li>Concern about worsening seizures with medication. </li></ul><ul><li>Concern about side effects. </li></ul><ul><li>Stigma. </li></ul>
    22. 22. Treatments for Depression and Anxiety <ul><li>Talk therapy: the first line of treatment </li></ul><ul><ul><li>Individual therapy </li></ul></ul><ul><ul><li>Group therapy </li></ul></ul><ul><ul><li>Family therapy </li></ul></ul><ul><ul><li>Support groups </li></ul></ul><ul><ul><li>Caregiver support </li></ul></ul><ul><li>Goals of therapy include: </li></ul><ul><ul><li>Developing solutions to immediate problems in living. </li></ul></ul><ul><ul><li>Implementing lifestyle modifications. </li></ul></ul><ul><ul><li>Correcting maladapative thoughts or behaviors. </li></ul></ul><ul><ul><li>Uncovering thoughts that lead to feelings of helplessness and hopelessness. </li></ul></ul><ul><ul><li>Overcoming fears of dependency or abandonment. </li></ul></ul><ul><ul><li>Learning new coping skills (relaxation techniques, imagery, focused breathing exercises, meditation, and progressive muscle relaxation). </li></ul></ul>
    23. 23. Medication for Depression and Anxiety <ul><li>Medications are a mainstay of management for people with Major Depression and Anxiety Disorders. </li></ul><ul><li>Antidepressants are safe and effective in people with Major Depression and Anxiety Disorders when taken under a doctor’s care . </li></ul><ul><li>Medications: </li></ul><ul><ul><li>Alleviate depressed mood and anxiety symptoms. </li></ul></ul><ul><ul><li>Reduce emotional lability, irritability, and worry. </li></ul></ul><ul><ul><li>Reduce social withdrawal. </li></ul></ul><ul><ul><li>Improve a person’s ability to participate in epilepsy treatments. </li></ul></ul><ul><ul><li>Improve overall functioning. </li></ul></ul>
    24. 24. <ul><li>Selective Serontonin Reuptake Inhibitors (SSRI’s): </li></ul><ul><ul><li>Prozac </li></ul></ul><ul><ul><li>Paxil </li></ul></ul><ul><ul><li>Zoloft </li></ul></ul><ul><ul><li>Celexa </li></ul></ul><ul><ul><li>Lexapro </li></ul></ul><ul><li>Selective Serotonin/Norepinephrine Reuptake Inhibitors (SNRI’s): </li></ul><ul><ul><li>Effexor </li></ul></ul><ul><ul><li>Cymbalta </li></ul></ul><ul><ul><li>Pristiq </li></ul></ul><ul><li>Mediciatons with unique mechanisms of action: </li></ul><ul><ul><li>Remeron </li></ul></ul><ul><ul><li>Buspar </li></ul></ul><ul><li>GABA-enhancing agents for Anxiety only: </li></ul><ul><ul><li>Xanax </li></ul></ul><ul><ul><li>Ativan </li></ul></ul><ul><ul><li>Valium </li></ul></ul><ul><ul><li>Klonopin </li></ul></ul>