Project CARE

1. Project Care 4 Epilepsy
Depression, Anxiety and
Epilepsy
Tatiana Falcone, M.D.
Jane Timmons-Mitchell, Ph.D.
December 16, 2014

2. Introduction
• Despite remarkable progress in diagnosis,
treatment and positive long term seizure
outcome in children with epilepsy, the high
prevalence of mental health problems has
not changed in 30 years
• Population studies of children with epilepsy
(CWE) reported poor psychosocial outcomes
in adulthood
• Davies et al. A population Survey of mental health problems in
children with epilepsy.Dev Med Child Neur 2003 45:292- 295
• Rutter and Yule Neuropsychiatric study in Childhood 1970

3. Why do people develop mental
illness?
Many factors contribute to mental health
problems, including:
• Life experiences, such as trauma or a
history of abuse
• Biological factors, such as genes or
chemical imbalances in your brain
(epilepsy)
• Family history of mental health problems
• Certain Medical problems- chronic medical
illness specially those that affect the brain

4. Psychiatric Comorbidities in
Epilepsy
• Depression and anxiety are the most
common psychiatric comorbidities
associated with epilepsy
• They affect quality of life and how a
patient responds to poor seizure control,
most cases of depression go
undiagnosed and untreated in these
patients
• Jacoby A et al. The clinical course of epilepsy and its psychosocial correlates,
findings from a UK community study. Epilepsia 1996; 37 :148 -61
• Boylan L. Depression but not seizure frequency predicts quality of life in
treatment resistant epilepsy. Neurology 2004; 62 :258- 61

5. Epidemiologic data
• Lifetime prevalence of
MDD 3.7-6.7 (general
population)
• Lifetime prevalence in
epilepsy 22.2%
• Higher rates of depression
in younger pts
• Lifetime suicidal ideation
in general population
13.3% (12.8 -13.9 95% CI)
• Lifetime suicidal ideation
in epilepsy 25% (16.6-
33.3% CI)
• Up to 40% of youth with
epilepsy experience
anxiety
• Tellez-Zenteno, et al psychiatric comorbidity
in epilepsy a population based analysis
Epilepsia 2007

6. Predictors of mood disorder in
children and adolescents
• Gender effect, with more depression in
adolescent girls with epilepsy
• Age effect, more depression older than 12
• No association with seizure variables
• No studies on suicidal ideation and seizure
variables
• More severe mood disorders in children with
mental retardation
• Increased family discord in children with
epilepsy, increased number of stressful life
events
• Caplan (2005), Dunn (2005), Hessdorffer (2005),
Jones (2008)

7. Mental Health Screening in the
Pediatric Epilepsy Clinic
• To improve access to services for
patients with epilepsy in a timely
fashion, every family during their
outpatient appointment
• Every patient is screened at least one
time every six months (if the patient is
coming for an appointment)
• Screening measure severity of epilepsy,
side effects from the medications,
impact on family function and mental
health screening

8. Mental health and Epilepsy
In 2007, a study of mental health
problems in children
• 16.7% epileptic children with
psychiatric diagnosis
Compared to:
• 6.4% in children with diabetes
• 4.2% in general population

9. Factors that Cause Mental Health
Issues
Internal Factors
- Biological Makeup
• Genetics
- Illnesses
• Disruption in brain
function (epilepsy) also
affects mood and
behavior
External Factors
o Environmental Conditions-
Bullying
o Reactions from others to
epilepsy
o Lack of acceptance by others
o Individuals own reaction and
acceptance of their condition

10. Bullying
20% of US high school
students were bullied on
school property
16.2% electronically bullied
ere bullied on school
property
(16)

11. Depression
 In general, there has been an increase in
stress and mental health issues during
childhood
 1 in 33 children experience depression
 1 in 8 adolescents are depressed
 Clinical depression often 1st appears in
adolescence

12. Symptoms of Depression in Teens
• Teens may feel sad or cry a lot, for long periods
of time.
• Feel guilty for no real reason; feel like they are
no good; or they have lost their confidence.
• Feel like life seems meaningless, or like nothing
good will ever happen again.
• Teens may have a negative attitude a lot of the
time (irritated), or seems like they have no
feelings.

13. Depression and Epilepsy
• Teens don't feel like doing a lot of the
things they used to do, like music,
sports, being with friends, going out,
and they want to be left alone most of
the time.
• Sleeping and eating more or less.
• Grades drop.

14. Extreme Symptoms of
Depression
• Talk about death and suicide.
• Use drugs and/or alcohol.
• Get into trouble with the law at school
or in the community.

15. Basic concepts –
• Did the symptoms of depression appear
following the introduction or increase of
the AED?
• Did the symptoms follow the
discontinuation of a psychiatric
medication?
• Did the symptoms occur after introduction
of enzyme inducing AED?
• Is the patient experiencing any other
psychiatric symptoms?

16. SUICIDE IN THE EPILEPSIES: A META-ANALYTIC
INVESTIGATION OF 29 COHORTS
M. Pompili et al. / Epilepsy & Behavior 7 (2005) 305–310

17. Symptoms of Anxiety
Anxiety affects the way a person thinks, but
the anxiety can lead to physical symptoms, as
well. Symptoms of anxiety can include:
• Excessive, ongoing worry and tension
• An unrealistic view of problems
• Restlessness or a feeling of being "edgy"
• Irritability
• Muscle tension
• Headaches

18. Symptoms of anxiety
• Choking, chest pains, distress
• Fear, fright, afraid, anxious
• Hot flashes, or sudden chills
• Tingling in fingers or toes ('pins and
needles')
• Fearful that you're going to go crazy or
are about to die

19. Panic Attacks
Symptoms of a Panic Attack include:
• Racing heartbeat , lightheadedness or nausea
• Difficulty breathing, feeling as though you
can't get enough air
• Terror that is almost paralyzing , feeling of
dread
• Nervous, shaking, dizziness,
• Trembling, sweating, shaking

20. Treatment
Do we have effective treatments?

21. What to do--Medication
• Medications for Anxiety and Depression
- SSRIs (selective serotonin reuptake
inhibitors) used most frequently
- Common brand names: Prozac,
Zoloft, Celexa, Lexapro, Paxil
- Common generic names: fluoxetine,
sertraline, citolopran, escitalopram,
paroxetine
- Can improve symptoms of anxiety
and depression without increasing
seizures

22. What to do --Psychotherapy
• Cognitive Behavioral Therapy (CBT)
can be effective.
• CBT helps youth interrupt and change
negative thoughts
• A behavioral health specialist is needed
to help youth learn specific strategies

23. Key components of CBT
• Learning how to recognize which thoughts
are not based in reality and how to change
them.
• Learning relaxation and deep breathing.
• Making a plan to increase social and
exercise activities.
• Identifying things that cause fear or worry
and learning how to tolerate them in small
steps.
• Talking with the entire family about the best
way to help your child.
• Including everyone who works with your
child in the plan.

24. Tools
• Charting, journaling
• Homework
• Family therapy
• Group therapy

25. What to do about Depression
• Developing a positive attitude about
epilepsy, for both you and your child.
• Learning skills to support self-esteem.
• Challenging extreme, disasterizing
thinking. (In Australia, “warpy”
thoughts)
• Learning to relax and manage stress

26. What to do--Bullying
• Burden falls to parents to advocate for their
children and teach age appropriate self-advocacy
skills.
• Promote expectation that there is something
positive to do that child can participate in and
adults can make happen.
• Attend school meeting; point out student’s
strengths.

27. What to do about Bullying?
• StandUp is a Bullying Prevention Program for
teens.
• We are enrolling for this free program, which
students complete on their own computer at
their convenience.
• If your child with epilepsy is in High School-
• Stand Up- Denise Hagen 216-444-0514

28. What is StandUp?
Stand Up is a computer-based program designed to help high
school students
develop and use skills for relating to others in healthy ways.
Using the skills and ideas in this program can help teens to:
• Treat themselves and others with respect
• Avoid being a bully
• Get help if they’re a victim of bullying
• Stand up to stop bullying when they see it going on around them
This program is designed for all teens, no matter if...
• They’ve had any experience with bullying or not
• They’re ready to make changes in the way they relate to others or
not
• They’re ready to take a stand against bullying or not

29. StandUp Teaches
Healthy Relationship Skills
1. Trying to understand and respect the other person’s feelings and needs
2. Using calm, nonviolent ways to deal with disagreements (for example,
leaving the room to cool down, offering solutions)
3. Respecting the other person’s boundaries (for example, how close they
want to get and what they’re comfortable and uncomfortable sharing with
others)
4. Communicating your own feelings and needs clearly and respectfully
5. Making decisions that you know are right for you in social situations
6. Taking a stand to stop bullying when you see it (for example, by saying
something to the bully, or telling an adult)

30. Your Role as
Parents/Caregivers
• Overcome Fears and Stigma
• Help your teenager to cope/manage illness
Self–esteem and a positive self-image are critical to
the success and happiness your teen experiences for
the rest of their life.

31. Now it is time for a Question
and Answer session