New research was presented at AES 2018, the American Epilepsy Society Annual Meeting, from November 30 to December 4 in New Orleans. The features below highlight some of the studies that emerged from the conference.
Depression Symptom Severity & Epilepsy Outcomes
Depression is a common comorbidity in patients with epilepsy, increasing suicide risk and decreasing quality of life. Appropriate recognition and management of neuropsychiatric conditions in this patient population may be achieves with identification of relationships between depression severity and clinical factors. To assess these relationships, researchers evaluated depression severity, quality of life, and comorbidities in patients with epilepsy. Approximately half of participants had at least moderate depression. Only inability of work was significantly associated with depression severity. Non-significant correlations with worse depression severity was observed with higher 30-day seizure frequency, panic disorder, and obsessive-compulsive disorder. No association between depression and medical comorbidities was observed.
Seizure Frequency During Pregnancy & Postpartum Epilepsy
Although previous research suggests that seizure frequency during the 9 months prior to pregnancy can predict the degree of seizure control during pregnancy, few studies have assessed this link during the postpartum period. For a study, investigators assessed whether increased seizure frequency during pregnancy and postpartum period is more likely in women with focal or generalized epilepsy, and whether it differs by the localization of seizures. The study team recorded seizure frequency over 9-months preconception, during pregnancy and 9 months postpartum. Patients with generalized epilepsies were more likely to maintain baseline seizure control during pregnancy, with increased seizure frequency in 2.56% of pregnancies, compared with 21.92% in those with focal epilepsies. The gap narrowed and reversed, but not significantly, in the 9-month postpartum period, with 7.14% of focal epilepsies and 12.12% of generalized epilepsies experiencing increased seizure frequency above the preconception baseline. Compared to women with focal epilepsies of other localizations, Women with frontal lobe epilepsy had increased seizure frequency in 57.14% of pregnancies and in 18.18% during the 9-month postpartum period.
Assessing Cannabidiol Tolerance
The use of cannabidiol to manage symptoms is not uncommon in children and adults with treatment-resistant epilepsy. And while previous research has shown that the effectiveness of cannabinoids can decrease when used for pain management, no large studies have assessed this among patients with epilepsy. To do just this, study investigators reviewed the necessity to increase cannabinoid does in 30% or more following reduction of efficacy or response reduction of more than 30% among patients aged 1-37 with treatment-resistant epilepsy between January 2014 and September 2017. Over the study period, nearly one-third of patients developed tolerance, reported on an average dose of 12.6 mg/kg/day and with a mean time until appearance of tolerance of 7.3 months. Of these patients, 58% showed more than a 50% reduction in mean monthly seizure frequency. While trying to resist the tolerance effect, cannabinoid dose was increased in most patients with observed tolerance.
Treatment Gap in Newly Diagnosed Epilepsy
Data indicate that as many as 90% of patients with epilepsy in resource-poor countries do not receive antiepileptic drug (AED) therapy, a treatment gap generally attributed to socioeconomic factors. The extent of this gap and the reasons for it in high-income countries have not been examined. Adults who attended the First Seizure Clinics of publicly funded hospitals in Western Australia were recruited for a study that sought to determine the proportion of untreated patients and the reasons for not starting treatment at each follow-up visit over a median of 5.2 years. Of those diagnosed to have epilepsy by their treating neurologists, 36% were not treated immediately. The most common reasons for treatment not being offered were presence of seizure precipitating factors (29%), having had single seizure (23%), and waiting for further investigation (18%). Among patients who declined treatment, the most common reasons were being unconvinced of necessity of treatment (39%), presence of seizure precipitating factors (15%), and concerns about adverse effects (8%). AED therapy was more likely to be started in patients who were older and had lower socioeconomic status, epileptogenic lesions on imaging, and more seizures, when compared with untreated patients.
Mobile Diaries for Longitudinal SUDEP Risk Stratification
Although a significant contributor of epilepsy-related mortality, sudden unexplained death in epilepsy (SUDEP) is poorly understood. Using a large-scale, patient-reported database that serves as an online and mobile seizure diary, researchers stratified data into high, medium, and low risk for SUDEP based on previously identified risk factors and monitored how this changed between December 2007 and February 2018. The number of generalized seizures for each year since an initial seizure diary entry was calculated for each user and each year given a designation of low, medium, or high risk for SUDEP. Survival analysis was used to assess the probability of SUDEP risk diverging from the initial risk stratification. The vast majority of the patients who began with a low risk of SUDEP remained in this category, whereas those who began at medium or high risk left this category, either by changing risk groups or discontinuation of app use. After 3 years of tracking seizures, approximately 30% of patients in the high- and medium-risk groups left their initial risk group, compared with 7% in the low-risk group.
Depression Screening in Pediatric Epilepsy
To identify patients with depressive symptoms and ensure referral to appropriate behavioral health services, the Children’s Health Comprehensive Epilepsy Center developed a behavioral health screening protocol for teens with epilepsy. The Patient Health Questionnaire-9 is administered to all patients aged 15-18 years during their epilepsy clinic visit. Among patients screened with this protocol, 87% had minimal/mild depressive symptoms, 8% had moderate/moderately severe, and 5% rated suicidal ideation or previous suicide attempt. Overall, 13% of those screened required behavioral health referral or intervention, highlighting the importance of having a behavioral health protocol within an epilepsy clinic, write the study authors.