A comprehensive assessment of new-onset epilepsy should include screening for psychiatric conditions, which can impact up to 50% of this patient population.
“The relationship between epilepsy and psychiatric disorders, including mood and anxiety disorders, is very complex,” Andres M. Kanner, MD, explains. “We now know that there is a bidirectional relation between epilepsy on the one hand and mood, anxiety disorders, suicidality, ADHD, and psychotic disorder on the other. Thus, psychiatric disorders can precede the onset of epilepsy in a significant number of patients. Additionally, if you have a comorbid mood disorder, your likelihood of becoming seizure-free on antiseizure medications is two times less likely than someone with new-onset epilepsy and no history of depression.”
The link between epilepsy and suicidality is also complex, he continues. “If you have epilepsy without any comorbid psychiatric condition, you still have a two-fold higher risk of committing suicide. If you have a mood disorder, you have a 32-fold higher risk of committing suicide. If you have anxiety disorders, you have a 12-fold higher risk of committing suicide.”
However, the specific types of mood and anxiety disorders associated with suicidal ideation and suicidal attempt among adults with newly diagnosed focal epilepsy, and the clinical manifestations of suicidality in this patient population, are not well established.
For a study published in Neurology, Dr. Kanner and colleagues sought to address this research gap. They enrolled adults aged 18-60 with newly diagnosed focal epilepsy within 4 months of beginning treatment, looking at the types of mood and anxiety disorders, types of suicidal ideation, and history of suicide attempts.
Bipolar & Panic Disorders Occur Most Frequently
The analysis included 347 patients, nearly half of whom met the criteria for at least one mood and/or anxiety disorder. Specifically, 134 patients (38.6%) had a mood or anxiety disorder, 58 of whom also endorsed symptoms of suicidality (16.7%). In 17 of these patients (5%), the researchers identified suicidal ideation only. In comparisons of patients with and without psychopathology, Dr. Kanner and colleagues reported no differences related to age, sex, or the presence of structural pathology.
“Almost half the study population had a psychiatric diagnosis, and these were all patients with newly diagnosed epilepsy,” Dr. Kanner notes. “It’s been established that you are more likely to experience a psychiatric disorder after having epilepsy for a long time. But these patients had just been diagnosed.”
Predictive variables for suicidality included major depressive disorders, bipolar disorders, panic disorders, and agoraphobia (Table). Bipolar disorders and panic disorders had the strongest predictive value, particularly for active suicidal ideation and suicidal attempts.
“Very often, bipolar disorders are not recognized in patients with epilepsy,” Dr. Kanner says. “Our data show that these disorders are actually more prevalent than previously suspected. This is an important finding, because bipolar disorders are more difficult to manage than unipolar depressive disorders.”
Raising Awareness to Improve Treatment & Outcomes
The results emphasize the importance of recognizing mood and anxiety disorders among patients with newly diagnosed focal epilepsy, as well as their association with increased symptoms of suicidality, Dr. Kanner continues.
“Neurologists have started to pay attention to depression in this patient population, but I’m not sure that we’re yet giving anxiety and panic disorders the same level of attention that is required,” he says. “You cannot provide a comprehensive evaluation of a patient with epilepsy, or comprehensive treatment, without screening for these frequent comorbid psychiatric conditions.”
Additionally, certain antiseizure medications may have negative psychotropic properties, which can result in the development of psychiatric symptoms following their introduction.
“It’s the same as screening for a history of high blood pressure and diabetes in a patient who has had a stroke,” Dr. Kanner says. “The same applies for psychiatric disorders in patients with epilepsy because these conditions will have an impact on treatment and the course of the disease. There are 32 antiseizure medications. Selection of the medication has to be based on the type of epilepsy, comorbid medical and psychiatric conditions, and a determination of whether the medications you’re selecting will improve those comorbid conditions or make them worse.”
