Epilepsy is a chronic neurological disorder characterized by the recurrence of unprovoked epileptic seizures and associated with a series of comorbidities, among which psychiatric comorbidity is one of the most frequent. The risk of psychopathology in people with epilepsy is higher than in the general population and compared to control groups affected by neurological and non-neurological pathology. Although the real prevalence of psychiatric pathology in people with epilepsy is not yet well defined, most studies report that it occurs in 20-40% of cases more frequently in people with drug-resistant epilepsy. The topic was the focus of the session entitled 'Bridges and boundaries between neurology and psychiatry' that took place during the 62nd National Congress of SNO (Hospital Neurological Sciences) underway in Florence. The event, which opened yesterday, is scheduled until September 30 at the Palazzo degli Affari.
“Psychiatric comorbidity represents a serious problem for the patient and his/her family members/carers, worsening the quality of life, complicating the treatment and management of epilepsy and increasing the risk of death,” explained Dr. Vincenzo Belcastro, director of the UOC of Neurology at the Ospedale Maggiore in Lodi, ASST-Lodi. “Furthermore, it raises a series of questions about treatment regarding the characteristics of the drug to choose, potential pharmacological interactions and the efficacy/tolerability profile. Psychiatric disorder in comorbidity with epilepsy may precede the diagnosis of epilepsy, arise at the same time as it or subsequently.” For this reason, according to the expert, it is essential to investigate anamnesis whether the person with epilepsy has a family history of psychiatric disorders, a family and personal history of 'functional seizures', the duration of the psychiatric disorder, the manner of onset, the effect of anti-seizure therapy and surgery.
But what could be the cause of a psychiatric disorder in a person with epilepsy? Dr. Belcastro explained it during the meeting: “It could be linked to neurobiological mechanisms common to both conditions, it could be the consequence of epilepsy or simply represent pure chance. However - the expert underlined - identifying a psychiatric disorder in a person with epilepsy is of fundamental importance both to correctly adjust the therapy and for the need for a multidisciplinary approach with psychiatric professionals”. Psychiatric comorbidity in a person with epilepsy is therefore associated with a poor quality of life and a high use of healthcare resources due to the high access to emergency departments and the high number of dedicated visits at an outpatient level.
“After having defined the screening, it is important to confirm the diagnosis, since a psychiatric symptom can be present in different conditions, including peri-ictal semiology in a seizure or be a side effect of a medication.
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A study conducted in people with drug-resistant epilepsy showed that depression was the post-ictal symptom in 43% of cases and anxiety in 45%, while psychosis occurred as a post-ictal symptom in 7%. These symptoms occurred in the post-ictal phase in 50% of total seizures in people with drug-resistant epilepsy and the duration of the psychiatric symptom in the post-ictal phase could last even more than 24 hours. "Psychiatric symptoms in people with epilepsy - the neurologist highlighted - appear as a side effect of anti-seizure drugs, this event occurs on average in 1 in 6 patients. Sodium channel blockers are less associated with the appearance of psychiatric side effects, but there are no ongoing studies comparing the various drugs on this specific topic".
Therefore, it is necessary to consider how de novo psychiatric effects can occur with any antiseizure drug in people with a predisposition to psychiatric comorbidity. In epilepsy, therefore, treatment and prognosis are dependent on the accurate definition of the epileptic syndrome. In this context, the same principle should be applied to define psychiatric comorbidity. “Although the specific contribution of the epileptic syndrome, excluding temporal lobe epilepsy, in determining the onset of psychiatric symptoms in people with epilepsy has not been fully defined,” Dr. Belcastro emphasized, “the onset of a psychopathology must be considered for the long-term prognosis.” Citalopram and sertaline are considered “first-line” drugs in the treatment of depression in chronic disease conditions and therefore the same principle “may be valid” for people with epilepsy and depression.
Recent studies have finally shown that the risk of relapse and/or increase in seizures during treatment with antidepressant drugs, with the exception of high-dose clomipramine, in people with epilepsy is comparable to the risk observed with placebo. “Among antipsychotic drugs, clozapine is associated with a higher risk of seizures compared to placebo. As for anti-seizure drugs, the greatest evidence is related to levetiracetam and topiramate, but potentially all anti-seizure drugs can have a psychiatric effect in people with epilepsy with specific risk factors,” concluded the expert.
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