Epilepsy and Mental Health (Podcast)

For many of the 50 million adults and children dealing with epilepsy worldwide, seizures are only part of the story. Anxiety, depression and other psychiatric conditions often go hand-in-hand with neurological disorders – a sobering risk that can complicate the diagnostic process, course of treatment and patient’s quality of life.

“It’s cliché but true: mental health matters, especially in patients with chronic illnesses like epilepsy,” says neuropsychiatrist Anna Shapiro-Krew, MD, director of Epilepsy Psychiatry at Cleveland Clinic’s Neurological Institute. “When we're not addressing our patients’ behavioral concerns, we're setting them up for failure, which is why it’s so important to truly treat the whole person. Not only is the risk of morbidity and mortality greater in adults and children with untreated mental illness, but their psychiatric symptoms can actually exacerbate their seizure disorder and compromise the efficacy of treatment.”

In the latest episode of the Neuro Pathways podcast, Dr. Shapiro-Krew makes a case for early mental health screening and treatment in patients with epilepsy and discusses emerging research on the management of depression and anxiety. She covers:

• The link between seizure disorders, psychiatric comorbidities and suicidal ideation
• The neurobiology of mental health disorders, including psychosis
• Improving outcomes with effective mental health screening
• Special considerations when managing children and adolescents with epilepsy
• Evidence-based psychiatric treatments, including novel medications and peer support
• Ongoing, collaborative clinical research efforts

Click the podcast player above to listen to the 20-minute episode now, or read on for a short, edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

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Podcast excerpt

Podcast host Glen Stevens, DO, PhD: In the diagnostic process, when should we start screening patients with epilepsy for potential psychiatric-related comorbidities?

Dr. Shapiro-Krew: Honestly, right away. We see a lot of anxiety and depression with the initial diagnosis [of epilepsy], but the risk continues as the chronic disease progresses. [This is] particularly true when epilepsy is diagnosed in childhood or early adulthood. Mental health is something we can't forget about…because the risk of suicide in these patients is two to five times greater than in the general population.

Dr. Stevens: Why are there so many psychiatric pathologies in epilepsy patients – what's the theory?

Dr. Shapiro-Krew: It really goes back to the idea of neuroinflammation. When I was in training, this [concept] was still new. We had a lot of theories about monoamine transmission and glutamate and GABA dysregulation causing psychiatric disease – ideas that are still very valid. But [we now think] there's a somewhat-bidirectional neuroinflammatory process that may be responsible for psychiatric comorbidities in [patients with] severe neurologic diseases.

Studies have shown us that, in fact, the predominant symptom that arises before patients actually develop a disorder like epilepsy or Parkinson's disease tends to be depression or anxiety. Patients who have uncontrolled [mental health] symptoms often have worsening seizure symptoms – and vice versa.

Dr. Stevens: Are there any interesting studies you want to talk about?

Dr. Shapiro-Krew: I think it’s interesting that [researchers] are starting to approach epilepsy more collaboratively. One of my favorite things to read about and discuss right now is the utilization of old, unused antidepressants. For example, we've been looking at building a fenfluramine program here at Cleveland Clinic. Fenfluramine was initially designed as an antidepressant and then became an appetite inhibitor; now, it’s being modified again for use as an antiepileptic that can also serve as a mood stabilizer.

We also see [therapeutic potential] in neuromodulators like vagal nerve stimulators, which have been approved by the FDA for the treatment of depression. We're…now asking if [these agents] can be helpful for managing certain anxiety disorders. [In addition], we’ve conducted studies on deep-brain stimulators for the treatment of obsessive-compulsive disorder. [Through research], we're finding that we can kill multiple birds with one stone, which in my mind is very, very cool.