Mental Health and Epilepsy - What Do We Know?

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Mental health issues such as depression or anxiety are often neglected or misunderstood in people who also have comorbidity with epilepsy.

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Depression and anxiety are more common in patients with epilepsy than in the general population and as doctors we need to approach the management of these patients very differently.
Depression and anxiety are symptoms that can have lots of different causes. In epilepsy these symptoms can relate to the condition or the seizures themselves, to the medications or to the social circumstances that result from epilepsy.
Preictal depression or anxiety can occur a day to two before a seizure or the symptoms can be a manifestation of a seizure. Postictal depression or anxiety can also occur after a seizure or a flurry of seizures where a patient has a lucid period for 24 to 48 hours and then they experience severe anxiety, agitation or depression and that can last for days or weeks at a time and resolves spontaneously. So there is complex biochemical and electrical involvement in these cases.
In these situations the best management strategy is to optimise seizure treatment. By relying solely on psychiatric medication in these instances, you might actually make the situation worse because there are some psychiatric medications, such as antipsychotics, that can lower the seizure threshold. And certain drugs in this class are more commonly being used to treat anxiety and depression.
Children and adolescents can be especially vulnerable to the psycho-social causes of anxiety and depression that may be triggered or worsened by epilepsy. Particularly for teenagers, epilepsy can cause self-esteem issues and inhibit their normal drive for independence. Having a condition like epilepsy can make a teen feel more dependent on and controlled by their family and caregivers at a time when developmentally they are seeking greater self-determination. So for some adolescents and teenagers this can be very conflicting and can make them vulnerable to mental health issues.
Locus of control issues
Seizures can occur at any time in any place and this can cause a person to feel out of control of their situation. This can result in something called ‘locus of control’ issues where this feeling of loss of control extends beyond the seizure activity to their careers, their studies or personal life and this can result in a very negative mind set and the tendency to catastrophise.
There is a theory of depression called ‘the learned helplessness model’ which plays into this scenario where it doesn’t matter what a person does, they feel that have no control over the outcome. And this is commonly seen in people with epilepsy who are experiencing depression.
In instances of anxiety, a person with epilepsy may develop agoraphobia. Because a seizure can occur at any time a person may feel a loss of control and avoid leaving the house. It is not uncommon for patients with epilepsy and anxiety to develop a profound fear of having a seizure in public, of being in a crowded place or on public transport. In different people, the locus of control issue could manifest as depression and in other people it will present as anxiety.
Not all drugs are equal
Some types of epilepsy medication can cause symptoms of anxiety and depression. The type of epilepsy a person has will inform the medication their health professional prescribes for them. This makes putting together a treatment regime a challenging task and treating an epileptic patient presenting with mental health issues even more complex. Each patient must be assessed individually with an appreciation for how certain psychiatric medications can worsen symptoms of epilepsy and vice versa, the potential for drug interactions and how medications can interfere with the thyroid gland and vitamin synthesis.
Particularly when psycho-social issues have been identified as playing a role in a patient’s anxiety or depression then cognitive behavioural therapy will yield the best results. In these cases it is important for the patient to be referred to a psychologist familiar with the patterns of thinking common in people with epilepsy who can help them to identify and overcome the thoughts that are causing them to be psychologically unwell.
Whether epileptic and/or psychiatric medication needs adjusting or CBT is required or all three, the best results will be achieved when each individual patient is assessed separately. When a ‘root cause’ approach is employed rather than symptomatic treatment, there will be a better result for the patient. The approach is all important and the underlying cause of the anxiety or depression must be identified first in order for there to be a positive outcome.

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“Each patient must be assessed individually with an appreciation for how certain psychiatric medications can worsen symptoms of epilepsy and vice versa, the potential for drug interactions and how medications can interfere with the thyroid gland and vitamin synthesis.”

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Professor Harry McConnell
MD FRCPC
Professor Harry McConnell MD FRCPC is a NeuroPsychiatrist with a particular interest in epilepsy and multiple disabilities. He has published five textbooks and has a keen interest in Evidence Based Medicine and Evidence Based Mental Health and Disability Policy, working as a Clinical Editor at BMJ Clinical Evidence and also developing a successful Neuropsychiatric Service with a national referral base in the USA. Professor McConnell has worked extensively with the WHO, World Bank and other international agencies. He is Professor of Neuropsychiatry, Clinical Sub-Dean and Academic Lead in Mental Health at Griffith University School of Medicine and heads the Neuropsychiatric Service at Currumbin Hospital and the Second Opinion Neuropsychiatry Service at Gold Coast Hospital. He is active with many disability related NGOs, serves on the Queensland Council for Disability and is Chair of the Gold Coast Disability Council.