Audience Q&A with Dr. Kanner

How does the acceptance of an epilepsy diagnosis contribute to the development of both mood and anxiety disorders?

That’s a very important question. And this is a question that, unfortunately, we neurologists do not spend enough time discussing with patients. Because failure to accept the diagnosis of epilepsy is very frequent, a very important cause of the development of symptoms of depression and anxiety.

One of the most difficult things about dealing with epilepsy, in addition to having seizures, is the loss of the predictability of life. When you have epilepsy, you don’t know when or if you’re going to have another seizure. And that loss of predictability is very difficult to come to terms with in the beginning. It causes tremendous anxiety for the patient. It also causes tremendous uncertainty in parents of children with epilepsy. And it’s not unusual that some patients may deal with that unpredictability through denial and saying, “No, this was not epilepsy. This is not going to happen to me again.”

The emotional energy patients and families use to deny the diagnosis of epilepsy results in the opposite effect. They become more anxious and more depressed. In my experience, when a child or adolescent experiences epilepsy and senses their parent is having a very hard time accepting the diagnosis of epilepsy, the young person or child will react by denying the occurrence of the seizure disorder and will start acting out, becoming non-compliant. And it’s going to result in a vicious circle.

One of the common mistakes is that family members don’t want to upset the patients. And when they are talking about the epilepsy, they say, “No, no. Don’t worry about it. Everything is okay. We don’t want to upset you.” What needs to be done is the opposite. You need to talk openly about the diagnosis of the epilepsy, the fear of what can happen if you have epilepsy or an epileptic seizure.

And the big elephant in the room is, particularly for patients and parents, “Am I going to die if I have a convulsion?” That fear needs to be openly discussed by the patient, the family, and all family members. By coming to terms with the loss of predictability, which takes time and is equivalent to a mourning process, people come to terms with accepting the diagnosis. Then one morning, they wake up and say, “You know what? I can live with this.” But this is essential. This is a very essential part of accepting the diagnosis of epilepsy. And it prevents the development of unnecessary depression and anxiety that is a reactive process to the diagnosis.

In regard to surgery: Why can epilepsy surgery result in anxiety and depression right away? 

That’s a very interesting question, because this occurrence is not a very simple process. What we see is that about 20 to 30% of people who undergo temporal lobectomy may experience episodes of depression and anxiety during the following three to six months. After a period of 12 months, those symptoms remit completely in most of the patients, but about 10% of patients may continue to experience these symptoms.

The majority these individuals may have had depression and anxiety before epilepsy surgery, so what these episodes consist of are a reactivation of a presurgical depressive and anxiety disorder. Those depressive or anxious episodes need to be recognized before the patient goes to surgery, and the patient and family need to be educated on the possibility of these episodes recurring during the first three to six months post-surgery. The good news is, these episodes can be easily treated with low doses of antidepressant medication.

There is, however, about 15 to 20% of patients without a past history of anxiety and depression who develop these conditions after surgery. The explanation for that may lie in chemical changes that occur with a seizure disorder. That’s one of the hypotheses, but we really don’t know exactly how to explain this phenomenon.

Another interesting observation is that about 50% of patients who had a history of depression and anxiety prior to their surgery, stop experiencing those episodes after surgery. For these individuals with epilepsy, not only is the temporal lobectomy resulting in seizure improvement or remission, but also the remission of depression and anxiety disorders.

As a follow-up question, are there any studies that analyze patients pre- and post-surgery and examine their levels of anxiety and depression?

Unfortunately, there is very little in the way of formal studies that have been conducted. There were some studies done in Australia which identified that people with a previous history of depression and anxiety are more likely to experience depressive episodes after surgery. Hence why doctors could actually identify who is at increased risk of developing post-surgical episodes of depression by taking a very careful history of their psychiatric disorders before surgery.

We don’t have studies on the mechanisms that facilitate the development of the normal episodes of depression and anxiety. But hopefully, with new neuroimaging techniques and higher-solution MRI studies, we will have answers in the future.

Can you speak to the effectiveness of yoga, meditation, and homeopathic options and if patients can try these approaches before starting additional medications?

I advocate the use of yoga and relaxation techniques for people who report worsening seizures or an increase in seizure frequency when they are going through very stressful situations. In these patients, the use of these relaxation techniques – yoga in particular – can be very effective in teaching how to do self-relaxations, which in turn results in a decrease in seizure frequency.

With respect to the use of yoga and relaxation techniques for the actual treatment of depression or anxiety disorder, these practices can be beneficial, but if there is a long history of depression and anxiety disorder, it may be necessary to use additional treatment strategies. If medication is something the patient is not interested in considering, cognitive behavior therapy is a very effective form of treatment for depression and anxiety.

Cognitive behavior therapy is a form of therapy provided by psychologists. It consists of 12 sessions, one session a week, in which the psychologist teaches patients how to counteract and overcome the symptoms of depression and anxiety. The effect of this therapy is extremely impressive, and can be as good or even better than the results seen with medications. We refer our patients for cognitive behavior therapy to neuropsychologists in the community with very good results.

Is research being done to determine if cannabidiol (CBD) helps to control not only seizures, but also some mood disorders associated epilepsy?

There is no data on the use of cannabidiol on the treatment of mood and anxiety disorders in epilepsy that I’m aware of. I know there is very extensive use of marijuana by patients as a way of self-management of anxiety and depressive symptoms. The psychiatric literature on the impact of marijuana on a mood and anxiety disorder is indicative that, in the long term, it has a negative effect.

Now we’re talking about marijuana, which has a THC component. We’re not just talking about the cannabidiol extraction being used for the treatment of some epilepsy conditions. People with a history of mood and anxiety disorders have to be careful with the use, and particularly excessive use, of marijuana as a self-treatment, because in the long term it can worsen these conditions.

We don’t know cannabidiol’s effect on the treatment of depression and anxiety. This topic is one I’m sure will be investigated in the future, but today we don’t know.

Should a patient request the completion of the questionnaires you mentioned in your presentation, or are they just a normal part of the diagnosis and treatment?

Many clinics today in the United States are using those questionnaires when the patients come into the epilepsy clinic. The patient fill out these questionnaires in the waiting room, then give them to the physician. This is a nice way for the physician to screen for the presence of mood and anxiety disorders and to know to follow-up about these symptoms.

If the clinician the patient is seeing is not using those screening instruments, patients can suggest it. These instruments can be downloaded for free from the American Epilepsy Society or the Epilepsy Foundation. Or patients can email me and I’ll be happy to give them the reference of where they can obtain these instruments.

I think physicians who use the questionnaire have found it to be extremely effective. The NDDIE now has become adopted by the International League Against Epilepsy as the screening instrument for depression. In addition, it has been translated into close to 17 languages, so it’s widely used across the world.

Did the studies you referenced in your presentation account for gender differences and associated hormonal and catamenial epilepsy?

Yes, that’s a very important question. We know that women have a higher incidence of depression than men among non-epileptic patients with depression. In people with epilepsy, we’re not seeing that gender difference. The risk of depression is as high in men as it is in women. That’s an important difference we see in people with and without epilepsy.

In the case of catamenial epilepsy, which consists of seizures occurring around the time of menstrual periods, there is a change in mood during the menstrual period that women may experience. There are some women who notice they can become more easily depressed around their menstrual periods. They may have to push themselves to do things, they may become more tearful over little things, they may become irritable or cranky, they may notice their concentration is affected. So it’s like they are experiencing mini depressive episodes which last a few days every month.

Women with these conditions often have a previous history of depression or have a family psychiatric history of mood and depression disorders, as these disorders are genetically mediated. When somebody has these conditions, the next generation (first-degree relatives) have an increased risk of experiencing these psychiatric disorders, because they are linked to several genes.

That being said, the occurrence of changes in mood around the time of menstrual periods should prompt the patient to see if they have any risk factors. Patients often find out that, “Oh, my mother used to suffer from severe depression or anxiety, my grandmother….” The fact is that the sexual hormones have the same impact on seizures as on the development of symptoms of depression.

Can you summarize the main causes of mood disorders that affect epilepsy patients?

Mood and anxiety disorders have multiple causes. As previously discussed, one cause can be a reaction to the diagnosis of epilepsy and the lifestyle implications (not being able to drive, reduced independence, etc.). Also as previously mentioned, there are risk factors associated with family history of mood and anxiety disorders, including whether there’s a first or a second-degree relative who has suffered from these kind of psychiatric disorders.

A third cause is the chemical changes that happen in the brain which are associated with the seizure disorder, as well as side effects of both pharmacologic and surgical antiseizure treatments.

There are also peri-ictal psychiatric symptoms, which is when the symptoms of depression and anxiety are related to the actual occurrence of the seizure itself. This situation has to be distinguished from the causes mentioned above, because obviously those symptoms have a different mechanism of development and are not responsive to pharmacologic treatment with antidepressant medications.

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The information contained herein is provided for general information only and does not offer medical advice or recommendations. Individuals should not rely on this information as a substitute for consultations with qualified health care professionals who are familiar with individual medical conditions and needs. CURE strongly recommends that care and treatment decisions related to epilepsy and any other medical condition be made in consultation with a patient’s physician or other qualified health care professionals who are familiar with the individual’s specific health situation.