Selecting an Antidepressant for Use in a Patient with Epilepsy

Abstract

Depression is a common and disabling condition and is especially disabling for patients who also have epilepsy. Antidepressants, particularly the tricyclic antidepressants are well known to be associated with seizure activity, but this is a very neglected area of research. Most of the data on the proconvulsive effects of antidepressants come from either work in animal models or from research into the effects of antidepressants in overdose. Both of these situations may tell us little about the behaviour of antidepressants in patients with epilepsy. The selective serotonin [5-hydroxytryptamine; 5-HT] reuptake inhibitors have a low seizure propensity, are well tolerated in overdose and have a favourable adverse effect profile, making them suitable as first line treatments for depression in patients with epilepsy. Other antidepressants, e.g. trazodone, moclobemide, mirtazepine, are also likely to have minimal proconvulsive effects, but adverse effects, interactions with other drugs, especially anticonvulsants, or the lack of clinical data may make their use less attractive. Although this review has focused on these clinically important issues it is clear that considerably more research needs to be undertaken on the seizure propensity and clinical efficacy of antidepressants in patients with epilepsy.

Psychiatric Comorbidity in Chronic Epilepsy: Identification, Consequences, and Treatment of Major Depression

“…However, the study of epilepsy could benefit from the demonstration of effective models of intervention and treatment of major depression in other settings. More generally, there are several helpful resources pertinent to the issue of treatment and intervention, including careful discussions of antidepressant medication treatment in epilepsy (62)(63)(64)(65)(66)(67), the consensus statement on the undertreatment of depression (26), and the report from the Agency for Health Care Policy and Research (68), which provides guidelines for acute, continuation, and maintenance treatment of depression along with consumer information on depression. In addition, information is available concerning public screening and other public health programs for identification and awareness of depression (69)(70)(71)(72), and the recently released Surgeon General's report on mental health contains information of interest on mood and other disorders for both consumers and clinicians (73).…”

Depression in Epilepsy: A Common but Often Unrecognized Comorbid Malady

“…There are no reports in the literature of tricyclic AD (TCA)-induced seizures at therapeutic plasma concentration. Patients taking therapeutic doses of TCAs and presenting with drug-induced seizures have been found to be slow metabolizers of these drugs (105,106). Furthermore, the clinical evidence shows that depressive symptoms in epileptic patients can be treated with modest doses of ADs, equivalent to half of the doses required for depressive disorders in nonepileptic patients.…”

Use of Antidepressants in Epileptic Patients

“…Yaşlılar genellikle daha uzun eliminasyon yarı ömürleri ve daha olumsuz etkiler gösterirler. CYP substratları, diğer eş substratların metabolizmasını kompetitif olarak inhibe eder ve bazı ilaçlar kendi metabolizmalarını başka ilaçlarmış gibi inhibe eder veya indüklerler [77].…”

“…Antidepresanların Antiepileptik İlaçlar Üzerine Etkileri TCA'lar, AEİ'ların eliminasyonu üzerinde toksik fenomen riski ile birlikte inhibitör etkiye sahip olabilir [77,80,81]. Nortriptilin, imipramin,nomifensin, trazodon veya viloxazin ile tedavi edilen hastalarda, bu ilaçlar fenitoin düzeylerini artırabilmektedir.…”

“…Hangi antidepresan seçilirse seçilsin, hastalara düşük dozda başlatılmalı ve terapötik doz elde edilene kadar kademeli olarak arttırılmalıdır. Buna ek olarak, antidepresanlar, antikonvülzanlar ile etkileşime girebileceğinden, özellikle tedavinin ilk aşamasında antikonvülzanların plazma konsantrasyonları dikkatle izlenmelidir [77].…”