The pharmacological management of psychiatric comorbidities in patients with epilepsy

Abstract

Psychiatric disorders represent a frequent comorbidity in patients with epilepsy affecting quality of life, morbidity and mortality. Evidence-based data on the management of these conditions are limited but a number of recommendations are now available to guide clinical practice. The present paper reviews the pharmacological treatment of psychiatric problems in epilepsy with special attention to data coming from randomised controlled trials (RCTs), pharmacological interactions with AEDs and the issue of seizure worsening during treatment with psychotropic drugs. Epidemiologically or clinically relevant psychiatric conditions are discussed namely mood and anxiety disorders, psychoses and attention deficit hyperactivity disorder.

Developments in depression in epilepsy: screening, diagnosis, and treatment

“…Screening for depression should always be linked to well-defined and effective care pathways [69]. In general terms, data on treatment of depression in epilepsy is still limited and relies heavily on individual clinical experience [70]. Two documents, an International Consensus Statement and a US consensus paper have issued a number of recommendations [25,71].…”

“…In general terms, all these studies seem to suggest that SSRIs (Table 3), sertraline and citalopram in particular, are safe and effective, but the level of evidence is low and the reported response rates are quite heterogeneous and ranging from 24% [82] to 97% [80]. The variability in response rates can be due to many reasons such as the heterogeneity of participants (from newly diagnosed epilepsy to drug-resistant epilepsy) and pharmacokinetic interactions, especially the effect of inducers [70].…”

“…AEDs have a different potential for pharmacokinetic interactions. Among first generation of AEDs, carbamazepine, phenytoin and barbiturates are inducers of several drugmetabolizing enzymes including the CYP and the UGT systems, while valproate is a wellknown inhibitor [70,92]. Among second generation AEDs, oxcarbazepine is a weak inducer, while topiramate has some inducing properties at doses higher than 200 mg per day [92].…”

“…In general terms, the clearance of almost all antidepressants is increased by AEDs with inducing properties with a reduction in blood levels of about 25% for all SSRIs, mirtazapine and venlafaxine [70] [92]. However, there is no clear evidence that these interactions are clinically relevant with the exception of bupropion whose clearance can be increased by up to 90% when carbamazepine is introduced [70].…”

A case of interictal dysphoric disorder comorbid with interictal psychosis: Part of the same spectrum or separate entities?

“…Sertraline [22], [23], citalopram [24], [25], [26], reboxetine [26], mirtazapine [26], and fluoxetine [23] were all shown to be effective in open trials, although there is no randomized-controlled trial to date that shows the superiority of SSRIs over other types of antidepressants or antiepileptic drugs with psychotropic effects [27]. As such, the treatment of interictal depression is recommended to tentatively be similar to that of endogenous depression [27].…”