Mental Health and Epilepsy PDF Review Article 2019

Hindawi Behavioural Neurology Volume 2019, Article ID 2571368, 4 pages https://doi.org/10.1155/2019/2571368 Review Article Assessment and Management of Depression and Anxiety in Children and Adolescents with Epilepsy 1,2 David Plevin and...

Hindawi Behavioural Neurology Volume 2019, Article ID 2571368, 4 pages https://doi.org/10.1155/2019/2571368 Review Article Assessment and Management of Depression and Anxiety in Children and Adolescents with Epilepsy 1,2 David Plevin and Nicholas Smith2,3 1 Cramond Clinic, The Queen Elizabeth Hospital, Woodville South, South Australia 5011, Australia 2 School of Medicine, The University of Adelaide, Adelaide SA 5005, Australia 3 Department of Neurology, Women’s and Children’s Hospital, North Adelaide SA 5006, Australia Correspondence should be addressed to David Plevin; [email protected] Received 31 October 2018; Accepted 7 April 2019; Published 2 May 2019 Academic Editor: Francesco Pisani Copyright © 2019 David Plevin and Nicholas Smith. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Anxiety and depression in children and adolescents with epilepsy are common comorbidities which place a significant burden on patients and families and complicate the clinical management of epilepsy. This paper presents a narrative review on the aetiology, phenomenology, assessment, and management of depression and anxiety among paediatric patients with epilepsy. The recognition of affective comorbidity in paediatric epilepsy is limited at present, and the contributory role of antiepileptic medication towards such comorbidity must be considered by clinicians. 1. Introduction 2. Factors Contributing to Anxiety and Depression in Paediatric Epilepsy In developed countries, the incidence of childhood epilepsy ranges from 33.3 to 82 cases per 100,000 persons per year. 2.1. The Psychological Sequelae of Chronic Illness. Chronic The prevalence is much higher, lying between 3.2 and illness itself can lead to anxiety and depression. This may 6.3 cases per 1,000 persons. A significant proportion be symptomatic of the illness itself; a consequence of the of these children will experience either anxiety or depression. course and management of the illness, leading to a sense of In clinic-based studies, the prevalence of anxiety in children lack of control and uncertainty or hopelessness and helpless- with epilepsy is around 30 to 35%, while the prevalence of ness from poor prognoses; an increasing fear of death; stigma depression is around 12.7 to 36.5%. The burden of psychi- and ostracism from peers; overprotective parental behaviour; atric comorbidity in children and adolescents with epilepsy is and side effects from treatment [3, 4]. Overall, the rates of significant, leading to increased morbidity and impact on anxiety in paediatric chronic illness have been reported as patients and their families. It is also clinically significant, as between 7 and 40%. In insulin-dependent diabetes it complicates the management of epilepsy. Clinicians may mellitus, for example, around 20% of children have anxiety not recognise the complex relationship between psychiatric disorders and over 25% have major depression. One symptoms, epilepsy, and medications used to treat it. Any meta-analysis reported higher rates of most forms of psycho- additional medications that are prescribed to manage psy- pathology in children with epilepsy, including anxiety/ chological symptoms, aside from having inherent individual depression, compared to healthy children. The magnitude risk profiles, may further contribute to drug burden and drug of the difference was markedly smaller between children with interactions with existing antiepileptic medication regimens. epilepsy and other children with chronic illnesses. Notably, In addition, the side effects of antiepileptic drugs themselves however, in comparison to other children with chronic may contribute to neurobehavioural and psychiatric out- illness, the effect sizes were larger for attention, social, and comes in this population. thought problems, suggesting that these issues, rather than 2 Behavioural Neurology anxiety and depression, may be more specific to epilepsy. as vigabatrin, topiramate, and levetiracetam. Vigabatrin, for These findings indicate that the psychiatric consequences of example, compared to placebo, has been associated with a epilepsy may, in part, relate to the chronic disease burden greater than threefold increased incidence of depression itself; however, these results may also reflect confounding, (2.5% versus 0.3%, p < 0 05) and a greater than eightfold as children with neurocognitive deficits may be harder to increased incidence of psychosis (12.1% vs 3.5%, p < 0 001). screen for affective symptoms. This is discussed in further In controlled trials, between 17 and 28% of patients on detail below. topiramate developed “abnormal thinking,” and, in compar- ison studies, episodes of psychosis occurred at a much higher 2.2. Organic Contributions. In most studies, no relationship rate in those patients receiving topiramate compared to those has been found between the type of seizure and the receiving gabapentin or lamotrigine. development of anxiety or depressive symptoms , with It is prudent to consider the adverse effect profile when the possible exception of temporal lobe epilepsy. In a cohort selecting antiepileptic drugs. Although neurobehavioural of children and adolescents with either cognitive difficulties adverse effects have been reported with all antiepileptic or who were considered as potential candidates for surgical drugs, neurobehavioural effects are less common with certain management of intractable epilepsy (n = 132, age range: agents, such as lamotrigine or oxcarbazepine. 6 to 18), anxiety, depression, and withdrawal were assessed The use of antiepileptic agents in combination is also using a caregiver questionnaire—the Behavior Assessment associated with neurobehavioural adverse effects. A recent System for Children 2: Parent Rating Scale (BASC-2: PRS). systematic review has reported that while the use of antiepi- Patients with temporal lobe epilepsy had a statistically signif- leptic polytherapy is widespread, it is not supported by icant increase in mean depression scores compared to those high-quality evidence backing its efficacy. There were no with frontal lobe epilepsy (p < 0 01). There was no difference identified randomized controlled trials assessing the efficacy between temporal and frontal lobe epilepsy groups for mea- or neurobehavioural safety of polytherapy. Furthermore, sures of anxiety or withdrawal. Within the subset of children several observational studies indicated that polytherapy has with partial epilepsy, there were no differences in affective statistically significant associations with depression, anxiety, symptoms based on seizure laterality, and, in the cohort as and behavioural disturbances. a whole, there was no difference in affective symptoms between those children with partial epilepsy and those with generalised epilepsy. Another cohort of children with 3. Phenomenology of Depression and Anxiety in diagnoses of complex partial seizures and childhood absence Paediatric Epilepsy epilepsy (n = 171, age range: 5 to 16) reported that children with complex partial seizures—essentially the same patient In the overall population with epilepsy, affective symptoms population as those with temporal lobe epilepsy—have a may be temporally related to seizure occurrence. It has been higher rate of depression and comorbid depression and anx- reported that, in paediatric patients, pre-ictal symptoms iety disorders and a lower rate of anxiety disorders (p < 0 02), of depression include aggression, irritability, and motor when compared to childhood absence epilepsy, a common hyperactivity. generalised epilepsy of childhood. In this study, the Kid- Previous reviews suggest that the typical features of die Schedule for Affective Disorders and Schizophrenia depression in adults, such as low mood and melancholic (K-SADS) for School-Age Children, Epidemiologic Version features, including disturbed sleep and appetite, anhedonia, (K-SADS-E) or Present and Lifetime Version (K-SADSPL) and psychomotor retardation, are rarely present in children. was used to determine the presence of affective, anxiety, Instead, irritability and negative cognitions about self, others, and disruptive disorders. Similarly, in the adult literature, and the world are seen [18, 19]. Irritability and aggression there are indications that temporal lobe epilepsy is related may also be presenting features of anxiety in children. with psychopathology [10–12]. The possible relationship There is a paucity of literature exploring the phenome- between complex partial seizures/temporal lobe epilepsy nology of anxiety and depression in paediatric epilepsy. and interictal psychiatric symptoms may implicate a limbic Furthermore, in the paediatric epilepsy population, one pathology in the development of these symptoms. Indeed, practical difficulty that arises is the question of diagnosing in animal studies, electrical or chemical stimulation of limbic psychiatric symptoms in those children and adolescents with structures, such as the hippocampus and amygdala, have led intellectual disability. For example, while there are a limited to emotional changes similar to anxiety. number of assessment tools for anxiety in children with intellectual disability, it has been noted that some of these 2.3. Pharmacotherapy. Certain individual antiepileptic agents tools lack sufficient evaluation as a measure of anxiety, and, may be associated with adverse psychiatric effects in children. for other tools, it is not known whether there can be extrap- Phenobarbital, for example, has been associated with much olation from assessment of anxiety symptoms to the diagno- higher rates of major depressive disorder and suicidal idea- sis of anxiety disorders. In addition, a cohort study of tion than carbamazepine. Levetiracetam approximately adolescents (n = 50) with mild and moderate intellectual doubles the risk of behavioural problems in children, includ- disability found no correlation between three different assess- ing aggression, hostility, and nervousness. Similarly, in ment scales of depression, two of which were informant- adult populations, there is a documented risk of psychiatric reported and the other one was self-reported. These adverse effects with certain antiepileptic medications, such difficulties in diagnosis are compounded by the paucity of Behavioural Neurology 3 research in assessing psychological symptoms in children no statistically significant differences in the number of with comorbid epilepsy and intellectual disability. episodes of depression between the cognitive-behavioural intervention and the treatment as usual groups. 4. Management 5. Conclusions The cornerstone of management is vigilant recognition and active monitoring for psychiatric morbidity in children and Recognition of psychiatric comorbidity in children and adolescents with epilepsy. This is particularly critical in adolescents with epilepsy remains limited and must be patients at a possible higher risk for such morbidity, such as improved upon, if we are to achieve a meaningful reduction those with temporal lobe epilepsy [8, 9] and those receiving in the burden of these symptoms on patients and their polytherapy. As previously noted, the diagnosis of families. While rarely singularly causative, the impact of psychiatric morbidity in those patients with intellectual anticonvulsant medication should be considered and appro- disability presents a particular difficulty. Assessing affective priately addressed by clinicians in this context. symptoms in children with intellectual disability is challeng- ing and often overlooked: an outcome which is reflected in Conflicts of Interest the paucity of research assessing the frequency and origin of these symptoms amongst children with epilepsy. Indeed, The authors declare that there is no conflict of interest there is a clear imperative to improve recognition of neu- regarding the publication of this paper. robehavioural symptoms in children and adolescents with comorbid epilepsy and intellectual disability so that clini- Acknowledgments cians may provide appropriate support and management. Clinical assessment for psychological symptoms should The authors are grateful for the assistance of Dr. Jon be part of regular clinical follow-ups. Proactive management Jureidini, Child Psychiatrist, Women’s and Children’s options, which may include providing additional supports or Hospital (Adelaide, Australia), and University Department formal specialist psychiatric review, may be beneficial for of Paediatrics, School of Medicine, The University of those patients who are at particular risk of developing psy- Adelaide, who provided help during the preparation of chopathology and their families and caregivers. Screening this manuscript. tools for psychiatric comorbidity, where available, may be profitably incorporated into routine clinical assessment. For example, for adolescents with epilepsy, a recently References available screening tool based on self-report—the Neuro- P. Camfield and C. 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