Project Care 4 EpilepsyDepression, Anxiety and Epilepsy

Tatiana Falcone, M.D.Jane Timmons-Mitchell, Ph.D.

December 16, 2014

Introduction• Despite remarkable progress in diagnosis, treatment

and positive long term seizure outcome in children with epilepsy, the high prevalence of mental health problems has not changed in 30 years

• Population studies of children with epilepsy (CWE) reported poor psychosocial outcomes in adulthood

• Davies et al. A population Survey of mental health problems in children with epilepsy.Dev Med Child Neur 2003 45:292- 295

• Rutter and Yule Neuropsychiatric study in Childhood 1970

Why do people develop mental illness?

Many factors contribute to mental health problems, including: • Life experiences, such as trauma or a history

of abuse • Biological factors, such as genes or chemical

imbalances in your brain (epilepsy)• Family history of mental health problems • Certain Medical problems- chronic medical

illness specially those that affect the brain

Psychiatric Comorbidities in Epilepsy

• Depression and anxiety are the most common psychiatric comorbidities associated with epilepsy

• They affect quality of life and how a patient responds to poor seizure control, most cases of depression go undiagnosed and untreated in these patients

• Jacoby A et al. The clinical course of epilepsy and its psychosocial correlates, findings from a UK community study. Epilepsia 1996; 37 :148 -61

• Boylan L. Depression but not seizure frequency predicts quality of life in treatment resistant epilepsy. Neurology 2004; 62 :258- 61

Epidemiologic data• Lifetime prevalence of MDD 3.7-6.7 (general population)• Lifetime prevalence in epilepsy 22.2%• Higher rates of depression in younger pts• Lifetime suicidal ideation in general population 13.3% (12.8 -13.9 95% CI)• Lifetime suicidal ideation in epilepsy 25% (16.6-33.3% CI)• Up to 40% of youth with epilepsy experience anxiety• Tellez-Zenteno, et al psychiatric comorbidity in epilepsy a population based analysis Epilepsia 2007

Predictors of mood disorder in children and adolescents

• Gender effect, with more depression in adolescent girls with epilepsy

• Age effect, more depression older than 12• No association with seizure variables• No studies on suicidal ideation and seizure variables• More severe mood disorders in children with mental

retardation• Increased family discord in children with epilepsy, increased

number of stressful life events• Caplan (2005), Dunn (2005), Hessdorffer (2005), Jones (2008)

Mental Health Screening in the Pediatric Epilepsy Clinic

• To improve access to services for patients with epilepsy in a timely fashion, every family during their outpatient appointment

• Every patient is screened at least one time every six months (if the patient is coming for an appointment)

• Screening measure severity of epilepsy, side effects from the medications, impact on family function and mental health screening

Mental health and Epilepsy

In 2007, a study of mental health problems in children

• 16.7% epileptic children with psychiatric diagnosis

Compared to:• 6.4% in children with diabetes• 4.2% in general population

Factors that Cause Mental Health Issues

Internal Factors– Biological Makeup

• Genetics– Illnesses

• Disruption in brain function (epilepsy) also affects mood and behavior

External Factorso Environmental Conditions- Bullyingo Reactions from others to epilepsyo Lack of acceptance by otherso Individuals own reaction and

acceptance of their condition

Bullying

20% of US high school students were bullied on school property

16.2% electronically bullied ere bullied on school property

(16)

Depression

In general, there has been an increase in stress and mental health issues during childhood

1 in 33 children experience depression 1 in 8 adolescents are depressed Clinical depression often 1st appears in

adolescence

Symptoms of Depression in Teens • Teens may feel sad or cry a lot, for long periods of time. • Feel guilty for no real reason; feel like they are no good;

or they have lost their confidence.

• Feel like life seems meaningless, or like nothing good will ever happen again.

• Teens may have a negative attitude a lot of the time (irritated), or seems like they have no feelings.

Depression and Epilepsy

• Teens don't feel like doing a lot of the things they used to do, like music, sports, being with friends, going out, and they want to be left alone most of the time.

• Sleeping and eating more or less.

• Grades drop.

Extreme Symptoms of Depression

• Talk about death and suicide.

• Use drugs and/or alcohol.

• Get into trouble with the law at school or in the community.

Basic concepts –

• Did the symptoms of depression appear following the introduction or increase of the AED?

• Did the symptoms follow the discontinuation of a psychiatric medication?

• Did the symptoms occur after introduction of enzyme inducing AED?

• Is the patient experiencing any other psychiatric symptoms?

SUICIDE IN THE EPILEPSIES: A META-ANALYTIC INVESTIGATION OF 29 COHORTS

M. Pompili et al. / Epilepsy & Behavior 7 (2005) 305–310

Symptoms of Anxiety

Anxiety affects the way a person thinks, but the anxiety can lead to physical symptoms, as well. Symptoms of anxiety can include:

• Excessive, ongoing worry and tension• An unrealistic view of problems• Restlessness or a feeling of being "edgy"• Irritability• Muscle tension• Headaches

Symptoms of anxiety

• Choking, chest pains, distress • Fear, fright, afraid, anxious • Hot flashes, or sudden chills • Tingling in fingers or toes ('pins and needles') • Fearful that you're going to go crazy or are

about to die

Panic Attacks Symptoms of a Panic Attack include:

• Racing heartbeat , lightheadedness or nausea• Difficulty breathing, feeling as though you can't get

enough air • Terror that is almost paralyzing , feeling of dread• Nervous, shaking, dizziness, • Trembling, sweating, shaking

TREATMENT

Do we have effective treatments?

What to do--Medication

• Medications for Anxiety and Depression– SSRIs (selective serotonin reuptake inhibitors)

used most frequently– Common brand names: Prozac, Zoloft, Celexa,

Lexapro, Paxil– Common generic names: fluoxetine, sertraline,

citolopran, escitalopram, paroxetine– Can improve symptoms of anxiety and depression

without increasing seizures

What to do --Psychotherapy

• Cognitive Behavioral Therapy (CBT) can be effective.

• CBT helps youth interrupt and change negative thoughts

• A behavioral health specialist is needed to help youth learn specific strategies

Key components of CBT• Learning how to recognize which thoughts are not

based in reality and how to change them.• Learning relaxation and deep breathing.• Making a plan to increase social and exercise

activities.• Identifying things that cause fear or worry and

learning how to tolerate them in small steps. • Talking with the entire family about the best way

to help your child.• Including everyone who works with your child in

the plan.

Tools

• Charting, journaling• Homework• Family therapy• Group therapy

What to do about Depression

• Developing a positive attitude about epilepsy, for both you and your child.

• Learning skills to support self-esteem. • Challenging extreme, disasterizing thinking. (In

Australia, “warpy” thoughts) • Learning to relax and manage stress

Burden falls to parents to advocate for their children and teach age appropriate self-advocacy skills.

Promote expectation that there is something positive to do that child can participate in and adults can make happen.

Attend school meeting; point out student’s strengths.

What to do--Bullying

What to do about Bullying

• StandUp is a Bullying Prevention Program for teens.

• We are enrolling for this free program, which students complete on their own computer at their convenience.

• If your child with epilepsy is in High School-• Stand Up- Denise Hagen 216-444-0514

What is StandUp?

Stand Up is a computer-based program designed to help high school studentsdevelop and use skills for relating to others in healthy ways.

Using the skills and ideas in this program can help teens to:• Treat themselves and others with respect• Avoid being a bully• Get help if they’re a victim of bullying• Stand up to stop bullying when they see it going on around them

This program is designed for all teens, no matter if...• They’ve had any experience with bullying or not• They’re ready to make changes in the way they relate to others or not• They’re ready to take a stand against bullying or not

StandUp Teaches Healthy Relationship Skills

1. Trying to understand and respect the other person’s feelings and needs

2. Using calm, nonviolent ways to deal with disagreements (for example,leaving the room to cool down, offering solutions)

3. Respecting the other person’s boundaries (for example, how close they want to get and what they’re comfortable and uncomfortable sharing with others)

4. Communicating your own feelings and needs clearly and respectfully

5. Making decisions that you know are right for you in social situations

6. Taking a stand to stop bullying when you see it (for example, by sayingsomething to the bully, or telling an adult)

Your Role as Parents/Caregivers

• Overcome Fears and Stigma• Help your teenager to cope/manage illness

Self–esteem and a positive self-image are critical to the success and happiness your teen experiences for the rest of their life.