Depression and stress in epilepsy management strategies
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Depression and stress in epilepsy: Management strategies Lorna Myers, Ph. D. Director of Clinical Neuropsychology Northeast Regional Epilepsy Group Chronic epilepsy and psychiatric disorders 50-60% of patients with chronic epilepsy have depressive or anxiety disorders

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Depression and stress in epilepsy management strategies l.jpg

Depression and stress in epilepsy: Management strategies

Lorna Myers, Ph. D.

Director of Clinical Neuropsychology Northeast Regional Epilepsy Group


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Chronic epilepsy and psychiatric disorders

50-60% of patients with chronic epilepsy have depressive or anxiety disorders

  • No known association between depression and seizure type, frequency, duration, or age of seizure onset

  • Left temporal or frontal lobe epilepsy exhibits a greater association to depression


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Chronic epilepsy and psychiatric disorders

* Changes in neurotransmitters or folic acid deficiencies can worsen depression

* Suicide: 5 times higher than in the general population and 25 times higher in complex partial seizures (temporal lobe)


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In Epilepsy

  • Inter-ictal: Depression that occurs between seizures-not during an active seizure

  • Peri-Ictal: Depression just before or after (hours or days) a seizure

  • Ictal: the seizure co-occurs with depressive symptoms


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Characteristics of depression in epilepsy

  • Peri-ictal depressions tend to be associated to psychotic or paranoid symptoms

  • They tend to respond to changes in anti-epileptic or antidepressive medications

  • These patients tend to be more irritable and emotional

  • Many have dysthymia between seizures


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Types of depression?

  • Major Depression

  • Minor Depression (dysthymia)

  • Bipolar Disorder (manic-depressive)


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Important Facts about depresison

  • Over 80% of those treated for depression improve.

  • Depression can affect people of all ages, races, SES, and genders. However, the ratio of women to men is 2:1

  • Nearly half of all people who are depressed do not receive the appropriate treatment because they are not correctly diagnosed

  • Severe depression is associated to decline in mental function as time passes


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What is major depression?

  • Depressed mood almost all day long

  • Reduced interest in activities or people

  • Weight change (5% in one month)

  • Insomnia/hypersomnia

  • Motor retardation or activation

  • Fatigue

  • Guilt or low self worth

  • Concentration problems

  • Suicidal thoughts or acts


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Minor Depression

  • Feeling depressed almost every day for at least 2 years

  • Having 2 or more of the following:

    • Changes in appetite

    • Insomnia/hypersomnia

    • Low self esteem

    • Fatigue

    • Concentration problems

    • Hopelessness


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Bipolar Disorder

  • Manic cycles (hyperactivity, agitation, insomnia, hypersexuality, grandiosity, sometimes, psychosis, racing thoughts, pressured speech) lasting one week or more

  • Intense depressive cycles


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GAD and epilepsy

  • GAD: disabling and free floating anxiety that lasts for at least 6 months (+poor sleep, appetite, concentration).

  • In epilepsy: it can present with a fear of future seizures/of medical complications


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Panic attacks and epilepsy

  • Sudden and severe panic on a frequency of more than one attack per week for a period of at least 1 month

  • Patients with epilepsy have panic attacks up to six times more frequently than control populations


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Why depression and anxiety in epilepsy?

  • Psychological reaction to epilepsy (sadness, hopelessness)

  • Social factors (lost driver’s license, job, loss of control)

  • Secondary medication effects (eg. polypharmacy, high doses, sudden discontinuation)

  • The effect of electrical discharges in or near the limbic system


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Treatments for clinical range depression/anxiety

  • Prescription of psychiatric meds with the epileptologist’s blessing

  • Talk-therapy with a psychologist/social worker

  • Close monitoring by the epileptologist especially if there is a connection between epilepsy and mood


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Treatments for clinical range depression/anxiety

  • Biofeedback

  • Family therapy and psychoeducation

  • Vagal Nerve Stimulator (FDA approved for mood disorders)

  • For refractory major depression: Electro shock (ECT) or Transcranial magnetic stimulation (TMS)


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Alternative treatments

  • Must consult with doctor prior to taking any of the following herbs/supplements: St. John’s Wort, Echinacea, Valerian-they have the potential to interact with AEDs

  • Careful with some hands on techniques (thai massage, cranio sacral massage, chiropraxis). Consult your doctor.


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What can I do to help myself?

  • Exercise: yoga, pilates, non-aerobic physical exercise, weight lifting under supervision). 30’ per day improves mood

  • Diet: consult with nutritionist: proper calorie intake, fruits, vegies, whole wheat, low fat meats

  • Get treatment for my sleep disorder

  • Attend epilepsy support group and activities


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What can I do to help myself?

Strategies to support treatment or work on small mood shifts:

  • Apply positive psychology principles

  • Use a diary

  • Learn and use relaxation techniques

  • Watch out for Worry Words


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How can you become more optimistic

  • In your diary, write down a bad event that happened to you:

    • how will I know when I start to bounce back from this, how will this have limited effects on the rest of my life?

  • Reframe an event, finding a hidden blessing or strength (cognitive restructuring)


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Optimism

  • Write a Future diary (“It is now 6 months since I … and now I am ….”)

  • Gratitude (Which three people in your life have most helped you. Write them a letter, call them, write about them)

  • Savoring life (enjoy each moment)


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How to achieve greater happiness

Practice acts of kindness, volunteer

  • Learn to forgive/ Forgiveness is a way of healing yourself

  • Take time for yourself (walk, massage, facial, read a book, go to the gym, watch a movie, etc.

  • Focus on what you can control and let go of the rest.

  • Try not to judge yourself or others (should, could)


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How to achieve greater happiness?

  • Commit to your goals and pursue them (even small ones)

  • If finding yourself in an unhappy situation, start planning how you will change this.

  • Use humor

  • At times you may need to avoid unhappy people


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How do I work on my stress levels?

  • Breathing exercises (when nervous, we breathe fast, shallow. When calm, we breathe slow and deep)

  • Autogenic training

  • Deep muscle relaxation


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Track your worry words

  • Tune into your self-talk

  • Get a small notepad and carry it with you for a few days.

  • Listen to what you say to yourself when stressed and write down the internal chatter.

  • Then check your monologue for worry words


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What are worry words?

Extremist: Horrible, awful, dreadful, etc.

All-or-none: All, always, completely, never, none, etc.

Judging, commanding, and labeling: bad, wrong, must, should, idiot, jerk, pig, etc.

Victim: I Can’t, impossible, overwhelmed, worn out, etc.


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Correcting worry words to reasonable alternatives

  • Extremist example: That presentation in front of people was torture.

  • Reasonable alternative: That was difficult but not unbearable.

  • All or none example: “You always criticize me”.

  • Reasonable alternative: “Right now, I feel that you are being critical of me”.


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Practice makes perfect

  • Keep your diary on daily basis

  • Practice relaxation techniques daily (at least 2 months running)-30 minutes

  • Establish self-care activities in your regular schedule (e.g. hair stylist appt, watch a favorite show, facials)

  • Watch your diet regularly but allow yourself some pleasures.

  • Physical exercise


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Thank you!

Be well


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References and resources

  • Psychiatric Issues in Epilepsy, Edited by Ettinger, A & Kanner A (2001). Lippincott, Williams & Wilkins

  • http://www.nimh.nih.gov/publicat/spdep5122.cfm

  • 1-866-615-NIMH (6464)

  • Autogenic training (http://www.youtube.com/watch?v=t05S6O6YWgw)

  • Deep muscle relaxation (http://www.youtube.com/watch?v=KxQJIiu9tK0&feature=related )



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