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

ABSTRACT

Introduction: Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated.

Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur.

Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.

KEYWORDS:

• Epilepsy
• depression
• antiepileptic drugs
• interictal dysphoric disorder
• NDDI-E
• BDI
• screening
• diagnosis
• treatment
• antidepressant drugs

Article highlights

• A number of clinical instruments have been validated in adults with epilepsy and psychometric properties are available.

• The NDDI-E showed to be the most practical screening tool because it is freely available in the public domain, it has been already validated in a number of languages, and it is easy to score but different clinical settings may require different clinical instruments.

• Data on screening tolls in children is still almost non-existent and studies are urgently needed

• A non-negligible proportion of patients with epilepsy develop a depressive syndrome, not in keeping with internationally accepted classificatory systems.

• The atypical features of depression in epilepsy are due to the high comorbidity rates with anxiety disorders and the different clinical scenarios where depressive symptoms can occur such as peri-ictal symptoms and as a side effect of AEDs.

• Evidence on the treatment of depression in epilepsy is still based on low-quality data

• Even if there is no reason to hypothesis that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous treatment studies are needed in order to have proper outcome measures.

Despite seizures are mentioned as a potential adverse event of antidepressants, the evidence, in the general population, is entirely against that assumption showing no increased risk as compared to placebo. Studies in people with epilepsy are needed.

Declaration or interest

M Mula has disclosed that he has previously received consultancy fees from Eisai, UCB, Bial, and Elsevier and also has intellectual property rights with Springer. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded