Depression in Epilepsy: Chipping Away at Obstacles to Diagnosis and Care

Clinical depression is an increasingly well-recognized sequela of epilepsy (see "Optimizing Treatment of Seizures by Addressing Psychiatric Comorbidities," Applied Neurology, August 2006, pages 41-42). Questions are therefore surfacing as to whether patients with epilepsy are being adequately identified and treated.

Several poster sessions were presented on this topic at the annual meeting of the American Epilepsy Society, which took place December 1 to 5 in San Diego. Three studies--2 conducted through the Comprehensive Epilepsy Center (CEC) at Weill Medical College, Cornell University, New York, and the other through the Cleveland Clinic--provided a few puzzle pieces about physician awareness, patients' attitudes about depression and intervention, and barriers to care.

A study conducted by the CEC team led by Cynthia Harden, MD, associate professor of neurology at Weill, found that the large majority of epilepsy specialists who responded to an Epilepsy Foundation survey regularly assess patients for clinical depression, understand the close connection between epilepsy and depression, and either treat or refer patients with depression.¹ However, another, larger study conducted through the Cleveland Clinic and based on direct patient evaluation noted that nearly half of patients with epilepsy and concomitant clinical depression had never seen a mental health specialist, and only a third of these patients were taking antidepressant medication at the time of evaluation.²

The third study--this one conducted through investigators at the CEC and led by Harden--found that more than a third of patients with epilepsy presenting to the CEC who also had clinical depression refused referral to a mental health specialist for various reasons that ranged from denial of the diagnosis to concerns about having to take yet another medication.³

RECOGNITION AND OBSTACLES

The Epilepsy Foundation survey¹ included respondents who voluntarily filled out a questionnaire that they either picked up at the 2004 annual meeting of the American Epilepsy Society (n = 99) or received through an e-mail query that was randomly sent to 900 members of the American Academy of Neurology (AAN) (n = 156, or 17% of the queried AAN population). Most of the respondents (168 [66%]) were in academia, and 68 (27%) were in private practice. Although physicians in the academic setting were younger and in practice for a shorter time than respondents in private practice, responses were similar between the demographic groups.

The overwhelming majority (90%) of respondents acknowledged that mood has a significant effect on patients' quality of life, and 68% of respondents reported that they "often" or "always" question patients about their mood. They did not have qualms about prescribing antidepressant agents or referring for mental health care; indeed, the consensus among respondents was that antidepressant medications were effective for the treatment of depression in epilepsy (82% agreed or strongly agreed) and that psychotherapy was effective as well (69% agreed or strongly agreed). Of interest, only 25% either agreed or strongly agreed that the vagus nerve stimulator was an effective treatment for depression in epileptic patients; 31% marked "neither agree nor disagree" and 31% marked "don't know" on their surveys, suggesting that the specialty is in need of further information about this intervention.

The red flag picked up by the study investigators, however, was that the patients' health insurance coverage sometimes (33%), often (28%), or overwhelmingly (7%) posed obstacles to referral for mental health care. The investigators surmised that the reason more epilepsy specialists who participated in the survey--particularly those in private practice--treated rather than referred patients with depression was because of barriers to mental health care imposed by health insurance carriers. They remarked that, although it appears that many patients with epilepsy are also being treated for depression by their neurologist, the effectiveness of treatment in the absence of more comprehensive psychiatric evaluation and intervention is unknown.

The approach taken by neurologists, they said, may in part be "dictated by necessity due to difficulty in referring to psychiatrists." The question, therefore, remains whether depression is being adequately treated in patients with epilepsy, they said.

The other study presented by the Cornell team sought insight about how patients with epilepsy react when referred for a depression diagnosis. It found that a significant proportion of patients with epilepsy and a depression diagnosis refused mental health care.³

In this study, 113 consecutive adult patients (64% women) presenting to the CEC were evaluated for depressive symptoms using the Quick Inventory of Depressive Symptomology-Self Report (QIDS-SR), a 16-item scale that rates depressive symptoms as "none," "mild," "moderate," "severe," or "very severe." Patients then met with a clinical social worker who counseled them about their scores. The decision to refer the patient for mental health intervention was based on the QIDS-SR score and the clinical interview.

Of the 113 patients evaluated, 46 (41%) of the patients were deemed to need referral to a mental health practitioner. Seventeen (37%) of these 46 patients already were receiving mental health care, 13 (28%) accepted referral for such care, and the remaining 17 (37%) refused referral information.

The most common reasons given for refusal of referral were denial of depression, belief that current depressive symptoms were transitory, and concerns that follow-up regarding the depression diagnosis would result in having to add yet another drug to a medication regimen. The reason for refusal given by patients with severe and very severe symptoms was lack of benefit of treatment in the past.

The moral of the report was that of the 29 patients who required but were not receiving mental health care, the percentage that refused referral was a whopping 56%. The investigators concluded that one obstacle to care appears to be the patient's perception about depressive symptoms and the need for intervention.

TRENDS AND RISK FACTORS

The study by the Cleveland Clinic team confirmed information about prevalence of depression in epilepsy and pointed out characteristics and risks.² It also suggested that unlike the Epilepsy Foundation's survey-based study, many patients with epilepsy who also have moderate to severe depression are left untreated.

This study included 301 consecutive adult patients (56% women) with intractable epilepsy who were being evaluated for epilepsy surgery. As part of the evaluation, the patients filled out a mental health status (Beck Depression Inventory-II) self-report.

A history of mental health problems was reported in 72.5% of patients. Psychiatric conditions included depression (61.9%), anxiety (23.4%), psychosis (5.0%), and bipolar disorder (1.4%). Fewer than half (46%) of these patients reported having seen a mental health specialist previously, and 41.5% reported having taken psychotropic medications. At the time of presurgical evaluation, 43.4% of patients were deemed to be mildly, moderately, or severely depressed. Of note was that, overall, only 26.5% of depressed patients were currently taking psychotropic medications. Furthermore, only half of these patients had ever seen a mental health specialist. The rate of moderate to severe depression approached 27%. Of the patients with moderate to severe depression, only 35% to 40%, respectively, were taking psychotropic medications.

The study authors noted that higher education level and being employed (full- or part-time) were associated with lower Beck depression scale scores. Being on disability, cigarette smoking, and illicit drug use were associated with higher scores, as were predisposition to left-sided seizures, family history of depression, daytime sleepiness/fatigue, and medication burden. A history of psychotropic drug use also was a risk factor for a higher depression scale score--an element of the study that harkens to the CEC study in which patients with severe or very severe depression who refused psychiatric referral did so on the grounds that they had received psychopharmacologic intervention in the past without benefit.

The authors said their findings suggest that depression in epilepsy is underrecognized and undertreated. They recommended that systems be put in place to screen for depression--at least in patients being evaluated for epilepsy surgery to avoid postoperative mood complications. They also recommended providing healthy lifestyle counseling to patients in an effort to ameliorate depressive symptoms. Furthermore, they stated that patients who receive psychotropic medications need to be monitored to gauge the adequacy of treatment.

REFERENCES1. Nikolov B, Labar D, Perrine K, et al. Survey of neurologists regarding mood in epilepsy. Presented at: 2006 Annual Meeting of the American Epilepsy Society; December 1-5, 2006; San Diego.
2. Crawford P, Thomas FM, Webster N. Mental health of patients being evaluated for epilepsy surgery. Presented at: 2006 Annual Meeting of the American Epilepsy Society; December 1-5, 2006; San Diego.
3. Quinn H, Nikolov B, Jovine L, et al. How do persons with epilepsy react when they are referred for symptoms of depression? Presented at: 2006 Annual Meeting of the American Epilepsy Society; December 1-5, 2006; San Diego.