“The clinical manifestations of epilepsy are not restricted to seizures,” notes Elinor Ben-Menachem, MD, PhD. “In a significant number of people, their symptoms also include comorbid psychiatric problems that need to be identified and treated.”
Mood and anxiety disorders are the two most frequent psychiatric comorbidities in patients with epilepsy, according to Dr. Ben-Menachem, and are diagnosed in up to a third of this patient population. “Then there is depression. Depressive symptoms are one of the leading independent predictors of a lower QoL in epilepsy and have a more significant impact than seizure frequency and severity,” she says.
For a study published in Epilepsy & Behavior, Dr. Ben-Menachem and colleagues reviewed the factors that impair HRQoL among patients with drug-resistant epilepsy. PW spoke with Dr. Ben-Menachem to learn more about the investigators’ findings.
PW: What prompted this research?
Elinor Ben-Menachem, MD, PhD: The management of epilepsy remains complex. Even attaining freedom from seizures does not automatically completely improve QoL for patients. Since HRQoL is an under-researched area, we set out to explore the factors impairing patients’ HRQoL and what can be done to reduce the impact of epilepsy.
We already knew, but confirmed through a literature search, that drug-resistant epilepsy is associated with psychiatric and neurologic comorbidities in a bidirectional fashion.
Physicians must understand that depression can already be present in patients at the time of epilepsy onset. Further, antidepressants should be used and not withheld because of a false belief among neurologists and other physicians that antidepressants can elicit seizures.
How is HRQoL impaired in drug-resistant epilepsy?
From a patient’s perspective, epilepsy causes a considerable social and psychological burden across all age groups. People with epilepsy experience a constant sense of fear and anxiety and perceive their lives as marked by social sacrifice.
This perception concerns daily activities, such as leaving one’s home or ability to focus on studying, and long-term goals and achievements, including education, obtaining a driving license, pursuing a relationship, or employment opportunities. Other health-related aspects involve dealing with perceived social stigma, medication dependence, emotional disorders, and depression. Familial relationships are important here, as the family is usually the main source of interaction. Lack of family support can have dire consequences.
Seizure frequency is critical, as well as drug side effects—which can be substantial—,and depression as factors that influence HRQoL. Thus, there is a need for a broader approach to the management of drug-resistant epilepsy that alleviates the disease burden in the short term and prevents years of unnecessary deterioration of QoL in the long term.
What are the implications of your findings?
It is important to establish a therapeutic partnership between the treating physician. and patient. and other clinicians, such as epilepsy nurses, psychologists, and social workers, as a team, so that patients know that they are not alone and have a support group that can take action. Management of pharmacological interactions is important, as interactions and side effects, especially the psychiatric and cognitive side effects of antiseizure medications, can be substantial. Finally, the treating physician or team must address problems beyond seizures. This requires a multidisciplinary approach, which is not always possible. Therefore, it is good to be informed about self-management strategies and programs that are currently available online to help patients access them.
Neurologists can work with patients toward a better QoL by acting on several fronts. This includes addressing adverse effects and what the patient is willing to tolerate in favor of seizure reduction; taking advantage of the added benefits of newer antiseizure medications; and screening, and then promptly referring patients with complex management to specialized centers as needed or even to less-known interventions, such as cognitive rehabilitation.
What additional research is required in this area?
The needs that still exist are numerous, and we have a long way to go before we can cure all patients with drug-resistant epilepsy. Future research objectives include new drug discovery and addressing and treating comorbidities quickly and efficiently. The NIH and the American Epilepsy Society published Epilepsy Research Benchmarks that specify exactly what research we should focus on in these areas. They include the causes of epilepsy, treatment options, prevention, and the limiting or preventing of co-occurring conditions in epilepsy.
