Depression and stress in
epilepsy: Management
strategies
Lorna Myers, Ph. D.
Director of Clinical Neuropsychology
Northeast Regional Epilepsy Group
Chronic epilepsy and psychiatric
disorders
High estimates: 50-60% of patients with
chronic epilepsy have depressive or
anxiety disorders
More likely 30% have depression
Chronic epilepsy and psychiatric
disorders
• Changes in neurotransmitters, vitamin or
folic acid deficiencies can worsen
depression
• Life limitations (driving, working,
schooling) and stigma
* Suicide: 5 times higher than in the general
population and 25 times higher in complex
partial seizures (temporal lobe)
Depression 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
Characteristics of depression in
epilepsy
Peri-ictal depressions tend to be
associated to psychotic or paranoid
symptoms
They tend to respond to changes in antiepileptic or antidepressive medications
These patients tend to be more irritable
and emotional
Many have dysthymia between seizures
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
Types of depression?
Major Depression
Minor Depression (dysthymia)
Bipolar Disorder (manic-depressive)
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
Minor Depression
Feeling depressed almost every day for at
least 2 years
Having 2 or more of the following:
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Changes in appetite
Insomnia/hypersomnia
Low self esteem
Fatigue
Concentration problems
Hopelessness
Bipolar Disorder
Manic cycles (hyperactivity, agitation,
insomnia, hypersexuality, grandiosity,
sometimes, psychosis, racing thoughts,
pressured speech) lasting one week or
more
Intense depressive cycles
Anxiety and epilepsy
Generalized Anxiety Disorder (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
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
Why depression and anxiety in
epilepsy?
Psychological reaction to epilepsy
Social factors (lost driver’s license, job,
loss of control)
Secondary medication effects (eg.
polypharmacy, high doses, sudden
discontinuation)
Left temporal or frontal lobe epilepsy
exhibits a greater association to
depression
Why depression and anxiety in
epilepsy?
The effect of electrical discharges in or
near the limbic system
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
Treatments for clinical range
depression/anxiety
Individual therapy (cognitive behavioral
and supportive)
Family therapy and psychoeducation
Vagal Nerve Stimulator (FDA approved for
mood disorders)
For refractory major depression: Electro
shock (ECT) or Transcranial magnetic
stimulation (TMS)
Alternative treatments
Must consult with doctor prior to taking any
of the following herbs/supplements: St.
John’s Wort, Echinacea, Valerian or
aromatherapy-they have the potential to
interact with AEDs
Careful with some hands on techniques
(thai massage, cranio sacral massage,
chiropraxis). Consult your doctor.
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, avoid caffeine and alcohol
Sleep hygiene
Attend epilepsy support group and
activities
What can I do to help myself?
Strategies to support treatment or work on
small mood shifts:
Apply positive psychology principles
Learn and use relaxation techniques
Watch out for Worry Words
Work towards Optimism
Exercise 1: 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)
How can you become more
optimistic
Reframe an event, finding a hidden
blessing or strength (cognitive
restructuring).
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Not being able to drive for 6 months or a year
will allow me to start walking much more.
Being at home more time allows me to spend
time on my garden.
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 avoid judging yourself or others
(should, could)
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
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
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
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.
Correcting worry words to
reasonable alternatives
Extremist example: That was the worst
speech I ever gave.
Reasonable alternative: Could’ve done
better but at least got through it in one
piece.
All or none ex: “I’m always so bad at this”.
Reasonable alternative: “With practice I
know I will improve”.
Practice makes perfect
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
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=t05S6O6YW
gw)
Deep muscle relaxation
(http://www.youtube.com/watch?v=PYsuvRNZfx
E)
Thank you!
Be well