Expert: Ivan Goldberg, M.D. - 1/25/2008

Question
Good Morning Dr. Goldberg,
My husband has a a-typical personality disorder with bipolar. This diagnosis was concluded after a 4 hour test.
Anyways, he has a seizure diorder due to a head injury over 20 years ago. He cannnot be treated for the bipolar effectively due to the seizures. He is on Lamictal, Neurontin and Ativan. The Lamictal seems to have no effect on the mental illness, the Neurontin definately helps the depression, and the ativan (as my husband puts it), slows down his mind so he can concentrate on one thing at a time.
Today I was reading about electroconvulsive therapy. I know that experts say that they are not sure how this works, but i know that it does. The reason I say this is that after my husband has a seizure, he always has said that he feels cleansed. He seems normal in his reasoning and temperment for up to a week. I guess what I am wondering is this, already having a seizure disorder, is he a candidate for this type of treatment? Also, do the effects last longer then a week from this kind of treatment?
Thank you for your time and your help!
Susan

Answer
Hi, Susan . . .

ECT is an appropriate treatment for people with epilepsy who are depressed. Usually a series of treatments are given 2 or three times a week for 4 or 5 weeks and then more treatments may be given one a week or once every 2 weeks.

below are some abstracts or articles on the subject.

Best regards . . .
Ivan
%%%%%%
1: World J Biol Psychiatry. 2007 May 8;:1-3 [Epub ahead of print]

Electroconvulsive therapy for major depression in an elderly person with
epilepsy.

Kucia KA, Stepanczak R, Tredzbor B.

Department of Psychiatry and Psychotherapy, Medical University of Silesia,
Katowice, Poland.

The case of a 72-year-old woman with a history of 40 years of epilepsy and
medication-refractory severe depression is described. Despite the chronicity of
the present depressive episode, mild MRI pathology and somatic complications,
especially pneumonia and drug-induced hyponatraemia, we observed rapid and
complete remission of depressive symptoms in the course of ECT. Neither cognitive
impairment nor a perceptible influence on the neurological illness was seen, and
no increase in seizure threshold has been observed during the course of 2 years
maintenance ECT treatment. This article is offered in an attempt to enrich the
clinical literature in this field and therefore encourage psychiatrists to
consider ECT and MECT as a safe and efficacious option in epileptic patients with
major depressive disorder.

PMID: 17853286 [PubMed - as supplied by publisher]

2: Epileptic Disord. 2007 Mar;9(1):1-10. Epub 2007 Feb 15.

Depression in epilepsy: phenomenology, diagnosis and management.

Seethalakshmi R, Krishnamoorthy ES.

The Institute of Neurological Sciences, Voluntary Health Services, Taramani,
Chennai, India.

1) Depression is a common and important accompaniment of epilepsy. 2) Depression
in epilepsy is phenomenologically different from the usual forms of depression
and it is essential that treating physicians assess for these varied forms as
well. 3) Depression in epilepsy may be managed more effectively if the
relationship to the ictus is better understood. 4) Other factors such as
stressful life events, related or unrelated to epilepsy, may contribute to the
depressive symptoms. 5) Antiepileptic drugs, particularly GABAergic agents such
as vigabatrin, tiagabine, topiramate and phenobarbitone are depressogenic in
nature. 6) The newer antidepressants, SSRIs such as sertraline, citalopram and
paroxetine do not lower seizure threshold and can be safely used to treat
depression in epileptic individuals. Fluoxetine may be avoided because of its
longer half-life.

Publication Types:
   Review

PMID: 17307706 [PubMed - indexed for MEDLINE]

3: Epilepsy Behav. 2006 Sep;9(2):355-9. Epub 2006 Jul 28.

Electroconvulsive therapy in patients with epilepsy.

Lunde ME, Lee EK, Rasmussen KG.

Mayo Clinic Department of Psychiatry, Rochester, MN 55905, USA.

There are scant published data to guide the clinician about safe and effective
use of electroconvulsive therapy (ECT) in epileptic patients who suffer from
psychiatric disorders. In this report, we describe our experience treating 43
epileptic patients with ECT. Seven of the patients may have had spontaneous
seizures during the course of treatments, although the possibility of
pseudoseizures or nonictal phenomena seemed quite likely in several of these
cases. For the majority of patients, adequate seizures could be obtained during
ECT despite concomitant treatment with antiepileptic medications, although dose
reductions were required in a few cases. Most patients enjoyed moderate to marked
reductions in psychiatric symptoms with ECT, and one patient seemed to have a
marked reduction in spontaneous seizure frequency for several weeks after
completion of the ECT course. We conclude that most epileptic patients can be
treated with ECT without dose adjustment in antiepileptic medications and provide
general recommendations for safe use of ECT in this population.

PMID: 16876485 [PubMed - indexed for MEDLINE]

4: J ECT. 2003 Sep;19(3):173-6.

Safety and efficacy of ECT in mental disorders associated with epilepsy: report
of three cases.

Marchetti RL, Fiore LA, Peluso MA, Rigonatti SP.

Institute and Department of Psychiatry, University of São Paulo, São Paulo,
Brazil. rlmarche@dialdata.com.br

SUMMARY: The authors report on the use of electroconvulsive therapy (ECT) in the
treatment of three patients with mental disorders associated with epilepsy. They
discuss several aspects related to safety, efficacy, and indications of ECT in
these patients. The observed results, as well as published data, provide evidence
that ECT is a safe and effective therapeutic option for some patients with mental
disorders associated with epilepsy. The indications are the same as in patients
without epilepsy. There might be another possible indication for patients with
alternative mental disorders (forced normalization), although improvement after
spontaneous seizures may not always predict response to ECT.

Publication Types:
   Case Reports

PMID: 12972989 [PubMed - indexed for MEDLINE]

5: Epilepsia. 2003;44 Suppl 4:30-40.

The recognition and management of mood disorders as a comorbidity of epilepsy.

Barry JJ.

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford,
California 94305, USA. jbarry@leland.stanford.edu

Mood disorders, especially as a comorbid finding in people with medical disorders
in general, and in those with epilepsy in particular, have become increasingly
recognized as a serious health concern. Unfortunately, affective disorders are
underrecognized, and appropriate treatment is infrequent. The consequences of
poor detection of mood disorders in people with epilepsy are discussed, along
with a review of risk factors and the appearance of the disorder in this
population. Prevalence rates of both depressive and bipolar spectrum disorders in
people with epilepsy appear to be higher than in the general population. Recent
data from community samples show elevated rates of both disorders in people with
epilepsy, significantly above those in people with and without other chronic
diseases. Assessment issues, including the positive and negative side effects of
antiepileptic drugs, are reviewed. Treatment options are discussed, along with
caveats concerning the use of antidepressants in people with epilepsy, with a
focus on safety, utility, and drug interactions. Electroconvulsive therapy can
also be used safely in people with epilepsy, and vagus nerve stimulation may have
some utility in the treatment of depressive disorders as well. However, despite
improved detection methods and effective treatments, implementation of this
knowledge in neurology outpatient clinics is still problematic.

Publication Types:
   Comparative Study
   Review

PMID: 12823567 [PubMed - indexed for MEDLINE]

6: Neurology. 2002 Sep 24;59(6 Suppl 4):S48-55.

The co-morbidity of depression and epilepsy: epidemiology, etiology, and
treatment.

Harden CL.

Comprehensive Epilepsy Center, Weill Medical College of Cornell University, 525 E
68th Street, Room K-615, New York, NY 10021, USA.

Co-morbid depression is common in patients with epilepsy and is often
undiagnosed. The manifestation of depression in epilepsy is multifaceted with
many interacting neurobiological and psychosocial determinants, including
clinical features of epilepsy (seizure frequency, type, foci, or lateralization
of foci) and neurochemical or iatrogenic mechanisms. Depression is reported more
frequently in patients with temporal lobe epilepsy (TLE) and left-sided foci,
although not all studies support this finding. In patients with depression and
epilepsy, optimal control of seizures should be attained first and foremost with
appropriate anticonvulsant treatments including antiepileptic drugs (AEDs) and
vagus nerve stimulation (VNS) therapy. Some anticonvulsant treatments (VNS,
valproate, carbamazepine, lamotrigine, and gabapentin) have demonstrated mood
improvement in epilepsy patients and may have therapeutic potential for this
patient population. When antidepressants are necessary to treat depression in
patients with epilepsy, selective serotonin reuptake inhibitors (SSRIs) and
multireceptor antidepressants are considered first-line treatments.
Electroconvulsive therapy is not contraindicated for treatment-resistant or
psychotic depression. Depression must be recognized, diagnosed, and adequately
treated in patients with epilepsy.

Publication Types:
   Review

PMID: 12270969 [PubMed - indexed for MEDLINE]

7: CNS Drugs. 2002;16(5):291-302.

Mood disorders in patients with epilepsy: epidemiology and management.

Harden CL, Goldstein MA.

Comprehensive Epilepsy Center, Weill Medical College of Cornell University, New
York, New York 10021, USA. clharden@med.cornell.edu

Patients with epilepsy are at high risk for depression because of an incompletely
understood combination of factors that may be both psychosocial and neurological.
Interictal depression in patients with epilepsy is an undertreated condition, in
part because of concern regarding drug interactions and the risk of exacerbating
seizures with antidepressant treatment. Bipolar disorder is not described as
occurring with a higher than expected frequency in the population with epilepsy,
but high rates of depression and suicide are well recognised, highlighting the
need for more emphasis on antidepressive treatment in this group of at-risk
patients. Neurological factors, including site and lateralisation of seizure
focus, may be important for the development of depression, with left-sided
seizure foci having a higher association with depressive symptoms. Forced
normalisation may be a factor in the paradoxical onset of depression in patients
with epilepsy whose seizures suddenly become well controlled by anti-seizure
treatment. Lowering of folic acid levels by some antiepileptic drugs (AEDs) may
also influence the expression of depression in patients with epilepsy. New AEDs
continue to emerge as beneficial treatments themselves for mood disorders, with
lamotrigine, gabapentin and, to a lesser extent, topiramate having clinical
trials data to support their use in patients with bipolar disease. Similar
positive data are available for vagal nerve stimulation. Mood effects of AEDs can
be complicated, however, as many of these drugs (e.g. tiagabine) have also been
reported to cause depression as an adverse effect. Electroconvulsive therapy in
depressed patients with epilepsy requires special consideration.The selective
serotonin reuptake inhibitors (SSRIs) and antidepressants that act at multiple
receptors (e.g. nefazodone, venlafaxine) are the most appropriate treatments for
depressed patients with epilepsy. Among these agents, citalopram has a low risk
of interactions with AEDs. Bupropion, clomipramine and maprotiline are associated
with a greater risk of seizures compared with other antidepressants and
consequently should be used with caution in the treatment of depression in
patients with epilepsy.

Publication Types:
   Review

PMID: 11994019 [PubMed - indexed for MEDLINE]

8: Epilepsia. 1999;40 Suppl 10:S21-47.

Depression in epilepsy: etiology, phenomenology, and treatment.

Lambert MV, Robertson MM.

Department of Psychological Medicine (Neuropsychiatry), Institute of Psychiatry
and GKT School of Medicine, London, United Kingdom.

A history of depression or depressive symptomatology has been reported in up to
two-thirds of patients with medically intractable epilepsy, whereas community
studies have demonstrated affective disorder only in a quarter of these patients.
Depression has been reported peri- and interictally. However, differentiation may
be difficult in patients with frequent seizures. Most authors have found no
correlation between depression and epilepsy variables. However, complex partial
seizures, especially of temporal lobe origin, appear to be etiologic factors,
particularly in men with left-sided foci. Depression is also more common in
patients treated with polytherapy especially with barbiturates, phenytoin, and
vigabatrin. Depression has also been described de novo after temporal lobectomy.
Psychosocial factors also play a part, but underlying risk factors (e.g.,
genetic, endocrine and metabolic) may explain the increased rates of depression
in people with epilepsy compared to those with other neurologic and chronic
medical conditions. The depression appears to be endogenous. Patients tend to
exhibit fewer neurotic traits and more psychotic symptoms such as paranoia,
delusions, and persecutory auditory hallucinations. Treatment approaches include
psychotherapy, rationalization of antiepileptic drug medication, antidepressant
treatment, and ECT. The tricyclic and related antidepressants appear to be
epileptogenic, especially in people at high risk (personal or family history of
seizures, abnormal pretreatment EEG, brain damage, alcohol or substance
abuse/withdrawal and concurrent use of CNS-active medication). Seizures tend to
occur early in treatment or after dose increments, especially if rapidly
titrated. There is little evidence that the newer antidepressants, e.g.,
selective serotonin reuptake inhibitors, moclobemide, venlafaxine, or nefazodone
are more epileptogenic than placebo.

Publication Types:
   Review

PMID: 10609603 [PubMed - indexed for MEDLINE]