Journal of IMAB - Annual Proceeding (Scientific Papers) vol.

16, book 3, 2010

DEPRESSIVE DISORDERS IN EPILEPSY

K. Todorova1, M. Arnaoudova2
1) First Psychiatric Clinic, MHAT “St. Marina”,
2) Third Psychiatric Clinic, MHAT “St. Marina”,
Department of Psychiatry,
Medical University, Varna, Bulgaria

SUMMARY: employment, marital status, quality of life)(13).

Depressive disorders are the most frequent Controversy exists regarding the phenomenology of
psychiatric comorbidity in epilepsy but very often remain depression in epilepsy. According to many authors interictal
unrecognized and untreated. We examined 103 epileptic depressive disorder in epileptic patients most commonly
patients, aged 18-60 years, 40 males and 63 females, for the represents as a pleomorphic cluster of depressive symptoms
presence of interictal depressive disorder. All subjects characterized by fewer neurotic traits, higher trait and state
underwent clinical psychiatric examination, including of anxiety, most often related to seizures, high irritability,
evaluation on Hamilton Depression Rating Scale (HAM-D- explosive anger and somatic symptoms as pain, disturbed
17). A questionnaire for demographic and seizure-related sleep, decreased energy, tiredness and fatigue (1, 11, 12).
variables was also completed. Concurrent depressive Although the overall severity of these depressive disorders
disorder (clinically presented according to ICD-10 diagnostic is usually mild, they cause significant disruption to patients’
criteria) affected 28.3% of all evaluated patients. Based on daily activities, social relations and quality of life (11).
HAM-D-17 scores depression was defined as mild - 80% of
all depressed patients, moderate - 17% and severe - 3%. AIM:
Atypical presentation of interictal depressive disorder was The aim of our current study is to assess the
frequent. Depression has a tremendous effect on one’s frequency and some aspects of the phenomenology of
family, social and psychological functioning, even more than interictal depressive disorder in a random sample of adult
the actual seizure frequency and severity. Diagnostic patients with idiopatic epilepsy.
difficulties come through the atypical mode of presentation
of depressive disorders in epilepsy. Proper neuropsychiatric SUBJECTS AND METHODS:
evaluation is essential for improving treatment and quality We examined 103 consequative patients, 40 males and
of life for patients with epilepsy. 63 females, with idiopatic epilepsy, aged between 18 – 60,
Key words: Epilepsy, Depressive Disorders, Quality without any other somatic or neurological comorbidity at
of life the time of the psychiatric evaluation. The duration of
epilepsy had to be medically proven for more than 12 months
INTRODUCTION: and patients had to be seizure-free for the last 72 hours
In patients with epilepsy, mood disorders represent before entering the study. All subjects underwent clinical
a frequent psychiatric comorbidity. Depressive disorders psychiatric examination, including evaluation on Hamilton
lead the list with the prevalence of interictal depressive Depression Rating Scale (HAM-D-17) (7). A specially
disorder in patients with epilepsy shown to range between designed questionnaire for demographic and seizure-related
9 and 55% depending on the sample population and the variables was also completed.
methods of assessment (12). By contrast the prevalence of
depression in the general population is reported to be 1-3% RESULTS:
in men and 2-9% in women (8). A bidirectional relationship Concurrent depressive disorder (clinically presented
between epilepsy and depression is supposed and studies and according to ICD-10 diagnostic criteria) affected 30
suggest that depression and epilepsy may share common (28.3%) of all evaluated patients.
pathogenic mechanisms and the occurrence of one may Based on HAM-D-17 scores the severity of the
facilitate the development of the other and vice versa (9, depressive disorder was defined as mild (7-17 points) - 24
11). Multiple factors are implicated in the development of (80% ) patients, moderate (18-24 points) – 5 (17%) patients
depression in epilepsy including clinical (seizure frequency, and severe (>24 points) - 1 (3%) patient (Fig. 1).
seizure type or foci, epilepsy duration, age at onset, Among all depressed epilepsy patients 18 (60%) had
antiepileptic drugs) and psychosocial ones (life stressors, partial seizures, accompanied or not by secondary

/ JofIMAB; Issue: vol. 16, book 3, 2010 / 57

generalization (according to ILAE classification) and 12 (40%) DISCUSSION:
had primarily generalized seizures (9). Seizure free were 3 The results of the present study confirm the
(10%) of all depressed subjects, 7 (23%) had less than one assumption that patients with epilepsy are at high risk of
seizure/month and 20 (67%) had seizure frequency >1/month. depression. High rates of comorbidity may be due to a
Atypical presentation of interictal depressive disorder shared pathophysiological mechanism between epilepsy
was frequent and yet some typical features for the depressive and depression, however coincidence or selection bias
disorder in our patient group should be pointed out cannot always be excluded. In addition, genetic,
Overestimated ideas of worthlessness were reported by 12 psychosocial, and iatrogenic factors may also contribute to
(40%) of all evaluated patients and another 11 (36.7%) this finding (2). Controversy exists over the distinct and
reported overestimated ideas of guilt (Fig. 2). Feelings life is unique forms of psychopathology in epilepsy including the
not worth living reported 11 (37.9%) of all depressed phenomenology of depression. Neither traditional systems
patients, wishes to be dead – 3 (10.3%) and suicidal ideas or of classification used in psychiatry, such as the DSM or the
gestures shared 3 (10.3%) of all depressed patients (Fig. 3). ICD, which club the disorders under the broad umbrella of
In keeping with others we found that decrease in organic mental disorders, not the ILAE classification, which
energy level and productivity, fatigue or weakness were does not address the psychiatric components of the disorder
closely related to the comorbid depression in epilepsy and do justice to these “epilepsy-specific” syndromes.
a dissociation was detected between the high intensity of Regarding interictal depressive disorder, Blumer et al. (2000)
these symptoms and the predominating mild severity of the coined the term interictal dysphoric disorder and Kanner et
interictal depressive disorder (6). al. (2002) referred to it as dysthymic-like disorder of epilepsy
Thoughts and feelings of incapacity, fatigue or (4, 11). Our data is in consistency with the atypical mode of
weakness related to activities, work or hobbies reported 7 presentation of interictal depressive disorder in epilepsy
(23.3%) of all depressed patients, loss of interest in activity, which makes the diagnosis of depressive disorders in
hobbies or work was present in 8 (26.7%) and decrease in epilepsy population sometimes difficult. In keeping with
actual time spent in activities or decrease in productivity other data that epilepsy patients tend to minimize their
reported 10 (33.3%) of all depressed epilepsy patients(Fig. 4). psychiatric symptoms most of our patients reported the
Psychomotor retardation, based on observation of depressive symptoms when actively inquired for their
slowness of thought and speech, impaired ability to presence rather than spontaneously because of fear of being
concentrate, decreased motor activity was present in the further stigmatized or trying to consider them as a reflection
depressed epilepsy group and the comorbidity of epilepsy of a “normal adaptation process to the epilepsy itself” (10,
and depression probably augmented the frequency and 11).
severity of the symptom.
Comorbid depressive disorder and anxiety, wheather CONCLUSION:
or not related to seizures, are closely associated in epilepsy. Comorbid depressive disorder in epilepsy is relatively
Comorbid depressive disorder usually augments interictal common and no evaluation of these patients is complete
anxiety and the detection of high state of anxiety related to without investigation of a prior or concurrent depressive
seizures should raise questions about presence of comorbid symptoms. Advances in understanding the psychiatric
depression (3). comorbidity in epilepsy move the treatment of patients toward
High state of psychic anxiety based on HAM-D-17 a comprehensive biopsychosocial model that focuses on the
scores reported 24 (80%) of all depressed epilepsy patients. whole person rather than simply on the disease process which
Subjective tension and irritability were present in 9 (30%) is in favour of improving the Quality-of-Life of these patients.
of the patients with comorbid depressive disorder, 12 (40%)
were worrying about minor matters and 3 (10%) showed
apprehensive attitude apparent in face or speech (Fig. 5).
Somatic anxiety presented by psysiological
concomitants of anxiety: gastro-intestinal, cardio-vascular,
respiratory, urinary symptoms, etc. was detected in 23
(79.3%) of the epilepsy patients with comorbid depressive
disorder.

Fig. 1. Severity of the Comorbid Depressive Disorder

based on HAM-D-17 scores.

58 / JofIMAB; Issue: vol. 16, book 3, 2010 /

Fig. 2. Feelings of guilt according to HAM-D-17 scores.

Fig. 3. Suicide according to HAM-D-17 scores.

Fig. 4. Work and activities according to HAM-D-17 scores.

/ JofIMAB; Issue: vol. 16, book 3, 2010 / 59

 Fig. 5. Psychic anxiety according to HAM-D-17 scores.

REFERENCES:
1. Beghi, E., Roncolato, M., Visona, G. Terminology of the International League Ann Neurol. 2006 Jan;59(1):35-41.
Depression and altered quality of life in Against Epilepsy. Proposal for revised 10. Kanner AM. Depression in
women with epilepsy of childbearing age. classification of epilepsies and epileptic epilepsy: a complex relation with
Epilepsia, 45, 2004, 1, 64-70. syndromes. Epilepsia, 30, 1989, 389-399. unexpected consequences. Curr Opin
2. Beyenburg, S., Cristian D. 6. Ettinger, A. et al. Fatigue and Neurol. 2008, Apr;21(2):190-194.
Psychiatric comorbidity in epilepsy. Bull depression in epilepsy. Journal of epilepsy, 11. Kanner, A., Balabanov, A.
Soc Sci Med Grand Duche Luxemb, 3, 1998; 11(2): p105-109. Depression and epilepsy: how closely
2005, 238-292. 7. Hamilton M. A rating scale for related are they? Neurology, 58, 2002,
3. Beyenburg, S. et al. Anxiety in depression. J Neurol Neusurg Psychiatry Suppl.5,S27-S39.
patients with epilepsy: Systematic review 1960; Feb; 23:56-62. 12. Lambert, M., Robertson, M.
and suggestions for clinical management. 8. Harden, C., Goldstein, M. Mood Depression in epilepsy: etiology,
Epilepsy Behav, 7, 2005, 161-171. disorders in patients with epilepsy: phenomenology, and treatment. Epilepsia
4. Blumer D. Dysphoric disorders and epidemiology and management. CNS 40, 1999, Suppl.10, S21-47.
paroxysmal affects: Recognition and Drugs, 16, 2002, 291-302. 13. Titlic M, Basic S, Hajnsek S, Lusic
treatment of epilepsy-related psychiatric 9. Hesdorffer DC, Hauser WA, I. Comorbidity psychiatric disorders in
disorders. Harv Rev Psychiatry, 2000, Olafsson E, Ludvigsson P, Kjartansson O. epilepsy: a review of literature. Bratisl Lek
May-Jun;8(1):8-17. Depresson and suicide attempt as risk Listy. 2009;110(2):105-109.
5. Comission on Classification and factors for incident unprovoked seizures.

Address for correspondence:

Koralia Todorova, MD
First Psychiatric Clinic, MHAT “Sveta Marina“
1, Hristo Smirnenski str, 9010 Varna, Bulgaria
Mobile: +359/888 376 327
E-mail: [email protected]
60 / JofIMAB; Issue: vol. 16, book 3, 2010 /