Depression in patients with epilepsy along with discussion regarding ictal fear

Psychiatric co-morbidity in patients with neurological disease is always a mixture of biological symptoms and psychogenic reactions. Depression in patients with epilepsy is not an exception, in whom multiple facets of various problems interact, resulting in psychiatric disability. When confronted with a patient suffering from depressive state, it is essential to disentangle their complicated mixture of problems in order to focus on the individual roots. First, based on the chronological relationship to seizures, a depression-like state in patients with epilepsy can be divided into four subtypes; preictal or prodromal, ictal, postictal, and interictal. The former three are chronologically closely related to seizures, while the latter subtype occurs independently from seizure manifestations. Further, special attention must to be paid to depression in epilepsy patients following surgery, especially after a temporal lobectomy in those with medial temporal sclerosis. Among the variety of depressive states seen in epilepsy patients, interictal depression stands out overwhelmingly in regard to frequency. However, postictal and interictal depression are intermingled at times, and can be demarcated only with difficulty. The prevalence in patients with active epilepsy ranges from 20% to 55%, while that in those whose epilepsy is controlled ranges from 3% to 9%. The mortality rate from suicide is also reported to be elevated up to 10 times that seen in the general population. Particularly, the risk is high in patients with temporal lobe epilepsy, who have been reported to have a 25-fold higher risk of suicide. The first report of Robertson and Trimble, dating back to 1985, failed to demonstrate a difference between placebo and antidepressant administrations. On the other hand, most other previous reports have confirmed the effectiveness of antidepressant therapy for patients with epilepsy, though no random control trials have been performed. The safety of antidepressants, especially selective serotonin re-uptake inhibitors, seems to be well established. However, there may be some elevation of seizure susceptibility over the long term in such treated patients. Finally, two important practical issues will be re-emphasized as take-home messages. The first is misdiagnosis of ictal fear, or ictal anxiety, as a panic attack or psychogenic anxiety disorder, and the second is how to deal with irritable depression, which is frequently observed in patients with temporal lobe epilepsy. These pathological states are often serious enough clinically to heavily impact the life of the patient and their family members, thus awareness regarding these issues are important for medical personnel involved with treatment of patients with epilepsy.