1. Epilepsy & Mental Health Paola M. Bailey, Psy.D. Director of Mood Disorders & Epilepsy Program Northeast Regional Epilepsy Group

2. Why is a discussion on mental health relevant to people with epilepsy? Epilepsy is a chronic neurologic condition Depression is one of the most common complications of chronic illness  CDC estimates that ≈ 1/3 of individuals with a chronic medical condition experience symptoms of depression at some point in their life.

3. Why are chronic conditions, such as epilepsy, associated with changes in mood? 1) Chronic conditions can physiologically alter mood  Changes in neurotransmitters, hormone levels, etc.  In epilepsy, electrical discharges in, or near, the limbic system (controls certain emotions) can produce mood changes.

4. Other explanations for mood changes… 2) Mood changes can be a natural reaction to receiving a diagnosis.  Sadness, anger, frustration, etc. 3) Mood symptoms could be due to iatrogenic effect of certain medications:  Side- effect of some meds (e.g., phenobarbital)  High doses  Multiple AEDs  Sudden discontinuation

5. Other explanations for mood changes… 4) Mood changes could be a reaction to life changes associated with having epilepsy Lifestyle changes (e.g., work/school) Limitations on mobility (e.g., loss of license) Limitations on previously enjoyed activities (e.g., certain sports) Loss/reduction in independence Changes in learning/memory Sense of lack of control Changes in self-esteem

6. Why is it important to address depression in people with epilepsy? There is stigma & denial that interferes, but here are some reasons why you should seek treatment:  50-60% of patients with epilepsy have depression or anxiety- it’s more common than you think!  Depression caused by chronic disease can aggravate the condition.  Depression can cause person to have worse response to treatment (e.g., meds & compliance).  Depression can intensify and even cause pain.

7. Why is it important to address mental health in people with epilepsy? Depression can limit a person’s ability to interact with others and increase social isolation. Depression can increase risk of suicide. Risk of Suicide in Epilepsy:  People w/epilepsy: risk 5x ↑ than general population  People w/complex partial seizures: risk is 25x ↑

8. Chronic Epilepsy & Depression No known association between depression and:  Seizure type  Seizure frequency  Seizure duration  Age of seizure onset However, patients who do have higher risk of experiencing depression are:  People with left temporal lobe epilepsy  People with frontal lobe epilepsy

9. General Facts about Depression Depression can affect people of all ages, races, SES, and genders.  Ratio of women: men is 2:1 50% of people with depression do not get treatment; mostly because they are not diagnosed. Of those who do get treatment, > 80% improve!

10. What exactly is Depression? Three Types:  Major Depression  Minor Depression (Dysthymia)  Bipolar Depression (Manic-Depression)

11. Major Depression Depressed mood almost all day Reduced interest in activities or people Weight change (5%/month) Insomnia/hypersomnia Fatigue Motor retardation or activation Guilt or low self-worth Difficulties with concentration Suicidal thoughts or acts What am I looking for (in myself or others)? 5> symptoms, over 2 week period: Think a drastic change from “usual” state. Think degree to which it interferes with your life.

12. Minor Depression (Dysthymia) Feeling depressed almost every day for at least 2 years (in kids, 1 yr). Less acute, more chronic. Having 2> symptoms:  Changes in appetite  Insomnia/hypersomnia  Low self esteem  Fatigue  Concentration problems  Hopelessness

13. Bipolar Disorder (Manic-Depressive) Alternating between period of mania and depression. Manic cycles  4> symptoms; lasting 1 week: hyperactivity, irritability, agitation, insomnia, hypersexuality, grandiosity, racing thoughts, pressured speech. Intense depressive cycles  Symptoms previously mentioned Ratio of mania to depression can vary  Some people more manic, others more depressed

14. Ictal Depression Ictal- physiologic state or event such as a seizure (or stroke or headache). Inter-Ictal Depression:  Depression that occurs between seizures; not during an active seizure. Peri-Ictal Depression:  Depression just before or just after (hours or days) a seizure. Ictal Depression:  Depression that co-occurs with seizure.

15. Epilepsy & Anxiety Anxiety - Experience of fear or apprehension in response to anticipated danger/threat. Around 57% of people with epilepsy have high- level anxiety. Like in depression, it can be ictal (during), interictal (between), peri-ictal (before), or post- ictal (after).

16. Epilepsy & Anxiety Anxiety and types of epilepsy:  Risk of anxiety is ↑ in: People with focal rather than generalized epilepsy People with temporal lobe epilepsy People with frontal lobe epilepsy

17. Generalized Anxiety Disorder (GAD) Excessive anxiety & worry for 6> months; hard to control Symptoms of anxiety: Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tensions Sleep problems (difficulty falling/staying asleep, or restless sleep) In epilepsy, worry can be fear of future seizures/medical complications.

18. Panic Attacks Heart pounding Sweating Trembling/shaking Shortness of breath Feelings of choking Chest pain or discomfort Nausea or abdominal distress Numbness/tingling Feeling dizzy, unsteady, lightheaded, or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying Chills or hot flashes A discrete period of intense fear Develops abruptly & peaks within 10 minutes:

19. Panic Attacks Often, with panic attacks, the person develops a fear that it will happen again. So, although a panic attack if brief ( ≈ 10 mins), it can have a more long lasting effect on the person. Epilepsy & Panic Attacks:  6x more often than general population.

20. Phobias Phobia  Unreasonable fear/anxiety of being exposed to a particular thing (e.g., flying, germ, snakes, etc.).  In people with epilepsy, can be fear of becoming ill. Social Phobia  Unreasonable fear/anxiety of social situations, especially with people they don’t know or who they expect might judge them.  In people with epilepsy, can be fear of being judged or mocked because of condition. Agoraphobia  Avoidance or anxiety related to open spaces or any place outside of one's home or a “safe zone”.  In people with epilepsy, can be fear of leaving home and having a seizure outside.

21. What if I recognize these symptoms? Don’t let shame/embarrasment/stigma prevent you from getting help.  Remember, depression & anxiety are quite common in the general population and in people with epilepsy Think about the degree of suffering these symptoms bring you, then remember that >80% of those treated, improve! Seek professional diagnosis & treatment. Suicidal thoughts require immediate attention.

22. Treatments for Depression & Anxiety Medication  Anti-depressant medication: Longer time to take effect (2-8 weeks) Require you to take them daily Some side effects to keep in mind (weight gain, dry mouth, etc.) Little risk of addiction  Anti-anxiety medications: Most take effect immediately (within 15-20 minutes) Can be taken “as needed” Side effects can be stronger (drowsiness, lethargy, etc.) Risk of dependence, so short-term use is best  Important to check with epileptologist!!

23. Treatments for Depression & Anxiety Psychotherapy (individual or group talk therapy)  Supportive Less structured, more about providing support through difficult times Short or long-term  Process/Exploration Based More in-depth analysis of personality traits, family characteristic, life patterns, etc. Longer in duration  Skills Based Teaches specific skills to target specific problems (communication, anger, etc.) Short-term

24. Treatments for Depression & Anxiety Family Therapy  Can be conducted mostly with epilepsy patient & occasionally with family, or always with family.  Can be supportive, process (changes in family unit), and/or skills based. Psychoeducation  Education about condition as well as coping strategies.

25. Treatments for Depression & Anxiety Biofeedback  Technique that teaches people to use signals from their own bodies as cues for change (e.g., think thermometer or scale).  Computer monitoring allows for very specific information on bodily functions that might otherwise not be known to the person (e.g., heart rate, temp, electrical signals within muscles, perspiration, etc.).  Person is taught to make internal adjustments that alter these states and move person into a more relaxed state.  Often used for chronic pain, migraines & panic attacks.

26. Treatments for Depression & Anxiety Vagal Nerve Stimulator (VNS)  Vagus nerves run on each side of chest and connect to brain stem.  Device is implanted next to one nerve which sends electrical impulses to the brain: Used to control/prevent certain seizures. Also used to treat depression.

27. Treatments for Depression & Anxiety Electro-Convulsive Therapy (ECT)  Electric currents are passed through the brain which cause a brief seizure → causes a change in brain chemistry → quickly reverses symptoms of depression.  It often works when other treatments have been unsuccessful. Particularly for severe depression.  Can be used in people with epilepsy (with some debate).

28. Alternative Treatments Holistic Herbs & Natural Supplements  St. John’s Wort, Echinacea, Valerian Root, etc.  Must consult with doctor prior to taking any of the following herbs/supplements because they can interact with AEDs

29. What can I do to help myself? Exercise:  Yoga, Pilates, non-aerobic physical exercise, weight lifting under supervision.  30 minutes per day improves mood; if you can’t do 30, do what you can, any physical activity improves both your physical & mental health. Diet:  Make an effort to eat a balanced and healthy diet, as this too has an effect on mood Increase consumption of fruits, veggies, whole grains, legumes & nuts Focus on lean meats, unsaturated fats (plant based) Reduce: sugar (anxiety), coffee (anxiety), alcohol (depression)  Consult with your nutritionist for your specific needs

30. What Can I Do To Help Myself? Sleep:  Problems with sleep are not only a symptom of depression and anxiety, but can also trigger a mood episode!  Try to get on regular schedule; do not nap during day.  Try ear plugs, sound machine, eye mask.  If problem persists, get sleep study and medical treatment. Meditation:  Research has shown that meditation can improve symptoms of depression & prevent relapse in those with histories of depression.

31. What Can I Do To Help Myself? Attend Epilepsy Support Groups & related activities!  Increase connection to other people who might have similar struggles/fears/concerns are you, decrease social isolation, meet inspiring people, get involved in the community.  For list of support groups in NY & NJ: www.epilepsylifelinks.com

32. What Can I Do To Help Myself? Optimism has been linked with improved medical & mental health One way to teach yourself to become more optimistic is to practice “Gratitude”  Think about 3 people who have most helped you.  Call them, write them a letter, write about them.  Get yourself thinking about how blessed you are to have them in your life.

33. What can I do? Work on Stress! Stress is related to:  ↑ in medical problems (elevated blood pressure, elevated sugar levels, ulcers, etc.)  ↑ levels of depression, anxiety, sleep problems, irritability and many other negative emotional changes Important to monitor & regulate sleep, diet, and exercise, these are all linked to stress Try some easy stress reduction exercises…

34. Stress Reduction Exercises Deep Breathing (Diaphragmatic breathing)  When nervous/scared, we breathe fast & shallow.  When calm, we breathe slow & deep.  So, if you purposefully deepen and slow down your breath, you “trick” your brain in to thinking you are calm.  Try it (with caution)!

35. Stress Reduction Exercises Deep Muscle Relaxation  Systematic technique for achieving a deep state of relaxation  Researchers discovered that a muscle could be better relaxed by first tensing it for a few seconds and then releasing it  Tensing and releasing various muscle groups in sequence throughout the body produces a deep state of relaxation  Try it!

36. So… Now we know that depression and anxiety are frequently experienced by people with epilepsy. That there are a lot of different types of depression and anxiety reactions a person can have. AND, we also know that there are a large variety of treatment approaches, from the conventional, to the more natural/holistic approaches…one will work best for you!

37. What should I do if I think I’m suffering from depression or anxiety? First, you must obtain a proper diagnosis  Only by a trained and licensed mental health professional (psychiatrist, psychologist, or social worker) Then, you can obtain proper treatment. And remember, more than 80% of those treated for depression and anxiety, get better!

38. Where do I go for diagnosis/treatment? Ask your epileptologist/nurse for a referral. Ask your insurance company for a referral. Take suicidal thoughts/reports seriously. Contact the New York State Psychological Association:  www.nyspa.org and visit “Referral Service” Page www.nyspa.org Contact National Institute of Mental Health  (866) 615- NIMH (6464)

39. References & Resources Psychiatric Issues in Epilepsy, Edited by Ettinger, A & Kanner A (2001). Lippincott, Williams & Wilkins National Institute of Mental Health  1-866-615-NIMH (6464)  http://www.nimh.nih.gov/publicat/spdep5122.cfm http://www.nimh.nih.gov/publicat/spdep5122.cfm American Psychological Association (www.apa.org)www.apa.org NY State Psychological Association (www.nyspa.org)www.nyspa.org Breathing Exercises: Treatments2go  http://www.youtube.com/watch?v=_7ySGgAFAAo&feature=related Autogenic training: Subliminal Science  http://www.youtube.com/watch?v=t05S6O6YWgw Deep muscle relaxation: Cutgame  http://www.youtube.com/watch?v=KxQJIiu9tK0&feature=related http://www.youtube.com/watch?v=KxQJIiu9tK0&feature=related