Depression and stress in epilepsy: Management strategies

1. Depression and stress in epilepsy: Management strategies Lorna Myers, Ph. D. Director of Clinical Neuropsychology Northeast Regional Epilepsy Group

2. Chronic epilepsy and psychiatric disorders • High estimates: 50-60% of patients with chronic epilepsy have depressive or anxiety disorders • More likely 30% have depression

3. 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)

4. 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

5. Characteristics of depression in epilepsy • Peri-ictal depressions tend to be associated to psychotic or paranoid symptoms • They tend to respond to changes in anti-epileptic or antidepressive medications • These patients tend to be more irritable and emotional • Many have dysthymia between seizures

6. 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

7. Types of depression? • Major Depression • Minor Depression (dysthymia) • Bipolar Disorder (manic-depressive)

8. 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

9. Minor Depression • Feeling depressed almost every day for at least 2 years • Having 2 or more of the following: • Changes in appetite • Insomnia/hypersomnia • Low self esteem • Fatigue • Concentration problems • Hopelessness

10. Bipolar Disorder • Manic cycles (hyperactivity, agitation, insomnia, hypersexuality, grandiosity, sometimes, psychosis, racing thoughts, pressured speech) lasting one week or more • Intense depressive cycles

11. 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

12. 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

13. 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

15. Why depression and anxiety in epilepsy? The effect of electrical discharges in or near the limbic system

17. 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

18. 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)

19. 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.

20. 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

21. 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

22. 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)

23. How can you become more optimistic • Reframe an event, finding a hidden blessing or strength (cognitive restructuring). • 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.

24. 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)

25. 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

26. 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

27. 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

28. 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.

29. 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”.

30. 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

31. 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=t05S6O6YWgw) • Deep muscle relaxation (http://www.youtube.com/watch?v=PYsuvRNZfxE)

32. Thank you! Be well