Epilepsy: The Mental Health Symptoms We Overlook - Prof. Andres Miguel Kanner, University of Miami, USA
Psychiatric symptoms are common in the epilepsies, yet they are often overlooked in clinical care. Dr. Andres M. Kanner, epileptologist and Professor of Clinical Neurology at the University of Miami, explains why mental health symptoms are central to epilepsy outcomes - not peripheral! Topics include depression, anxiety, psychosis, ADHD, suicide risk, family psychiatric history, and how these factors influence antiseizure medication choices and quality of life. This episode is sponsored by EASEE® by Precisis GmbH and had no influence over the editorial content or discussion. Learn more about EASEE® here: https://precisis.de/en
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Episode Highlights
Psychiatric symptoms are expected in the epilepsies and directly influence seizure outcomes
Depression, anxiety, ADHD, and psychosis can appear before seizure onset
Family psychiatric history can guide safer antiseizure medication choices
Recognising mental health symptoms improves treatment decisions and quality of life
About Prof. Andres Miguel Kanner
Andres is Professor of Clinical Neurology, Head of the Epilepsy Section and Director of the Comprehensive Epilepsy Center at the University of Miami, Miller School of Medicine. Prior to coming to Miami, he was director of the Laboratory of Electroencephalography and Video-EEG-Telemetry, Associate Director of the Section of Epilepsy and of the Rush Epilepsy Center and Professor of Neurological Sciences and Psychiatry at Rush Medical College of Rush University in Chicago, IL.
Full profile: Andres Miguel Kanner
Topics mentioned
psychiatric symptoms
depression
anxiety
psychosis
attention deficit hyperactivity disorder (adhd)
suicidal ideation
bidirectional relationship
family psychiatric history
antiseizure medication side effects
quality of life
Related papers: https://www.researchgate.net/profile/Andres-Kanner-2
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Trailer
00:00 Andres M Kanner
There is a bidirectional relationship between psychiatric disorders and epilepsy. So that if you have epilepsy, you've got an increased risk of developing mood disorders, anxiety disorders, psychosis, attention deficit disorder. But if you have any of these psychiatric conditions to begin with, you have an increased risk of developing epilepsy.
Intro
00:22 Torie Robinson
Epilepsy is not only seizures. Actually, lots of people with an epilepsy don't even have seizures anymore - which is great! But what about the other, very common symptoms people can experience? Especially the mental health ones! Today we have someone who's an epileptologist and a trained psychiatrist with us - that’s Dr. Andres Kanner from the University of Miami. He’s a professor of clinical neurology, head of the Epilepsy Section, and director of the Comprehensive Epilepsy Centre - and he's gonna to share with us why psychiatric symptoms are not peripheral - like, not just a little thing on the edge of epilepsy - but they are central to how people feel, their health outcomes, and their quality of life.
If you’re new here, please subscribe so you don’t miss our chats with global leaders in the sphere of epilepsy - and let’s get into today’s episode - presented in partnership with EASEE®, by Precisis GmbH.
Why neurologists and psychiatrists don’t consider both epilepsy and psychiatric disorders
01:11 Torie Robinson
So psychiatric symptoms in epilepsy are extremely common, but they feel kind of peripheral in many clinics. Why do you think this is? Why do you think many clinicians are underestimating the psychiatric impact or symptoms?
01:26 Andres M Kanner
Part of it, I think, is a consequence of the training we give our medical students, residents, and fellows today, in that we are not training people to identify the psychiatric aspects of neurologic disorders, and we're not training psychiatrists to identify the neurologic aspects of psychiatric disorders. And that translates into the lack of understanding of the presence of psychiatric symptomatology in persons who suffer from a neurologic condition. And so, as a consequence, a neurologist will focus on the neurologic symptoms and doesn't think on inquiring about the comorbid psychiatric conditions that often happen. One out of every three persons with a neurologic disorder (it’s not only epilepsy but stroke, multiple sclerosis, dementia, Parkinson's disease), will have a comorbid neurologic and psychiatric condition. And the presence of the psychiatric condition (particularly mood and anxiety disorders), are going to have a direct bearing on the course of the neurologic disorder. For example, if you have a history of depression and anxiety, the probability that you're going to become seizure-free is less than if you don't have such history. If you have Parkinson's disease and you have comorbid depression, the course of the Parkinson's disease is going to be worse because the motor symptoms are going to worsen faster. If you've had a stroke and you have a history of depression, the chance of recovery from the sequela of the stroke is going to be not as good as if you don't have that comorbid depressive disorder. So, you can't separate the two, and yet, we have not done a good job in educating our trainees in identifying these two conditions. I have a saying and it's a sad reality “neurologists and psychiatrists don't talk to each other”.
04:07 Torie Robinson
Oh, so true!
04:90 Andres M Kanner
Even though we deal with the same brain!
04:10 Torie Robinson
It's the same organ! What are we doing?!
04:12 Andres M Kanner
And not only that, but in the United States, for example, you get boarded by the American Board of Psychiatry and Neurology. So, it's the same board, the same brain, and yet in the daily practice, the communication between the two disciplines is not what it should be. The consequences are that you're not looking at the big picture. As I tell my fellows in residence “You cannot have a neurologic condition and not expect that there's not going to be a psychiatric expression of the neurologic disorder. It just doesn't happen”.
Addressing this: look at the patient as a person and consider all symptoms
04:50 Torie Robinson
And so, tell us how you're trying to change/make a dent in all of this. You kindly invited me to speak to your students, your doctors the other day, to hear about the psychiatric aspects of the epilepsy. But what are you doing day to day with them?
05:04 Andres M Kanner
So, what I try to convince my trainees is to look at the patient not as a group of symptoms, but to look at the patient as a person. And in order to look at the patient as a person, you have to have an understanding of the…not only the neurologic symptomatology in exam, but you have to understand: where did the patient come from? What has been the achievements that that person has had, both professionally, socially? Is the patient married, single? Profession? What had been the obstacles to achieve, what they wanted to get to? I think that gives you a tremendous amount of information to understand (or very often) the neurologic conditions. Because many neurologic symptoms are affected by the patient's daily experiences. More than 50% of my patients with epilepsy recognise that when they are under a lot of stress, they're more likely to have seizures or more likely to have migraines. One of the things I do very often in patients like this, I tell them “Ok, take your cell phone out.” And they say “Why?”, I say “Just take your cell phone out and then go to the App Store and download this app that's called ‘Happier Meditation’”, and this is an app where you get self-taught on how to do self-mindfulness exercises. And when they do it, it really makes a big difference in their ability to cope with stressful situations on a daily basis, and it results in a decrease in the seizure frequency. And I think that that type of understanding of the neurologic symptoms and the patient's daily life is pivotal. And I don't think that you can understand the neurologic symptoms if you don't know if the patient has had a previous - and very importantly - a family psychiatric history. Because very often patients will say “Yeah, I got depressed because I was fired from my job.”. Yes, that's true! Anybody would get depressed because they got fired from their job! But, if you have had a previous psychiatric history of depression, your ability to cope with those stressful situations may not be as good as if you don't have that.
08:12 Torie Robinson
Mm-hmm.
Considering family psychiatric history is crucial
08:12 Andres M Kanner
And you may be able to cope better with those types of adverse situations when those comorbid conditions have been treated properly. And so I think having that perspective is essential. The other area that I find that is not recognised at all is looking at the family psychiatric history. Because when there is a family psychiatric history, that, in many instances is a risk factor for the first degree relative to develop similar type of psychiatric conditions…
08:55 Torie Robinson
Hmm.
08:55 Andres M Kanner
…when having a neurologic disorder. So, if you have somebody with a history of panic attacks in the father, the mother, and they go through a trial with certain antiseizure medications that can cause negative effects (like levetiracetam, phenobarbital, topiramate, zonisamide), if there is a family history of psychiatric conditions, those patients are the ones who are going to experience those psychiatric adverse events.
09:36 Torie Robinson
And so knowing this information about their family and their potential predisposition to psychiatric symptoms can influence whether the first choice of medication could be such and such.
09:47 Andres M Kanner
In my personal opinion, not knowing the psychiatric history of the patient and the family, limits you on making an informed, objective selection of the antiseizure medication. Because, if you have a person with a prior history of anxiety or mood disorders, you would select antiseizure medications that have mood-stabilising properties. Because that would basically allow you to kill two birds with one stone. Whereas if you select a drug that has negative properties, you're going to worsen the person's quality of life because the patient is going to start to get anxious, depressed, irritable, cranky. And when this happens in a person who’s just been diagnosed with epilepsy, and that person has to make all different types of adjustments in their daily life; they can't drive, they become dependent on others, and not only that, they have to face the anxiety: “I going to have another seizure?”. And that anticipation of when is the next seizure happening? Because you've lost the predictability of your life. And on top of that you start them on a drug that can cause them to become depressed, anxious or irritable. I mean, this is a nightmare!
11:20 Sponsor mention
Before we move on - with thanks to EASEE®, by Precisis GmbH.
Bidirectional relationship between psychiatric disorders and epilepsy
11:25 Torie Robinson
And also, isn't it interesting as well, though, then there's this other factor we have to take into consideration that sometimes the psychiatric symptoms arise before even seizure-onset. They can be part of, or a symptom, of the epileptogenesis. It's not always external factors, is it.
11:40 Andres M Kanner
Absolutely. We just published a paper on 347 people with newly diagnosed focal epilepsy (this is part of a multi-centre study, the Human Epilepsy Project, that includes epilepsy centres from the United States, Europe, and Australia). And what we found (and these are people who were newly diagnosed, so in order to be enrolled in the study, they couldn't have been treated for more than four months); 25% of these patients already met criteria for a form of mood disorder or an anxiety disorder, and 23% already had experienced suicidal ideation. And this is at the beginning of their diagnosis; that they already had been suffering from these psychiatric conditions. So, if you're not paying attention to those variables and you start these people on antiseizure medications that have negative psychotropic properties, you're going to make their quality of life much worse.
There is a bidirectional relationship between psychiatric disorders and epilepsy. So that if you have epilepsy, you've got an increased risk of developing mood disorders, anxiety disorders, psychosis, attention deficit disorder. But if you have any of these psychiatric conditions to begin with, you have an increased risk of developing epilepsy.
13:21 Torie Robinson
And that's what most people don't realise, yeah.
ADHD and epilepsy - risk
13:23 Andres M Kanner
So it goes both ways. And if you don't understand that, it can have dire implications! Because, if you have, for example, a child with attention deficit disorder who has a first convulsion and he's taken to the emergency room, very often the ED physician is going say “Well, you have the seizure because of the methylphenidate, because of the medication you're taking for treating your attention deficit disorder.”. And that's a huge misconception! Without taking into consideration that people with attention deficit disorder have a 3 to 4 higher risk of developing epilepsy. So the seizure was related to the natural course of the attention deficit disorder. And today we have evidence that people with attention deficit disorder whose attention deficit disorder is treated have a less likely risk of developing seizures than if you don't treat them.
So, it's a paradoxical thing. And so that's why, because the chemical changes in the brain that are operant in attention deficit disorder and epilepsy are, in many ways, they share common pathogenic mechanisms and the treatment interferes with the expression of those pathogenic mechanisms. And that, I think that the impact of that bi-directional relationship has direct bearings on the treatment of these patients.
Suicide and epilepsy
14:58 Andres M Kanner
One important consideration, for example, is when is a time when a person with epilepsy is more likely to commit suicide? In the first six months after the diagnosis. And who are the people who are more likely to commit suicide in the first six months after diagnosis? Probably those that had a previous psychiatric history. You don't recognise that. You're not preparing the patient to cope with these type of situations. So that complex interaction is such that it has direct bearing on the treatment you're going to provide the patients. And in the long term of their… of the course of their disease.
Neurologists and psychiatrists can easily broach this
15:45 Torie Robinson
And so, for people who might think, “God, this is all a bit scary. I thought I only had to study neurology and I'm not a psychiatrist.”. Can you give us some sort of a reassurance that it's not as scary as it might appear and that there are other clinicians out there who are doing this and one can help another?
16:40 Andres M Kanner
I personally don't think it's scary at all! I think it's not only not scary, but I think that it's an eye-opening in our ability to understand what's going on. You don't need to be a rocket scientist to understand the interactions or the close relationship between psychiatric phenomena and neurologic conditions. And managing patients with epilepsy that have psychiatric conditions actually is easier than managing patients with psychiatric conditions that don't have epilepsy! For example, if you have a major depressive disorder and you're started on an antidepressant medication, the chances that the first antidepressant medication will cause the symptoms to remit completely is only 30 to 40%. If you have epilepsy, the first antidepressant medication trial that will result in complete remission of symptoms is 60%. It's a fascinating phenomenon. I try to explain to my colleagues: treating these psychiatric comorbidities in people with epilepsy is not that complicated. And you just need to learn, you know, how to do it. We actually have recently published a special issue of 14 articles that show neurologists how to use psychotropic medications for people with epilepsy. It's like a cookbook type of thing. So if a person has a major depressive disorder with epilepsy, this is the medication you choose, this is how you increase the dose, this is your target dose, if that medication doesn't work, you go to these other medications, if the person fails to respond to antidepressant medication, that's it. That patient should be treated by a psychiatrist because that person probably has a treatment-resistant depression. And we did the same thing with anxiety disorders and the conditions that a neurologist should be able to recognise and treat. There are certain conditions that neurologists should not be treating, such as bipolar disorders or patients with psychotic disorders or patients with increased suicidal risk, etc. But I think we, as neurologists need to know how to manage the common comorbidities.
Final thoughts & thanks
18:54 Torie Robinson
Thank you so much Andres who gets it and is encouraging integrated care - neurology and psychiatry - and for us all to predict, prevent, identify, and effectively treat the psychiatric symptoms of the epilepsies - which are just as - or some would say equally or even more important - to manage (for quality of life) than seizures.
Again, huge thanks to EASEE®, by Precisis GmbH, for partnering with Epilepsy Sparks. Now, did you find our chat with Andres interesting? If so, please share the episode with your colleagues, friends, and family members and do give us a like and subscribe - because this really helps us keep going as a channel. Let us all, together, improve understandings of the epilepsies around the world! See you next time.