Antidepressant Choices for People with Epilepsy
Guidelines
A statement from the Special Interest Group in Epilepsy in the South West Peninsula of England These Guidelines, produced by the Peninsula Special Interest Group, are correct at time of print. They are compiled to help Doctors, choose antidepressant drugs. Information has been gathered from a number of sources. It is the intention, of the group, that information will continue to be updated and the guidelines reviewed, as and when necessary. It is not the intention of the Group to seek to dictate the prescribing practices of their colleagues, but to offer useful information to aid appropriate treatment choice for patients.
A wide range of research has reported that People with Epilepsy are under diagnosed and treated when presenting, to their physician, symptoms of depression. The Doctor may believe that prescribing antidepressants, for this specialised group, may exacerbate seizures. There is little or no evidence to support this view and some studies dispel the long held believe that antidepressants are pro-convulsant. Research has established that the proconvulsive risk is dose dependant, the risk of inducing seizures is relatively low in newer antidepressants and the risk of antidepressants provoking seizures, is generally over estimated. Research studies in antidepressants and Epilepsy have demonstrated that the vast majority of antidepressants are in fact safe in people with epilepsy, when used appropriately and at low dosages. Evidence suggests that people with epilepsy will greatly benefit from appropriate treatment of depression in both mood and seizure activity.
It is estimated that between 15 and 30% of people with epilepsy develop anxiety, depression, and low self-esteem. The highest frequency rate occurs in those patients with seizure disorders arising in the temporal or frontal lobes or who have poorly controlled epilepsy.
Anti epileptic drugs, have both a positive and a negative effect on mood. The negative effects may arise from polypharmacy, drug induced folate deficiency, dosage and titration of the epilepsy drugs. It has been indicated that drug
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induced depression is commoner in barbiturates, but it has also been recorded with topiramate, tiagabine, vigabatrin and felbamate. Zonisamide has been associated with hypomania. The positive effects of valproate, carbamazepine, topiramate, gabapentin, Lamotrigine and pregabalin have become the mainstay of “mood stabilizers”, with an elevation of mood without the exacerbation to switch to a manic stage.
Suggested recommendations for treatment:
Treatment of bipolar disorders can be problematic and the group recommends that advice should be sort from the NICE guidelines. However, of the selective serotonin reuptake inhibitors (SSRI), citalopram and escitalopram is the drug of choice, although all SSRIs are relatively low in inducing seizures. Of the tricyclic antidepressants (TCAs), we would recommend doxepin, but again, with the exception of maprotiline and amoxapine, TCAs are felt to be of low risk and seizure occurrence appears to be dose related. The classic antidepressants, now rarely used, should be avoided in those with epilepsy. Fluoxeine should be used with caution, in conjunction with phenytoin and carbamazepine as these may increase serum levels. Lamotrigine and valproate are both widely used in the management of bipolar disorders, but it is recommended that lamotrigine is not used as a first line drug for those with bipolar 1 disorder. Care should be taken when prescribing valproate to women of childbearing age. NICE further recommends that valproate; lamotrigine and carbamazepine should not be used within Primary Care without specialist support.
Counselling, behavioural therapy, and psychotherapy, in conjunction with traditional methods of treating depression, should be considered and offered to people with epilepsy. Individualised treatment plans focusing on coping mechanisms can help reduce anxiety and depression and improve seizure control. Electroconvulsive therapy is not contraindicated in epilepsy and can be of benefit to those with treatment resistant depression.
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Antidepressant Drugs and Seizure Incidence
Antidepressant Amitriptyline Amoxapine Clomipramine Desipramine Doxepin Imipramine Maprotiline
Group TCA TCA TCA TCA TCA TCA TCA
Likelihood of seizures <0.1-0.3% risk of seizures at high dosages 24.5-36.4% 0.7-3.0% < 0.1% < 0.1% minimal with improvement in seizures < 0.1-0.9% < 0.4-15.6% high risk of convulsions
Citalapram Fluoxetine Paroxetine Sertraline Venlafaxine Trazodone Mirtazapine Nefazodone
SSRI SSRI SSRI SSRI SNRI SNRI
< 0.1% minimal, unless overdosed < 0.1-0.2% may increase serum levels of Carbamazepine Phenytoin. < 0.1% < 0.1% < 0.1% minimal unless overdosed. <0.1% < 0.1% Limited information available
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References – Depression and Epilepsy
Baker Gus (2002) People with epilepsy; what they know and understand, and how does this contribute to their perceived level of stigma. Epilepsy and behaviour 3(2002) S26-S32
Barry J (2003) The recognition and management of mood disorders as a co morbidity of Epilepsy. Epilepsia, Vol 44 Suppl 4 p30-40. Barry J et al (2001) Psychotropic drug use in patients with epilepsy and developmental disabilities. Epilepsy and Developmental Disabilities: 205-217.
Blackwood D.H et al 1980. A study of the incidence of epilepsy following ECT. Journal of Neurology, Neurosurgery, Psychiatry. 1980; 43:1098 -1102.
Gillham R.A (1990) Refractory epilepsy; an evaluation of psychological methods in outpatient management. Epilepsia 1990; 31: 427-432
Kanner A.M (2002) Depression and Epilepsy. How closely related are they? Neurology 2002; 58:S27-S39
Ojemann L.M (1983) Effect of Doxepin on seizure frequency in depressed epileptic patients. Neurology 1983; 33; 646-648
Robertson M (1985) Depression in Patients with Epilepsy: an overview and clinical study.
Schmitz B (2002) Antidepressant Drugs: Indications and guidelines for use in Epilepsy. Epilepsia 43(suppl. 2) 14-18,
DC/PEIG/07.06 – modified 11.06
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