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Ettinger AB, Reed ML, Goldberg JF, Hirschfeld RM
Neurology 2005;65(4):535–540 [PubMed]
OBJECTIVE: To estimate the comparative prevalence of bipolar symptoms in respondents with epilepsy versus other chronic medical conditions.
METHODS: The Mood Disorder Questionnaire (MDQ), a validated screening instrument for bipolar I and II symptoms, in conjunction with questions about current health problems, was sent to a sample of 127,800 people selected to represent the U.S. adult population on selected demographic variables. A total of 85,358 subjects (66.8%) aged 18 or older returned the survey and had usable data. Subjects who identified themselves as having epilepsy were compared to those with migraine, asthma, diabetes mellitus, or a healthy comparison group with regard to relative lifetime prevalence rates of bipolar symptoms and past clinical diagnoses of an affective disorder.
RESULTS: Bipolar symptoms, evident in 12.2% of epilepsy patients, were 1.6 to 2.2 times more common in subjects with epilepsy than with migraine, asthma, or diabetes mellitus, and 6.6 times more likely to occur than in the healthy comparison group. A total of 49.7% of patients with epilepsy who screened positive for bipolar symptoms were diagnosed with bipolar disorder by a physician, nearly twice the rate seen in other disorders. However, 26.3% of MDQ positive epilepsy subjects carried a diagnosis of unipolar depression, and 25.8% had neither a uni- nor bipolar depression diagnosis.
CONCLUSION: Bipolar symptoms occurred in 12% of community-based epilepsy patients, and at a rate higher than in other medical disorders. One quarter were unrecognized.
Caplan R, Siddarth P, Gurbani S, Hanson R, Sankar R, Shields WD
Epilepsia 2005. May;46(5):720–730 [PubMed]
PURPOSE: This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables.
METHODS: A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children aged 5–16 years with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist.
RESULTS: Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation.
CONCLUSIONS: These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.
Interest in the emotional and behavioral problems that may be observed in people with epilepsy increased sharply beginning in the late 1940s when it was found that certain forms of epilepsy affected neural regions involved in emotional regulation. At the time, there was considerable enthusiasm that such relationships would lead to new insights into the neurobiology of mental illness. This enthusiasm was reflected in statements by prominent epileptologists, such as Fred Gibbs, who declared that “ …. the Sylvian fissure is one of the chief boundaries between neurology and psychiatry (1).”
Thus, began a debate, literally lasting decades, concerning the relative roles of nature versus nurture in the etiology of psychiatric comorbidity in epilepsy. The link to temporal lobe epilepsy was especially appealing for obvious reasons. In the years that followed, symposiums on the topic were common, debate was frequent, but viewpoints were habitually fixed and unmodifiable. The empirical findings were often anecdotal, observational, and/or correlational, and did not lead to unequivocal resolution of the issue. Time passed, tempers cooled, and this somewhat tempestuous period was replaced by a quieter and steadfast accumulation of empirical evidence characterizing the sheer magnitude of the problem—reflected in rates of psychiatric comorbidities, their impact on quality of life, and the degree to which they go unrecognized and are undertreated.
Two recent publications provide further characterization of the problem of comorbid psychiatric disorders from different points in the lifespan. Ettinger and colleagues cleverly took advantage of a very large population-based sample that had completed behavioral measures, including an inventory of bipolar symptoms and self-reported medical illnesses. Using this sample, they were able to compare rates of bipolar symptoms in people with reported epilepsy (n= 1,236) to rates of bipolar symptoms in people with other chronic medical conditions, including migraines (n= 8994), asthma (n= 7,951), diabetes (n= 7,342), and controls (n= 57,172). They found that people with epilepsy were five times more likely to report bipolar symptoms compared to individuals with other chronic health problems; the investigators noted the degree to which these comorbidities are overlooked in standard care, which is a point that Ettinger and colleagues made in prior publications concerning children with epilepsy.
Caplan and colleagues conducted extremely careful independent interviews with children (ages 5–16) with epilepsy and their parents to derive DSM-IV diagnoses. Their sample included children with CPSs (n= 100), childhood absence epilepsy (n= 71), and healthy controls (n= 93). It is pertinent to point out that the children with epilepsy had seizures of early-onset (mean = 5.7 years) and short duration (mean = 4.7 years). Caplan and colleagues reported that current affective/anxiety disorders were present in a surprisingly high proportion (33%) of the epilepsy patients versus 6% of the controls. Of equal or greater concern was the finding of a substantially elevated suicidal ideation (20%), but no attempts, in the children with epilepsy compared with the control children (9%). Similar to Ettinger et al. findings, a substantial proportion (66%) of these problems went undetected and untreated.
Study after study has provided evidence that psychiatric comorbidities in persons with chronic epilepsy, be they children or adults, are common, further undermine quality of life, continue to be underrecognized, and are not effectively treated. There is a paucity of evidenced-based outcome data to guide treatment of comorbid mental health conditions for children, adolescents, or adults with epilepsy. The etiologies underlying these disorders remain to be clarified, but advances in the general understanding of the neurobiology of mental illness should help in this regard. The critical point is that the two studies by Drs. Ettinger and Caplan and their colleagues are yet another reminder of this serious comorbidity that remains to be addressed—a problem that affects people with epilepsy throughout their lifespan.