Abstracts

Rationale: Depression, anxiety and posttraumatic stress disorders are relatively frequent psychiatric comorbidities in VWE. Most of these patients are treated pharmacologically with psychotropic drugs. The prevalent “misconception” that SSRIs and SNRIs can lower the seizure threshold even when prescribed at therapeutic doses has often precluded the achievement of optimal doses and of symptom remission.Methods: We identified VWE followed in one of the outpatient Epilepsy clinics at the Miami VA Medical Center from January 1st to June 1st 2015 who were diagnosed and treated for depression and anxiety disorders by the Psychiatry service. The pharmacologic treatment included SNRIs, SSRIs and mood stabilizer agents such as second-generation antipsychotics and / or antiepileptic drugs. Patients were asked to complete two screening instruments, the Neurologic Depressive Disorders Inventory in Epilepsy (NDDI-E) and the Generalized Anxiety Disorder 7, the former used to identify current major depressive episodes and the latter, generalized anxiety disorder if the total score was >10. Patients were considered to be symptomatic if their score on the NDDI-E and /or the GAD-7 were >15 and >10, respectively. We also identified the maximal doses of the SSRI and SNRI used and compared them to the maximal dose that could have been given for each of the antidepressants. In addition, we identified the type of antiepileptic drug (AED) that the patient was taking in particular if they had enzyme inducing properties as well as if they were AEDs with negative psychotropic properties.Results: 27 patients were identified. Their mean age was 50 years old (± 13.3 years; range: 28 - 81). Among these patients (N=19) 70% scored in the symptomatic range with NDDI-E and GAD 7; 17 (63%) were symptomatic on both instruments. Seven patients suffered from PTSD. Among the 19 patents that were symptomatic 11 patients (58%) had achieved maximal doses of the psychotropic drugs while 8 (42%) could have had their dose increased (p=0.03; Fisher Exact 2 tail). Failure to achieve an asymptomatic state was not accounted by the used of enzyme inducer AEDs, nor by lack of continuity of care be the psychiatrist and psychologist, lack of adherence to medical treatment of lack of use of mood stabilizer agents. Of note, 12 of the 19 symptomatic VWE (63%) were considered to be in remission by their psychiatrist in the last outpatient psychiatry clinic visit.Conclusions: This pilot study supported our hypothesis that failure to achieve remission of depression and anxiety disorder in VWE could be associated with the use of sub-therapeutic doses of antidepressant drugs. Another cause appears to be a failure of the treating psychiatrists to recognize that the patients may still be symptomatic and in need of additional dose adjustment of the medication and /or of other forms of treatment. Accordingly, the use of the NDDI-E and GAD-7 screening tools should be integrated as a part of the psychiatric evaluation in patient with epilepsy at the mental health clinic as well.