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Worrying More about Anxiety in Patients with Epilepsy

Commentary Approximately one-third of patients with epilepsy suffer from a psychiatric disorder (1). Depression and anxiety are the most common of these, especially with drug-resistant mesial temporal lobe epilepsy, and are responsible for reduced quality of life and overall worse outcomes (2, 3), including worse surgical outcomes (4). The rising number of research publications in the area of comorbidities with epilepsy focuses mainly on depression and has demonstrated that depression is both a risk factor for and a consequence of epilepsy. Anxiety is also extremely common in people with epilepsy, especially in those who are depressed, and in the general population exceeds depression (5). Far less effort has been focused on the impact of anxiety in people with epilepsy. Part of the reason may be that anxiety is more complicated to study. It is difficult to differentiate anxiety that is due to antiepileptic drug side effects, from anxiety that is due to ictal panic, or from an anxiety disorder. While difficult to study, there are new efforts to understand the incidence and prevalence of anxiety in people with epilepsy. One large, validated, general population-based health survey in Canada showed that anxiety and depression (suicidal thoughts) in those with epilepsy had odds ratios of 2.4 and 2.2 compared with those without epilepsy (1). Another study using a metaanalysis found the pooled prevalence of anxiety (20.2%) and depression (22.9%) in epilepsy were quite elevated and quite similar (6). Validated instruments such as the Generalized Anxiety Disorder, Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire-9 (rapid depression screen), or Neurologic Disorders Depression Inventory for Epilepsy (NDDI-E) are important for neurologists to incorporate into their regular visits in order to formally screen their patients and uncover who is at higher risk of harm and who needs treatment, although there are likely systems reasons that this is generally not done. Many clinicians may pick up clues that their patient is anxious without ever asking a direct question and they may have the common experience that direct questions can lead to denial of symptoms and concern about the stigma of appearing like they need a psychiatrist. Scott et al. (6) showed that there is a significantly higher rate of capturing anxiety if formal screening is used (27.3%) rather than just “clinician evaluation” (8.1%). This means that efforts need to be made to train physicians on the importance of using standardized screening instruments over their own clinical intuition. It is also likely that training is required to demonstrate best practices in how to do this so that the patient is accepting and the doctor-patient relationship is enhanced and not harmed. Neurologists should be taught to facilitate the integration of care with their patient’s mental health needs. The treatment will differ depending on the type and severity of the symptoms and when they occur, though, strikingly nearly one-third of patients with comorbid anxiety or depression are not receiving any treatment at all (7). Neurologists may be reluctant to “play psychiatrist” and may just notice their The Prevalence of Anxiety and Associated Factors in Persons With Epilepsy.