# 15 - Psychiatric comorbidities in epilepsy

# Psychiatric comorbidities in epilepsy

Drug treatment of psychiatric symptoms in the context of other conditions 
CHAPTER 10
Epilepsy
Psychiatric comorbidities in epilepsy
People with epilepsy (PWE) have an elevated prevalence of several psychiatric disorders 
including depression (13–37%), anxiety (20%) and psychosis (5%).1,2 Suicide is threefold higher in PWE compared with the general population3 and is an important cause 
of premature mortality.4 The link between epilepsy and mental illness is bidirectional as 
patients with depression, anxiety and psychosis have an increased risk of developing 
new-­onset epilepsy.5,6 Suicide attempts are also associated with the development of 
­epilepsy.7 This bidirectional relationship might be explained by a common underlying 
pathology between mental illness and epilepsy. Disturbances in neurotransmission, 
­neuroinflammation and the hypothalamic–pituitary–adrenal (HPA) axis have all been 
suggested8 to be the shared pathology.
Interictal psychiatric disorders (with symptoms occurring independently of seizures) 
are likely to require treatment with psychotropics.9–11 When prescribing psychotropics 
to people with epilepsy, the following general principles12,13 should be adhered to:
■
■First, rule out other possible causes of psychiatric symptoms (both peri-­ictal and 
iatrogenic – Table 10.3).
■
■Optimise the treatment of epilepsy (ideally before prescribing psychotropics).
■
■Consider using psychotropics with known antiseizure properties (e.g. antiseizure 
medications in bipolar disorder).
■
■Check for interactions with antiseizure medications.
■
■Start with a low dose and titrate according to tolerability and response (proconvulsive 
effects are dose-­related).
■
■If seizures do occur, consider changing the psychotropic drug or optimising the 
antiseizure medication.
Table 10.3  Possible causes of psychiatric symptoms in people with epilepsy (PWE) and their management.5
Cause of symptoms
Description
Management
Interictal 
psychiatric 
disorders
Symptoms occurring independently of seizures.
Although common in PWE, other causes and 
relatedness to seizures should be ruled out first.
Likely to require treatment with psychotropics.
See Table 10.5 for more information about 
the use of specific psychotropics in PWE.
Peri-­ictal symptoms
PWE may experience psychiatric symptoms 
that are temporally related to seizures.
All peri-­ictal psychiatric symptoms (pre-­ictal, 
postictal and ictal) are initially treated by 
optimising antiseizure medications.12
Peri-­ictal depressive symptoms do not 
appear to respond to treatment with 
antidepressants.14,15
Postictal psychosis can remit spontaneously 
or respond to treatment with low doses of 
antipsychotics.16 Short-­term symptomatic 
treatment with a benzodiazepine or 
antipsychotic is recommended for up to 
3 months.17 Taper off carefully after 
symptom resolution.15
There is no evidence that psychotropics can 
prevent ictal symptoms.18
Pre-­ictal symptoms
Typically presents as a dysphoric mood 
preceding a seizure by a period of 30 minutes 
to hours to 2 or 3 days.
Postictal symptoms
Typically presents between several hours to 
7 days following a seizure (depression, anxiety, 
suicidal ideation and psychosis reported)
PWE and interictal psychiatric disorders may 
experience worsening of symptoms previously 
in remission (breakthrough symptoms).
Ictal symptoms
May present as ictal fear/panic (most commonly), 
depressive symptoms or, rarely, psychosis.
(Continued )