Different types of psychotropic medications are available for treating psychiatric and behavioral symptoms in epilepsy patients, although some agents may adversely affect seizure control. Therefore, psychotropic agents need to be used with caution in patients with epilepsy. This section will address clinical indications for and side effects of these agents. A detailed discussion of the pharmacology of these drugs is beyond the scope of this chapter but is available in many standard pharmacology textbooks.
Antipsychotic medications are indicated for psychotic symptoms that extend beyond the ictal phase. As previously reviewed, these symptoms may include hallucinations, delusions, ideas of reference, and disorganized thought processes that approach a schizophrenia-like psychotic state. Other indications for antipsychotics include psychotic symptoms in the context of affective symptoms (such as depression or mania) and disorganized thought processes (such as those that may occur in delirium). These presentations should be differentiated from peri-ictal psychotic symptoms, for which the primary treatment should not be antipsychotics but antiepileptic medication. Additionally, other etiologies of psychoses in epilepsy (antiepileptic drug toxicity or withdrawal, folate deficiency, etc.) require a specific treatment approach.
Available antipsychotic medications are all essentially equal in efficacy, but they differ significantly in their side effect profiles. They can potentially exacerbate seizures in epileptic patients, although the various agents differ in this respect. The medications that carry the highest risk of exacerbating seizures include chlorproma-zine and clozapine—these medications should generally be avoided in epilepsy patients. Molindone and fluphenazine appear to carry a lower risk of exacerbating seizures and are relatively safer to use. The side effects of antipsychotics depend on their potency and chemical class but include sedation, anticholinergic effects, and extrapyramidal symptoms.
Antidepressant medications are indicated for a variety of sustained mood disorders, including depression and anxiety states (such as panic disorder). Like antipsychotics, antidepressant medications should not be used to treat psychiatric symptoms limited to the immediate peri-ictal period but rather to treat sustained symptoms (such as prolonged postictal depression and interictal psychiatric symptoms). A wide range of antidepressant medications are available. They are divided into several classes, including tricyclic antidepressants, serotonin-reuptake inhibitors, atypical antidepressants, and monoamine oxidase inhibitors (MAOIs). Medications with a higher potential for inducing seizure activity include maprotiline, amitriptyline, nortriptyline, and clomipramine. Relatively safer antidepressants for the epilepsy population include desipramine, doxepin, and MAOIs. Some newer antidepressants (such as fluoxetine, paroxetine, and sertraline) may also be relatively safe but can influence antiepileptic drug levels. In some cases, use of an antidepressant may improve seizure control, possibly by treating symptoms related to the depression such as disturbed sleep and appetite. MAOIs may have anticonvulsant properties and can be a useful antidepressant medication in this population, although the clinician must be aware of potential drug and food interactions before prescribing MAOIs.
Mood-stabilizing medications (such as lithium carbonate, carbamazepine, and valproic acid) are indicated for periods of elevated mood and associated symptoms that may be consistent with "mania" during the interictal phase. For bipolar disorder, defined as a history of at least one episode of mania with or without a history of episodes of depression, lithium is the best-established mood-stabilizing medication; lithium, however, is associated with cognitive symptoms in some patients and has desynchronizing effects on the EEG. Lithium carbonate has been associated with increased seizure activity or behavioral deterioration in some patients. Carbamazepine and valproic acid have been used extensively in nonepileptic bipolar patients with success, and either one may be a more appropriate first choice in epileptic patients with bipolar mood symptoms.
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