Epilepsy and comorbidities —What are we waiting for?

Abstract

During the past several decades, a vast world literature has beenamassedthat unequivocally demonstratestheimportanceof the cogni-tive, psychiatric,linguistic,and social comorbidities associatedwith pe-diatric and adult epilepsies across the lifespan (reviewed in [1,2]). Inindividuals with normal intelligence, there is a wide and diverse rangeof psychopathology andvariable severity of cognitiveandlinguisticim-pairmentthatispresent,problematic,unrelatedtoepilepsysyndromes,and observed even in the “benign” syndromes (reviewed in [1,2]). Epi-lepsy leaves a lasting mark, including in cases of remitted epilepsy intermsofsubsequentacademicachievement[3]andvocationalindepen-dence [4,5]thatclearlyalertsustothedevelopmentalimpactofseizuresat younger ages.Epilepsy increases the likelihood of depression, anxiety disorders,attention deficit hyperactivity disorder (ADHD), a schizophrenia-likeinterictal psychosis, autism, as well as suicidal behavior in patientswith an unprovoked seizure, focal epilepsy, idiopathic cryptogenic epi-lepsy, and self-reported epilepsy [6–10]. Individuals with these psychi-atric diagnoses and suicidal behavior are more likely to have epilepsy[6,9,11,12]. The bidirectional relationship between psychopathologyandepilepsyisunrelatedtotheseverityofepilepsy,epilepsysyndrome,and type of psychiatric disorder. The likelihood for depression, anxiety,substanceabuse,andsuicidalbehaviorisincreasedinthe3 yearsbeforeand 2 years after the onset of epilepsy [9]. Similarly, the risk of an un-provoked seizure is increased in the 2 years before and 2 years afterpsychiatric hospitalization for depression or psychosis [6]. These rela-tionshipsunderscoretheinterrelatednatureofepilepsyandthepsychi-atric comorbidity and highlight critical periods for timely assessmentand intervention of psychopathology.In fact, the role of psychopathology rather than seizures in the poorlong-term outcome of child- [5] and adolescent-onset epilepsy [4] andof psychopathology [13–15] and cognition [16] in the quality of lifeof children and adults with epilepsy, together with the previouslydescribed poor academic achievement and vocational outcome, unam-biguously emphasizes the continuing unmet needs of patients withepilepsy.However, despite decades of research, despite characterization ofthese problems across countries and cultures, despite greater under-standing of the importance of the comorbidites for well-being acrossthe lifespan, and despite numerous federal studies, benchmarks, andrecommendations, contemporary standards of practice fail to integratescreening and treatment of the comorbidities into routine clinical care.Again and again it is pointed out that the comorbidities continue to beunderrecognized and undertreated and that patients with epilepsyhave significant unmet mental health needs [17]. Nonetheless, there isnoindicationthatthisdisappointingstateofaffairswillchangeanytimesoon.Translation of research data to clinical practice may be hindered bytime constraints in the clinical setting, limited reimbursement for criticalpsychiatric and cognitive evaluations, understaffing, and at times disin-terest onthepartof criticallyimportantdisciplines. Providerinteractionswithpatientsareincreasinglydrivenbyadministrativedirectivesregard-ing patient flow, access, and financial issues. Furthermore, adequatetreatment of the comorbidities is handcuffed by lack of evidence-basedstudies. While research can often address unmet clinical needs whichotherwise may not be funded, the number of funded RCT designed toprovideClass1evidencetoimprovethecognitive,psychiatric,vocational,and social complications of epilepsy is embarrassingly rare [1].Critical national initiatives such as the NINDS Epilepsy Benchmarks,Institute of Medicine report on epilepsy, and the CDC Living Well withEpilepsy meetings have all underscored the need to advance basic andclinical researchand providecomprehensive care for patients with epi-lepsy. However, too often, there has been a lack of attached new reve-nue to support these large-scale efforts to achieve the stated goals.One of the earliest publically supported reports on epilepsy was thePlan for Nationwide Action on Epilepsy produced by the Commission fortheControlofEpilepsyandItsConsequences(1977).Tothisday,thisre-mains a remarkable multivolume document for its process, findings,and recommendations. Although many of the recommendations arestillcurrent,viable,andrepeatedinsubsequentefforts,theystillremainunfunded. We simply cannot allow yet more decades to pass withoutmajor fiscal support to move forward on the clinical and researchfront of treatment and intervention. The time has come for aggressivebut respectful advocacy and collaborative efforts by all concernedparties —clinicians,researchers,patientsandtheirfamilies,andnationalepilepsy organizations.Hindering progress toward these aims is the fact that we are nowfirmly entrenched in one of the most complicated and challengingfunding environments that will likely persist for the foreseeable future.Fiscal constraints and cutbacks in the public and private sectors at bothstate and national levels are widespread. These constraints have