IEC 2023: Key Challenges for Epilepsy Patients Include Status Epilepticus and Anxiety Management

Underdiagnosed Yet Crucial Factor

The significance of anxiety in epilepsy was the focus of a lecture block. Neurologists and epileptologists should listen carefully to their patients and pay attention to triggers, especially those related to anxiety. This was highlighted by neurologist Dr. Heidi M. Munger Clary from Wake Forest Baptist Medical Center in Winston-Salem, USA. According to her findings, anxiety symptoms are a major issue in the lives of epileptics and their families. This is due to feelings of embarrassment, helplessness, and fear related to the fact that seizures come unexpectedly and at any time.

Anxiety in epileptic individuals is underdiagnosed – this is evidenced by a meta-analysis where the prevalence of anxiety disorders in unstructured physician assessments was only 8.1% (95% confidence interval [CI] 5.7–11.4%), whereas according to the results of structured clinical interviews, it was 27.3% (95% CI 22.1–33.3%).¹ Studies, however, suggest the opposite connection – epilepsy increases the risk of anxiety disorder, but there is also an increased risk of developing epilepsy in individuals with anxiety.^{2, 3}

Assessing and Treating Anxiety in Epilepsy Patients

The extent of psychological difficulties in children and young people with epilepsy is much higher than in their peers without epilepsy, and children often have multiple anxiety disorders simultaneously.⁴ According to clinical psychologist Dr. Sophie Bennett from the UCL Great Ormond Street Institute of Child Health in London, more general clinical skills and flexible protocols (such as the SDQ questionnaire, RCAD scale, DAWBA online interview, clinical interviews used to determine treatment priorities and goals) are recommended for assessing anxiety in children.

Psychiatrist Dr. Gaston Baslet from Harvard University in Boston added that anxiety disorders in patients with epilepsy can be easily verified in clinical practice, and a reliable medical history can help diagnose the type of anxiety. Managing anxiety can then positively affect many aspects of the patient's quality of life. However, it is necessary to consider both the positive and negative effects of antiepileptic drugs in people with epilepsy. Effective treatment of anxiety disorder in epilepsy includes psychotherapy and psychopharmacology. Currently, selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are available for first-line psychopharmacotherapy.

In a panel discussion, it was emphasized that it is important to reassure patients that some of the symptoms they experience are manageable, to comfort them, to emphasize that treatment exists, and to spend enough time discussing and educating them.

Development of Epilepsy After Status Epilepticus

The IEC 2023 program, of course, included the topic of status epilepticus (SE). For instance, a study was presented indicating that several factors following an SE episode in patients without a history of epilepsy, such as EEG changes and periictal MRI, were associated with the development of late epilepsy. The median age of the 230 participants was 65.9 years; 86.1% had an acute symptomatic etiology, while 13.9% had a cryptogenic cause. During 2.8 years of follow-up, 55 of them developed unprovoked seizures (mostly within 2 years after the episode), and 175 were seizure-free. The development of unprovoked spontaneous and delayed seizures correlated with the presence of super-refractory SE, delay in SE treatment, a specific pattern in EEG, and cryptogenic etiology.⁵

Machine Learning for Predicting Seizure Recurrence After De Novo SE

A retrospective monocentric study conducted at the Vall D'Hebron University Hospital in Barcelona examined the ability of machine learning to predict seizure recurrence after de novo SE (dnSE). The machine learning algorithm was based on various clinical variables, as well as literature (e.g., sex, age, state etiology, time from SE diagnosis to treatment initiation). The algorithms were trained on 70% of the sample and confirmed the prediction for the remaining 30%.

In a set of 268 patients, 67% had no recurrent seizures after 2 years, 27.2% experienced recurrence within 1 year, and 5.6% had recurrence between 1 and 2 years. Acute symptomatic etiology appeared to be a protective factor, while progressive etiology was a relevant risk factor for seizure occurrence. Also crucial were EEG patterns and treatment delays (over 1.5 hours). Machine learning technology performed better in predicting 2-year seizure recurrence than logistic regression.⁶

Treating Seizures With Midazolam for 12 Years

An effective option to stop prolonged seizures is the first buccal rescue therapy with midazolam approved for the treatment of prolonged acute convulsive seizures in infants, toddlers, children, and adolescents (from 3 months to 18 years old) 12 years ago.⁷ The buccal route of administration facilitates administration; the onset of action and achievement of effective control occur quickly – with a median of 8 minutes compared to 15 minutes with rectal diazepam.⁸ Educational support is also available through video instructions for proper administration, demonstration kits, and patient materials.

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Sources:
1. Scott A. J. et al. Anxiety and depressive disorders in people with epilepsy: a meta-analysis. Epilepsia 2017; 58 (6): 973–982.
2. Hesdorffer D. C. et al. Epilepsy, suicidality, and psychiatric disorders: a bidirectional association. Ann Neurol 2012; 72 (2): 184–191.
3. Adelöw C. et al. Hospitalization for psychiatric disorders before and after onset of unprovoked seizures/epilepsy. Neurology 2012; 78 (6): 396–401.
4. Davies S. et al. A population survey of mental health problems in children with epilepsy. Dev Med Child Neurol 2003; 45 (5): 292–295.
5. Roberg L. E. et al. Prediction of long-term survival after status epilepticus using the ACD score. JAMA Neurol 2022; 79 (6): 604–613.
6. Rodrigo-Gisbert M. et al. Prediction of long-term unprovoked seizures after status epilepticus. Epilepsia 2023; 64 (9): 2399–2408.
7. SPC Buccolam. 
8. McIntyre J. et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 2005; 366: 205–210.