Better Screening Methods on Tap for Depression, Anxiety in Epilepsy

Edinburgh, Scotland – Newer screening tools for depression and anxiety in persons with epilepsy have been developed that are much faster and easier to use than anything previously available.

The tools long favored by psychiatrists, including the Hospital Anxiety and Depression Scale and the Beck Depression Inventory, are too lengthy, cumbersome, and hard to score for use as routine screening instruments by busy primary care physicians, neurologists, and epilepsy nurses. Also, these are verbal tests, and patients with epilepsy often have difficulty in concentrating and completing them, Dr. Niruj Agrawal said at the congress.

Depression and anxiety are far more common in patients with epilepsy than in the general population. These conditions are underdiagnosed in patients with epilepsy and adversely affect their quality of life. Routine screening is warranted. The newer, brief instruments, such as the Emotional Thermometer-7 (ET-7) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), make this much more practical, said Dr. Agrawal, a psychiatrist at St. George’s Hospital, London.

Multiple studies conducted in various parts of the world show that roughly one-third of patients with epilepsy seen in primary care settings are depressed. The prevalence rises to about 50% among patients seen in specialty neurologic settings for more resistant epilepsy. A large U.S. study has shown that patients with epilepsy and comorbid depression are heavier users of health care services, with more visits to primary care clinics and emergency departments than patients with epilepsy alone (Epilepsy Behav. 2007;10:539-46).

One of the most compelling arguments for routine screening for anxiety and depression in persons with epilepsy is that these comorbidities massively increase suicide risk. A large national Danish study showed that individuals with epilepsy alone had a suicide rate 2.4-fold greater than controls, while those with epilepsy plus an anxiety disorder had a suicide rate 11.4-fold greater than controls, and patients with epilepsy and depression had a stunning 32-fold increase in suicide (Lancet Neurol. 2007;6:693-8).

Quality of life scores in the two-thirds of patients with epilepsy who become seizure-free with treatment are similar to scores in the general population, but patients with refractory epilepsy tend to score poorly on such measures. A prospective study at New York University showed that depression was present in 54% of a series of patients hospitalized for refractory epilepsy, of whom only 17% were on antidepressants. Depression was a powerful predictor of quality of life scores in this study, whereas seizure frequency was not (Neurology 2004;62:258-61).

These findings have been replicated elsewhere. The message is that alleviating depression in patients with treatment-resistant epilepsy will do more to improve their quality of life than reducing their seizure frequency, unless the seizures can be eliminated altogether, Dr. Agrawal said.

Turning to the brief instruments designed for rapid detection of depression in epilepsy, he noted that the NDDI-E had a negative predictive value of 96%, a positive predictive value of 62%, sensitivity of 81%, and specificity of 90% in a study of 205 adult outpatients with epilepsy (Lancet Neurol. 2006;5:399-405).

The NDDI-E was developed by neurologists at Columbia University in New York who were seeking a simple means of differentiating true depression from the common adverse effects of antiepileptic drugs, which can mask some symptoms of depression or cause symptoms that can be mistaken for depression, such as disturbances in sleep, concentration, and appetite.

Patients taking the NDDI-E assign scores of 1-4 on each of 6 items: everything is a struggle; nothing I do is right; I feel guilty; I’d be better off dead; I feel frustrated; and I have difficulty finding pleasure. The scores range from 1 point if the patient never experiences a particular symptom to 4 points if they always or often do. The investigators found that a score of 15 is the best cutoff point.

Dr. Agrawal has been working with the ET-7, a series of patient-rated visual analog scales originally developed by Dr. Alex J. Mitchell of the Leicester (U.K.) Royal Infirmary for use in screening cancer patients for depression and anxiety (Psychooncology 2010;19:125-33; Psychooncology 2010;19:134-40).

Dr. Agrawal recently performed a comparative study of five screening tools in a series of 250 epilepsy patients. The five instruments were the ET-7, the NDDI-E, the BDI-II, the HADS, and the Major Depression Inventory. Using the ICD-10 diagnostic criteria as the gold standard, the most accurate test was the BDI-II, which Dr. Agrawal considers impractical for use by busy non-psychiatrists. He was able to confirm the reliability of the NDDI-E, which in this population had a sensitivity of 87% and specificity of 81%. The ET-7, a brief nonverbal instrument, had a sensitivity of 74% and specificity of 86%.

This study underscored the high degree of overlap between depression and anxiety. Half of the 250 epilepsy patients had significant anxiety symptoms and 37% were depressed. But only 5% of patients with depression did not have anxiety, and only 10% of patients who had anxiety did not have depression, the psychiatrist noted.

He declared no conflicts of interest.

Edinburgh, Scotland – Newer screening tools for depression and anxiety in persons with epilepsy have been developed that are much faster and easier to use than anything previously available.

The tools long favored by psychiatrists, including the Hospital Anxiety and Depression Scale and the Beck Depression Inventory, are too lengthy, cumbersome, and hard to score for use as routine screening instruments by busy primary care physicians, neurologists, and epilepsy nurses. Also, these are verbal tests, and patients with epilepsy often have difficulty in concentrating and completing them, Dr. Niruj Agrawal said at the congress.

Depression and anxiety are far more common in patients with epilepsy than in the general population. These conditions are underdiagnosed in patients with epilepsy and adversely affect their quality of life. Routine screening is warranted. The newer, brief instruments, such as the Emotional Thermometer-7 (ET-7) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), make this much more practical, said Dr. Agrawal, a psychiatrist at St. George’s Hospital, London.

Multiple studies conducted in various parts of the world show that roughly one-third of patients with epilepsy seen in primary care settings are depressed. The prevalence rises to about 50% among patients seen in specialty neurologic settings for more resistant epilepsy. A large U.S. study has shown that patients with epilepsy and comorbid depression are heavier users of health care services, with more visits to primary care clinics and emergency departments than patients with epilepsy alone (Epilepsy Behav. 2007;10:539-46).

One of the most compelling arguments for routine screening for anxiety and depression in persons with epilepsy is that these comorbidities massively increase suicide risk. A large national Danish study showed that individuals with epilepsy alone had a suicide rate 2.4-fold greater than controls, while those with epilepsy plus an anxiety disorder had a suicide rate 11.4-fold greater than controls, and patients with epilepsy and depression had a stunning 32-fold increase in suicide (Lancet Neurol. 2007;6:693-8).

Quality of life scores in the two-thirds of patients with epilepsy who become seizure-free with treatment are similar to scores in the general population, but patients with refractory epilepsy tend to score poorly on such measures. A prospective study at New York University showed that depression was present in 54% of a series of patients hospitalized for refractory epilepsy, of whom only 17% were on antidepressants. Depression was a powerful predictor of quality of life scores in this study, whereas seizure frequency was not (Neurology 2004;62:258-61).

These findings have been replicated elsewhere. The message is that alleviating depression in patients with treatment-resistant epilepsy will do more to improve their quality of life than reducing their seizure frequency, unless the seizures can be eliminated altogether, Dr. Agrawal said.

Turning to the brief instruments designed for rapid detection of depression in epilepsy, he noted that the NDDI-E had a negative predictive value of 96%, a positive predictive value of 62%, sensitivity of 81%, and specificity of 90% in a study of 205 adult outpatients with epilepsy (Lancet Neurol. 2006;5:399-405).

The NDDI-E was developed by neurologists at Columbia University in New York who were seeking a simple means of differentiating true depression from the common adverse effects of antiepileptic drugs, which can mask some symptoms of depression or cause symptoms that can be mistaken for depression, such as disturbances in sleep, concentration, and appetite.

Patients taking the NDDI-E assign scores of 1-4 on each of 6 items: everything is a struggle; nothing I do is right; I feel guilty; I’d be better off dead; I feel frustrated; and I have difficulty finding pleasure. The scores range from 1 point if the patient never experiences a particular symptom to 4 points if they always or often do. The investigators found that a score of 15 is the best cutoff point.

Dr. Agrawal has been working with the ET-7, a series of patient-rated visual analog scales originally developed by Dr. Alex J. Mitchell of the Leicester (U.K.) Royal Infirmary for use in screening cancer patients for depression and anxiety (Psychooncology 2010;19:125-33; Psychooncology 2010;19:134-40).

Dr. Agrawal recently performed a comparative study of five screening tools in a series of 250 epilepsy patients. The five instruments were the ET-7, the NDDI-E, the BDI-II, the HADS, and the Major Depression Inventory. Using the ICD-10 diagnostic criteria as the gold standard, the most accurate test was the BDI-II, which Dr. Agrawal considers impractical for use by busy non-psychiatrists. He was able to confirm the reliability of the NDDI-E, which in this population had a sensitivity of 87% and specificity of 81%. The ET-7, a brief nonverbal instrument, had a sensitivity of 74% and specificity of 86%.

This study underscored the high degree of overlap between depression and anxiety. Half of the 250 epilepsy patients had significant anxiety symptoms and 37% were depressed. But only 5% of patients with depression did not have anxiety, and only 10% of patients who had anxiety did not have depression, the psychiatrist noted.

He declared no conflicts of interest.

Edinburgh, Scotland – Newer screening tools for depression and anxiety in persons with epilepsy have been developed that are much faster and easier to use than anything previously available.

The tools long favored by psychiatrists, including the Hospital Anxiety and Depression Scale and the Beck Depression Inventory, are too lengthy, cumbersome, and hard to score for use as routine screening instruments by busy primary care physicians, neurologists, and epilepsy nurses. Also, these are verbal tests, and patients with epilepsy often have difficulty in concentrating and completing them, Dr. Niruj Agrawal said at the congress.

Depression and anxiety are far more common in patients with epilepsy than in the general population. These conditions are underdiagnosed in patients with epilepsy and adversely affect their quality of life. Routine screening is warranted. The newer, brief instruments, such as the Emotional Thermometer-7 (ET-7) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), make this much more practical, said Dr. Agrawal, a psychiatrist at St. George’s Hospital, London.

Multiple studies conducted in various parts of the world show that roughly one-third of patients with epilepsy seen in primary care settings are depressed. The prevalence rises to about 50% among patients seen in specialty neurologic settings for more resistant epilepsy. A large U.S. study has shown that patients with epilepsy and comorbid depression are heavier users of health care services, with more visits to primary care clinics and emergency departments than patients with epilepsy alone (Epilepsy Behav. 2007;10:539-46).

One of the most compelling arguments for routine screening for anxiety and depression in persons with epilepsy is that these comorbidities massively increase suicide risk. A large national Danish study showed that individuals with epilepsy alone had a suicide rate 2.4-fold greater than controls, while those with epilepsy plus an anxiety disorder had a suicide rate 11.4-fold greater than controls, and patients with epilepsy and depression had a stunning 32-fold increase in suicide (Lancet Neurol. 2007;6:693-8).

Quality of life scores in the two-thirds of patients with epilepsy who become seizure-free with treatment are similar to scores in the general population, but patients with refractory epilepsy tend to score poorly on such measures. A prospective study at New York University showed that depression was present in 54% of a series of patients hospitalized for refractory epilepsy, of whom only 17% were on antidepressants. Depression was a powerful predictor of quality of life scores in this study, whereas seizure frequency was not (Neurology 2004;62:258-61).

These findings have been replicated elsewhere. The message is that alleviating depression in patients with treatment-resistant epilepsy will do more to improve their quality of life than reducing their seizure frequency, unless the seizures can be eliminated altogether, Dr. Agrawal said.

Turning to the brief instruments designed for rapid detection of depression in epilepsy, he noted that the NDDI-E had a negative predictive value of 96%, a positive predictive value of 62%, sensitivity of 81%, and specificity of 90% in a study of 205 adult outpatients with epilepsy (Lancet Neurol. 2006;5:399-405).

The NDDI-E was developed by neurologists at Columbia University in New York who were seeking a simple means of differentiating true depression from the common adverse effects of antiepileptic drugs, which can mask some symptoms of depression or cause symptoms that can be mistaken for depression, such as disturbances in sleep, concentration, and appetite.

Patients taking the NDDI-E assign scores of 1-4 on each of 6 items: everything is a struggle; nothing I do is right; I feel guilty; I’d be better off dead; I feel frustrated; and I have difficulty finding pleasure. The scores range from 1 point if the patient never experiences a particular symptom to 4 points if they always or often do. The investigators found that a score of 15 is the best cutoff point.

Dr. Agrawal has been working with the ET-7, a series of patient-rated visual analog scales originally developed by Dr. Alex J. Mitchell of the Leicester (U.K.) Royal Infirmary for use in screening cancer patients for depression and anxiety (Psychooncology 2010;19:125-33; Psychooncology 2010;19:134-40).

Dr. Agrawal recently performed a comparative study of five screening tools in a series of 250 epilepsy patients. The five instruments were the ET-7, the NDDI-E, the BDI-II, the HADS, and the Major Depression Inventory. Using the ICD-10 diagnostic criteria as the gold standard, the most accurate test was the BDI-II, which Dr. Agrawal considers impractical for use by busy non-psychiatrists. He was able to confirm the reliability of the NDDI-E, which in this population had a sensitivity of 87% and specificity of 81%. The ET-7, a brief nonverbal instrument, had a sensitivity of 74% and specificity of 86%.

This study underscored the high degree of overlap between depression and anxiety. Half of the 250 epilepsy patients had significant anxiety symptoms and 37% were depressed. But only 5% of patients with depression did not have anxiety, and only 10% of patients who had anxiety did not have depression, the psychiatrist noted.

He declared no conflicts of interest.