Brain health and mental health: Common vascular risk factors and practical implications.

The pandemic dramatized the close links among cognitive, mental, and social health; a change in one reflects others. This realization offers the opportunity to bridge the artificial separation of brain and mental health, as brain disorders have behavioral consequences and behavioral disorders affect the brain. The leading causes of mortality and disability, namely stroke, heart disease, and dementia, share the same risk and protective factors. It is emerging that bipolar disorders, obsessive compulsive disorders, and some depressions share these risk factors, allowing their joint prevention through a holistic life span approach. We need to learn to focus on the whole patient, not simply on a dysfunctional organ or behavior to mitigate or prevent the major neurological and mental disorders by fostering an integrated approach to brain and mental health and addressing the common, treatable risk factors.

Best clinical and research practice in adult epileptology.

To properly address the psychosocial health of people with epilepsy, service and resource allocation, standards of care, and research should reflect the differing needs of patients presenting at different care levels and in different parts of the world. Ideally, people with epilepsy should have access, according to need, to adequately trained primary care physicians and nurse practitioners; to dedicated secondary care epilepsy clinics staffed by trained multidisciplinary teams; and to tertiary level dedicated staff, able to offer a range of psychosocial interventions and supported by comprehensive assessment tools for psychosocial screening, diagnosis, and management. Established protocols linking the various tiers of care would be important, as would a dedicated, nationally applicable online EMR system. In developing countries, best practice needs to be tailored to be realistic and achievable, and some potentially useful models are already available.

Depression in epilepsy: phenomenology, diagnosis and management.

1) Depression is a common and important accompaniment of epilepsy. 2) Depression in epilepsy is phenomenologically different from the usual forms of depression and it is essential that treating physicians assess for these varied forms as well. 3) Depression in epilepsy may be managed more effectively if the relationship to the ictus is better understood. 4) Other factors such as stressful life events, related or unrelated to epilepsy, may contribute to the depressive symptoms. 5) Antiepileptic drugs, particularly GABAergic agents such as vigabatrin, tiagabine, topiramate and phenobarbitone are depressogenic in nature. 6) The newer antidepressants, SSRIs such as sertraline, citalopram and paroxetine do not lower seizure threshold and can be safely used to treat depression in epileptic individuals. Fluoxetine may be avoided because of its longer half-life.

Prevalence of stroke among Chinese, Malay, and Indian Singaporeans: a community-based tri-racial cross-sectional survey.

BACKGROUND AND PURPOSE: Stroke prevalence data among mixed Asian populations are lacking. Prevalence rates of stroke were studied among Singaporeans aged > or =50 years of Chinese, Malay, and Indian origin. METHODS: Study participants were selected by disproportionate stratified random sampling by race. Trained interviewers performed face-to-face interviews with subjects using the World Health Organization screening protocol for neurological diseases. Data were also collected on a self-report of stroke. Subjects suspected to have had a stroke underwent a clinical evaluation to diagnose or exclude stroke. Case notes review was performed for those who were unable to come for clinical evaluation. RESULTS: The study involved 14 906 participants: 6734 men, 8172 women, age range 52 to 106 years, Chinese:Malay:Indian ratio 3:1:1. Participation rate was 66.9%. Six hundred and six were diagnosed to have a stroke, yielding a crude prevalence rate of 4.05% (95% CI, 3.75 to 4.38) and a World Health Organization world population age-gender-standardized rate of 3.65% (95% CI, 3.36 to 3.96). Prevalence rates rose with age (P<0.001 for trend) and were higher among men compared with women, 4.53% (95% CI, 4.05 to 5.07) versus 2.91% (95% CI, 2.57 to 3.29), P<0.01. Age and gender-standardized rates among Chinese, Malays, and Indians were 3.76% (95% CI, 3.38 to 4.17), 3.32 (95% CI, 2.72 to 4.07), and 3.62% (95% CI, 2.95 to 4.44), respectively, P>0.2. Prevalence was highest among Chinese men at 4.78% (95% CI, 4.14 to 5.50) and lowest among Malay women at 2.81% (95% CI, 2.08 to 3.81), P=0.01. CONCLUSIONS: There is no difference in stroke prevalence among Chinese, Malay, and Indian Singaporeans. Prevalence is highest among Chinese men and lowest among Malay women. The reasons for these differences warrant further investigation.

Personality and Psychopathology in Nonepileptic Attack Disorder and Epilepsy: A Prospective Study.

To study the nature of personality and psychopathology in nonepileptic attack disorder (NEAD) and epilepsy, we prospectively assessed 45 consecutive attendees to a specialist assessment unit for epilepsy. Patients with NEAD were more likely to report clinically significant symptoms of anxiety, worry, disordered eating, and somatoform disorder. An ICD-10 diagnosis of anxiety or phobic disorder was significantly more common in NEAD patients. Together DSM-IV personality Clusters A and C were more common in epilepsy than NEAD. Hierarchical logistic regression with diagnosis as the target variable found anxiety, eating, and worry but not somatoform symptoms were reliably associated with NEAD. Together the Present State Examination (PSE) eating, PSE worrying/tension, PSE expansive mood, past psychiatric history, and gender variables allowed for correct classification of more than 88% of all cases. Personality and psychopathology variables seem to be valid clinical predictors of epilepsy and NEAD, and should be examined in epidemiological studies.

Peri-ictal and ictal cognitive dysfunction in epilepsy.

Disturbances in cognitive function, particularly memory, are a common complaint of patients with epilepsy. Factors contributing to cognitive dysfunction are the type of epilepsy, type and frequency of seizures, anti-epileptic drugs and the location of underlying brain lesions. Whilst a great deal of attention has been paid to permanent cognitive impairment, the nature and underlying mechanisms of ictal and peri-ictal cognitive changes are poorly understood. In-depth investigation of seizure related cognitive dysfunction is of great clinical relevance, as these changes are potentially reversible and treatable, thus reducing the cumulative effect of frequent seizures. Greater knowledge of peri-ictal and ictal cognitive dysfunction would improve seizure prediction, localization of seizure focus and assessment of treatment effectiveness, greatly reducing distress and disability. This paper will review current understanding of peri-ictal and ictal cognitive dysfunction and discuss future directions for research.

The evaluation of behavioral disturbances in epilepsy.

The evaluation of behavioral disturbances in epilepsy is an area fraught with complexity. On the one hand, there are no instruments that have been developed specifically for the assessment of behavioral disturbances in epilepsy. On the other hand, the phenomenology and pathophysiology of behavioral disturbances in epilepsy are unique and defy conventional descriptions in the psychiatric literature. The vast majority of studies have used instruments that have not been validated for this purpose. Studies with a psychiatric orientation generally tend to employ unvalidated semistructured or structured tools except for the Structured Clinical Interview for DSM, which has been validated for epilepsy. Studies with a neurological orientation generally use screening questionnaires and interpret the results of these as diagnostic. Neither approach is valid and both generally fail to measure potential confounders, such as seizure frequency, seizure severity, temporality of seizure occurrence in relation to time of assessment, life events, disablement, quality of life, and other socioeconomic indicators. Furthermore, instruments are generally employed using cutoff scores that may not be valid for epilepsy populations; the emphasis is often on symptom severity rather than symptom multiplicity (or load), which may also have an impact on the patient's outcome. In addition, instruments that have a basis in psychiatric criteria as opposed to symptomatology have inherent pitfalls at the interface between epilepsy and behavior. These and other issues in evaluating behavioral disturbances in people with epilepsy are reviewed and some solutions for the future are proposed.

Treatment of depression in patients with epilepsy: problems, pitfalls, and some solutions.

Many people with epilepsy suffer from comorbid depression. Despite this, there have been few studies addressing the treatment of depression in this population, and the literature on psychiatric management techniques in patients with epilepsy is composed largely of opinions rather than evidence from randomized, controlled trials or other systematic investigations. Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors, can be used to treat patients with epilepsy and comorbid depression. Nonpharmacological treatment options include vagus nerve stimulation, transcranial magnetic stimulation, and psychological therapies including cognitive-behavioral therapy, individual or group psychotherapy, patient support groups, family therapy, and counseling. Another important area that remains largely uninvestigated is psychiatric research in patients with epilepsy in non-Western cultures (with the exception of Japan). Factors such as problems with access to and acceptability of therapies in many developing nations have further implications for the treatment of psychiatric disorders in epilepsy.

Abulia: a delphi survey of British neurologists and psychiatrists.

Abulia is the relatively uncommon yet debilitating lack of spontaneous, goal-directed behaviour that is seen predominantly with lesions of the basal ganglia and the frontal lobes. We sought to confirm the existence of abulia as an entity recognized by clinicians, to generate a set of items characteristic of the condition, and to see how clinicians differentiate between overlapping disorders. The Delphi technique was used to survey consultant neurologists and psychiatrists at three hospitals in London. The study consisted of two phases: semi- structured interviews of a small group of neurologists and psychiatrists, followed by a survey of a larger group of consultants using postal questionnaires. Both neurologists and psychiatrists recognized abulia to be a distinct clinical entity but its status as a syndrome was unclear. Features such as difficulty in initiating and sustaining spontaneous movements and reduction in emotional responsiveness, spontaneous speech, and social interaction were identified as being characteristic of abulia. The information generated by this study may help to develop a working classification for disorders of diminished drive and motivation, and instruments for clinical assessment and decision making.

Mesial temporal structures and comorbid anxiety in refractory partial epilepsy.

We used quantitative magnetic resonance imaging (MRI) to examine the mesial temporal structures in subjects with refractory partial epilepsy and comorbid anxiety and found preservation with a right-sided preponderance. The findings indicate a role for this brain region in the genesis of anxiety.