Effects of psychotropic drugs on seizure threshold.

Psychotropic drugs, especially antidepressants and antipsychotics, may give rise to some concern in clinical practice because of their known ability to reduce seizure threshold and to provoke epileptic seizures. Although the phenomenon has been described with almost all the available compounds, neither its real magnitude nor the seizurogenic potential of individual drugs have been clearly established so far. In large investigations, seizure incidence rates have been reported to range from approximately 0.1 to approximately 1.5% in patients treated with therapeutic doses of most commonly used antidepressants and antipsychotics (incidence of the first unprovoked seizure in the general population is 0.07 to 0.09%). In patients who have taken an overdose, the seizure risk rises markedly, achieving values of approximately 4 to approximately 30%. This large variability, probably due to methodological differences among studies, makes data confusing and difficult to interpret. Agreement, however, converges on the following: seizures triggered by psychotropic drugs are a dose-dependent adverse effect; maprotiline and clomipramine among antidepressants and chlorpromazine and clozapine among antipsychotics that have a relatively high seizurogenic potential; phenelzine, tranylcypromine, fluoxetine, paroxetine, sertraline, venlafaxine and trazodone among antidepressants and fluphenazine, haloperidol, pimozide and risperidone among antipsychotics that exhibit a relatively low risk. Apart from drug-related factors, seizure precipitation during psychotropic drug medication is greatly influenced by the individual's inherited seizure threshold and, particularly, by the presence of seizurogenic conditions (such as history of epilepsy, brain damage, etc.). Pending identification of compounds with less or no effect on seizure threshold and formulation of definite therapeutic guidelines especially for patients at risk for seizures, the problem may be minimised through careful evaluation of the possible presence of seizurogenic conditions and simplification of the therapeutic scheme (low starting doses/slow dose escalation, maintenance of the minimal effective dose, avoidance of complex drug combinations, etc.). Although there is sufficient evidence that psychotropic drugs may lower seizure threshold, published literature data have also suggested that an appropriate psychotropic therapy may not only improve the mental state in patients with epilepsy, but also exert antiepileptic effects through a specific action. Further scientific research is warranted to clarify all aspects characterising the complex link between seizure threshold and psychotropic drugs.

Prevalence and characteristics of epilepsy in the Aeolian islands.

PURPOSE: To estimate the prevalence and define the clinical characteristics of epileptic disorders in the 13,431 residents of the Sicilian Aeolian archipelago, on June 1, 1999. METHODS: All established or suspected cases were identified by the neurologists of our working group from available medical information sources. Possible epilepsy cases were then evaluated by the epileptologists by using a standardized questionnaire. The patients were further reviewed by the whole research team to confirm the clinical diagnosis. For a more detailed syndromic definition, some patients underwent EEG or neuroradiologic investigations or both. RESULTS: The crude point prevalence rate of active epilepsy was 3.13 (95% confidence interval, 2.2-4.2). The prevalence rate age-adjusted to the 2001 Italian population was 3.01. Females had a slightly higher prevalence rate than did males. The highest age-specific prevalence was found in patients aged 5 to 14 years (5.05) and in those aged 65 to 74 years (5.41). Partial seizures with or without secondary generalization were more common (61.7%) than were generalized seizures. Eighty-three percent of cases had symptomatic or cryptogenic localization-related epilepsies, and 8.5% had idiopathic (generalized or partial) epilepsies. Epilepsy was unclassified in 8.5% of cases. CONCLUSIONS: The prevalence of active epilepsy in the Aeolian islands is lower than that in other developed areas, including northern Italy, but is similar to that in Sicily. Partial seizures were the most common type, and localization-related symptomatic epilepsies were the largest syndromic category.

Impact of sociodemographic characteristics on cognitive performance in an elderly Sicilian population.

OBJECTIVE: To assess cognitive levels in an elderly Sicilian population and to evaluate the role of education and other sociodemographic characteristics in cognitive performance. BACKGROUND: The pattern of cognitive performance in the elderly has not been investigated extensively in well-defined Italian populations. This study was conducted as part of a door-to-door survey of common neurologic disorders (the Sicilian Neuro-Epidemiologic Study project). METHODS: Thirteen physicians administered an Italian version of the Short Portable Mental Status Questionnaire (SPMSQ) to all subjects aged 50 years or older who, on November 1, 1987, resided in either of two Sicilian municipalities (Terrasini, Palermo province, and Riposto, Catania province; n = 3,999). Performance was scored as the number of errors on the SMPSQ. To define cognitive impairment we corrected the score for education as suggested by Pfeiffer [J Am Geriatr Soc 1975;23:433-441]. RESULTS: The median SPMSQ score was equal to 2, and cognitive impairment was present in 4.6% of the subjects. In a bivariate analysis, age, sex, education, employment status at interview and principal lifetime occupation were all significantly associated with cognitive impairment. In a multivariate analysis, the same pattern was seen, except that principal lifetime occupation lost its significance. CONCLUSION: Our findings suggest that age, sex, education and employment status are the sociodemographic characteristics associated with cognitive impairment in the elderly as measured by the SPMSQ.

Ischaemic stroke in young people: a prospective and long-term follow-up study.

BACKGROUND: A few studies have comprehensively assessed the epidemiology, aetiology, prognosis, and secondary prevention of ischaemic stroke in young adults. To gain further information on this field, we have prospectively studied a hospital-based series of young adults with a first-ever episode of cerebral ischaemia (CI). METHODS: Sixty consecutive patients aged 17-45 with ischaemic stroke (55 patients) or transient ischaemic attack within 24 h before hospital admission were recruited and investigated by a standardized rigorous protocol. The patients were followed up for >or=1 year after hospital discharge. Arbitrary doses of aspirin 100 mg/d or ticlopidine 250 mg b.i.d. in case of intolerance to aspirin were given for the secondary prevention. Adjusted-dose oral anticoagulation (INR target 2.5) was used in the presence of cardioembolism or hypercoagulable states. Endpoints included the residual disability, rated by modified Rankin Scale (RS) and Barthel Index (BI), and poststroke recurrence. RESULTS: CI was associated with two or more risk factors in 61.6% of patients. Cigarette smoking was more frequently associated with male gender (p < 0.05) and migraine history with female sex (p < 0.05). The atherothrombotic diagnostic subtype and the subtype from 'other cause' predominated significantly among patients >or=35 years old (p < 0.05) and <35 years (p < 0.025), respectively. The 'other cause' subset was more frequent in female gender (p < 0.05). Transoesophageal echocardiography (TEE) detected potential cardiac sources of emboli (PCSE) at an extent 3 times higher (p < 0.0001) than transthoracic echocardiography. Congenital heart defects were nearly threefold more frequent than acquired ones, with a prevalence of patent foramen ovale. At a mean of 6.1 +/- 2.6 years (confidence interval 5.4 to 6.8), follow-up data were available for only 54 patients, since five patients were lost and one died in the acute phase. Poststroke recurrence rate was low (7.4%) and no event was fatal. General handicap was severe to moderately severe (RS>3) in 11% of the patients, slight to moderate (1>or=RSor=95), 38.9% partially dependent (BI 60 to 86), and 11.1% fully dependent (BI <60). Thirty-seven (68.5%) patients returned to work, although adjustments (other job or part-time employment) were necessary for 10 out of them (27%). CONCLUSIONS: The present study, though limited by the relatively small number of subjects, suggests that the overall prognosis of ischaemic stroke in young adults is good. We strongly recommend TEE in all patients with ischaemic stroke as an essential tool to increase the detection of PCSE and make the therapeutic approach more efficient.