Lay off the Keppra? An Evidence-based and Integrated Update on Neuropsychiatric Effects of Anti-epileptic Drugs

Epilepsy is a common neurological disorder that is strongly associated with a wide spectrum of neuropsychiatric disorders. Compounding this, the treatment of epilepsy can further exacerbate mental status. Up to 20% of adults taking anti-epileptic drugs (AED's) experience depression, anxiety, irritability, aggression, psychosis, and suicidal thinking. Consequently, consult psychiatrists frequently negotiate the predicament between seizure control and mental health.

Given this intimate relationship, we regularly make recommendations to suggest or discourage certain AED’s to our neurologist and neurosurgeon colleagues. However, these recommendations often rely upon reputation rather than data, with some AED's such as levetiracetam being especially contentious. Furthermore, because many psychiatrists are not familiar with the management of seizure, we may fail to consider the clinical reasoning of our colleagues who treat them, limiting an integrated understanding of patient care. Finally, while most psychiatrists are well-informed about the established AED's with psychiatric indications, the neuropsychiatric profile of novel AED's are less explored. Familiarization of these newer agents will update our knowledge to both minimize adverse events while also allowing us to exploit their potential benefit.

In this Neuropsychiatry SIG-sponsored symposium, we will present an integrated, current, and evidence-based review of AED's and their effect on mental health.

Dr. Roy will introduce the speakers and moderate the session. 5-10 minutes

Geared for an audience of psychiatrists, epileptologist Dr. Rahul Guha will discuss the common types of epilepsy, clinical scenarios requiring AED’s, an up-to-date rationale behind AED selection, and the pharmacodynamic interactions with other AED's. 15 minutes

Dr. St. Victor will give an overview of the relationship between epilepsy and neuropsychiatric disorders. She will characterize the risk factors that predispose to poor psychiatric outcomes as well as the neurobiological mechanisms underlying these adverse events. Finally, she will present a case of AED-associated suicide and emphasize the importance of proactive suicide screening.
15 minutes

Dr. Kalra will discuss the adverse neuropsychiatric (mood, cognition, irritability) events across AED's. She will then provide evidence-based management strategies that CL psychiatrists can apply to optimize mental health outcomes, including treatments, quantifiable risk stratification (1), and preventing non-adherence by ensuring optimal quality of life. 15 mins

Dr. Hu will review the established neuropsychiatric benefits of traditional AED's in specific psychiatric disorders. He will then place special focus on newer anti-seizure medications, with the intention of broadening our psychopharmacologic toolbox for psychiatric patients with concomitant epilepsy. 15 mins

The remaining 15 minutes will be used for answering questions from the audience.

1. 
   Josephson CB, Engbers JDT, Jette N, et al. Prediction Tools for Psychiatric Adverse Effects After Levetiracetam Prescription. JAMA Neurol. 2019;76(4):440–446. doi:10.1001/jamaneurol.2018.4561