Psychiatric care in epilepsy surgery: who needs it?

Abstract

At present there is considerable variability in the psychiatric evaluation and follow-up of patients in epilepsy surgery programs globally. There is a large body of research now demonstrating heightened risk for psychological disturbance in surgically remedial patients before and after surgery. This evidence provides a compelling case for the routine provision of psychiatric and psychological treatment to optimize the benefits of epilepsy surgery and patient outcomes. In a comprehensive model of care, presurgical psychiatric and psychosocial evaluation plays an integral role in shaping the team's understanding of surgical candidacy and the patient's capacity for informed consent. After surgery, efficacious treatment of psychiatric comorbidity increases the likelihood of seizure freedom as well as optimizes psychosocial functioning and quality of life. By contrast, failure to treat can allow psychiatric comorbidity to persist or psychological difficulties to develop as the patient adjusts to life after surgery.

Figure 1

Depressive disorders in epilepsy are considered to lie on a spectrum of severity ranging from low-grade ‘sub-syndromic’ depressive episodes to severe, suicidal depression. They may not always fit dominant category-based diagnostic systems such as DSM-IV-TR or ICD-10 (40,41), but can show overlapping features. Interictal Dysphoric Disorder is thought to be caused by paroxysmal, subthreshold hypersynchronous neural discharges that produce increasingly inhibitory responses in the mood network (7). The identification of IDD as a separate entity, however, has been clinically debated with further research needed to resolve the issue.