What is the best medication regimen for a 32-year-old woman with well-controlled focal motor seizures with impaired awareness, depression, and suicidal ideation, currently taking levetiracetam, sertraline, combined hormonal contraceptives (CHCs), and vitamin D?

Management of Focal Seizures in a Patient with Depression and Suicidal Ideation

Changing from levetiracetam to brivaracetam is the best recommendation for this patient with focal motor seizures, depression, and suicidal ideation.

Rationale for Medication Change

Levetiracetam carries a significant risk for worsening psychiatric symptoms, particularly in patients with pre-existing mental health conditions:

• The FDA label for levetiracetam explicitly warns that antiepileptic drugs, including levetiracetam, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication 1.
• Patients with a prior psychiatric disorder, like this patient with depression, constitute a specific subgroup with increased vulnerability to suicidal ideation when prescribed levetiracetam 2.
• The risk of suicidality with levetiracetam is particularly concerning in patients with pre-existing depression 3.

Benefits of Brivaracetam

Brivaracetam offers several advantages for this specific patient:

• Brivaracetam has a similar mechanism of action to levetiracetam but with fewer psychiatric side effects, making it an ideal alternative for patients with well-controlled seizures on levetiracetam who experience psychiatric adverse effects.
• Since the patient's seizures are well-controlled on levetiracetam, switching to brivaracetam (which has a similar mechanism of action) is likely to maintain seizure control while reducing psychiatric side effects.
• Brivaracetam does not interact with the patient's combined hormonal contraceptives, which is important as the patient does not want biological children 4.

Why Other Options Are Less Suitable

1. Continue current regimen: Not recommended due to:

   • Active suicidal ideation in a patient on levetiracetam, which has a documented risk of worsening suicidal thoughts 1, 2.
   • The FDA warning specifically notes that levetiracetam can increase the risk of suicidal thoughts or behavior, with the relative risk being higher in epilepsy patients than other conditions 1.

2. Change to topiramate: Not recommended due to:

   • Topiramate has been associated with cognitive impairment 5, which could worsen the patient's mental health.
   • Topiramate has also been associated with negative effects on mood 3.

3. Add on carbamazepine: Not recommended due to:

   • Adding carbamazepine would create a drug interaction with the patient's combined hormonal contraceptives, reducing contraceptive efficacy 4.
   • Carbamazepine can cause significant driving impairment, affecting arousal, sensory-perceptual, and cognitive functions 6.
   • Polytherapy increases the risk of adverse effects compared to monotherapy.

Implementation Plan

1. Transition plan:

   • Initiate brivaracetam while gradually tapering levetiracetam to minimize the risk of breakthrough seizures.
   • Start brivaracetam at a low dose and titrate up while simultaneously reducing levetiracetam.

2. Monitoring:

   • Closely monitor for changes in seizure frequency and severity during the transition.
   • Assess for improvement in mood and suicidal ideation.
   • Continue psychiatric follow-up as planned.

3. Patient education:

   • Explain the rationale for medication change.
   • Emphasize the importance of reporting any worsening of mood or suicidal thoughts immediately.
   • Reinforce the need to continue psychiatric care.

Common Pitfalls to Avoid

• Underestimating the impact of antiepileptic drugs on mental health: The FDA warning about increased suicidality risk with antiepileptic drugs should be taken seriously, especially in patients with pre-existing psychiatric conditions 1.
• Focusing only on seizure control: While the patient's seizures are well-controlled, the psychiatric side effects of levetiracetam pose a significant risk that outweighs the benefit of continued use.
• Ignoring contraceptive considerations: When managing epilepsy in women of childbearing age, medication choices should consider potential interactions with contraceptives, especially when the patient has explicitly stated she does not want biological children 4.

By changing from levetiracetam to brivaracetam, you address the patient's immediate psychiatric needs while maintaining seizure control and respecting her reproductive choices.