From the Guidelines
For individuals with epilepsy requiring psychiatric medication, SSRIs and SNRIs are the safest antidepressant options due to their lower seizure risk, as recommended by recent guidelines 1. When considering antidepressant options for individuals with epilepsy, it is crucial to prioritize medications with a lower risk of seizure induction.
- SSRIs, such as escitalopram and sertraline, are listed as first-line pharmacotherapy by NICE, indicating their safety and efficacy in this population 1.
- SNRIs, like venlafaxine, are also considered safe options, with the Canadian CPG listing them as first-line drugs for the treatment of social anxiety disorder 1.
- Other medications, including mirtazapine, reboxetine, and vortioxetine, are considered low-risk alternatives, although their use may be guided by specific clinical scenarios and patient factors. In contrast, TCAs and MAOIs should be avoided due to their high seizure risk, as they can significantly lower the seizure threshold and increase the risk of seizure activity. If antipsychotics are needed, aripiprazole is the safest choice, while clozapine and chlorpromazine should be avoided due to their high seizure potential 1. Regular follow-up appointments are essential to monitor both seizure control and psychiatric symptoms, with dose adjustments made as needed, and any new or worsening seizure activity following medication initiation should prompt immediate medical attention and potential medication changes. The safety profile of these medications relates to their neurochemical effects, with medications that strongly affect sodium channels or lower the seizure threshold posing greater risks, as discussed in the context of status epilepticus treatment 1.
From the Research
Antidepressant Safety in Epilepsy
- SSRIs and SNRIs are considered safer options for people with epilepsy, as they have a lower risk of inducing seizures 2, 3, 4, 5.
- Mirtazapine, Reboxetine, and Vortioxetine are also considered low-risk options for people with epilepsy 2, 3.
- TCAs and MAOIs should be avoided due to their high seizure risk 2, 3.
Antipsychotic Safety in Epilepsy
- Aripiprazole is considered the safest antipsychotic option for people with epilepsy, while Clozapine and Chlorpromazine pose the highest risk 2, 3.
Treatment of Depression in Epilepsy
- Depression is a common comorbidity in people with epilepsy, and treatment with antidepressants can improve depressive symptoms without worsening seizure frequency 4, 5, 6.
- SSRIs and SNRIs are effective in treating depressive symptoms in people with epilepsy, with response rates ranging from 43% to 82% 5.
- Antidepressants do not appear to increase the risk of seizures in people with epilepsy, and may even have a positive effect on seizure frequency in some cases 6.
Seizure Frequency and Antidepressants
- Studies have shown that SSRIs and SNRIs do not worsen seizure frequency in people with epilepsy, and may even be associated with a decrease in seizure frequency in some cases 6.
- The change in seizure frequency is independent of the improvement in psychiatric symptomatology, suggesting that antidepressants can have a positive effect on both depressive symptoms and seizure frequency 6.