Changes in psychiatric comorbidity during early ...

Download PDF
2 downloads 0 Views 259KB Size Report
Comment
standard anteromedial temporal lobectomy (3.5 cm on the dominant side and ..... temporal lobe epilepsy before and after anterior temporal lobectomy. J Neurol.
Epilepsy & Behavior 32 (2014) 29–33

Contents lists available at ScienceDirect

Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh

Changes in psychiatric comorbidity during early postsurgical period in patients operated for medically refractory epilepsy—A MINI-based follow-up study Soaham Desai a,b, Garima Shukla c,⁎, Vinay Goyal c, Achal Srivastava c, M.V. Padma Srivastava c, Manjari Tripathi c, Mamta Singh c, K. Shivanand d, Rajesh Sagar d, Aditya Gupta e, P. Saratchandra e, Ajay Garg f, C.S. Bal g, Madhuri Behari c a

Shree Krishna Hospital, Karamsad, Anand, Gujarat, India Dept. of Neuro-Medicine, Pramukhswami Medical College, Karamsad, Anand, Gujarat 388325, India c Dept. of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India d Dept. of Psychiatry, All India Institute of Medical Sciences, New Delhi 110029, India e Dept. of Neurosurgery, All India Institute of Medical Sciences, New Delhi 110029, India f Dept. of Neuro-radiology, All India Institute of Medical Sciences, New Delhi 110029, India g Dept. of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi 110029, India b

a r t i c l e

i n f o

Article history: Received 30 August 2013 Revised 20 November 2013 Accepted 27 November 2013 Available online xxxx Keywords: Psychiatric comorbidity Epilepsy surgery Outcome

a b s t r a c t Purpose: The purpose of this study was to assess axis-I DSM-IV psychiatric disorders in patients at baseline and 3 months after surgery for medically refractory temporal lobe epilepsy. Method: The Mini International Neuropsychiatric Interview (MINI) and Quality of Life in Epilepsy Inventory-10 (QOLIE-10) were evaluated before and 3 months after surgery in 50 consecutive patients (21 females, 29 males) with medically refractory temporal lobe epilepsy (persistent seizures N 2/month, despite treatment with ≥2 appropriate drugs in adequate doses for ≥2 years) who underwent surgery [anterior temporal lobectomy with amygdalo-hippocampectomy (for mesial temporal sclerosis in 40), electrocorticography-guided lesionectomy (for other lesions in 10)]. Results: Twenty-six patients (52%) had an axis-I psychiatric disorder [26% depressive disorder, 28% anxiety disorder] at baseline, while 30 (60%) patients had an axis-I psychiatric disorder [28% depressive disorder, 28% anxiety disorder] at 3 months after surgery. Twenty percent developed a new psychiatric disorder, while 12% showed improvement postsurgery. Mean QOLIE-10 scores improved from 23.78 to 17.80 [24 (48%) patients showed ≥5-point improvement]. Thirty-four (68%) patients had no seizure, 6 (12%) had non-disabling seizures, while 2 (4%) had disabling seizures after surgery. High frequency of seizures prior to surgery (p b 0.038) and seizure occurrence after surgery (p b 0.055) predicted the presence of psychiatric disorders after surgery. No clinical characteristic could predict development of new psychiatric disorder after surgery. Conclusion: Psychiatric dysfunction in the early postsurgery period is seen in nearly half of patients undergoing surgery for temporal lobe epilepsy, is mild in nature, and does not adversely affect quality of life but may cause significant clinical problems when it arises de novo postsurgery. © 2013 Elsevier Inc. All rights reserved.

1. Introduction Psychiatric disorders are frequently recognized to coexist in patients with medically refractory epilepsy [1,2]. They have also been described to appear de novo after surgery for medically refractory epilepsy [3–7]. Psychiatric symptoms, on the contrary, have also been reported to improve after surgery [8,9]. The overall outcome of epilepsy surgery is ⁎ Corresponding author at: Department of Neurology, Room no. 2, 6th floor, Neurosciences Center, All India Institute of Medical Sciences, New Delhi 110029, India. Fax: +91 26588166. E-mail address: [email protected] (G. Shukla). 1525-5050/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.yebeh.2013.11.025

determined not only by the reduction in seizure frequency but also by the cognitive and psychiatric state of the patient and the impact of all of these on overall quality of life. Clinical experience suggests that patients often develop psychiatric symptoms during the early post-epilepsy surgery period. Though many studies have assessed the incidence of depression and anxiety at a period of six months to 2 years postsurgery, the prevalence of Diagnostic and Statistical Manual [DSM]-IV axis-I psychiatric disorders and their effect on the quality of life in the early postsurgery period have not been adequately studied [10,11]. This may be important to assess how soon postoperative psychiatric disturbances, mainly depression, might manifest in patients operated for refractory epilepsy. This may provide an insight into the

30

S. Desai et al. / Epilepsy & Behavior 32 (2014) 29–33

mechanisms underlying this intriguing link between epilepsy and psychiatric comorbidity. We, therefore, initiated this study to assess the frequency and type of axis-I DSM-IV psychiatric disorders in the early postoperative period (first three months) in patients with refractory epilepsy undergoing surgery. Our secondary aim was to evaluate the early outcome of surgery at 3 months in terms of improvement in quality of life and seizure frequency or severity, as well as to assess the predictors of psychiatric disorders postsurgery. 2. Materials and methods Patients with medically refractory temporal lobe focal dyscognitive seizures of temporal lobe origin, who visited our intractable epilepsy clinic and subsequently underwent epilepsy surgery from December 2005 to July 2007 at the Neurology Department of All India Institute of Medical Sciences [AIIMS] New Delhi, India, formed the study population. This study was approved by the Ethics Committee of the institute. We included patients 16 years of age and older with ‘medically refractory temporal lobe epilepsy’ [refractoriness is defined (for this study) as patients having persistent seizures at a frequency of N2/month, despite treatment with at least 2 appropriate drugs in adequate doses for at least 2 years, who, on evaluation for epilepsy surgery, are found to have a temporal lobe-origin epileptic focus]. Patients with IQ b 70, unable to respond adequately on depression and anxiety scales, were excluded. Demographic and clinical information including age, education, occupation, seizure frequency and duration, medication history, past history of head injury/surgery, febrile seizures or febrile encephalopathy, and past history of psychiatric illness or treatment was recorded. Characterization of the epilepsy type and localization and lateralization of epileptic focus were on the basis of clinical seizure semiology, videoelectroencephalography [VEEG] data, 1.5-Tesla magnetic resonance imaging [MRI] of brain using an epilepsy protocol [specifically tailored to look for hippocampal sclerosis or cortical developmental malformations, including oblique coronal sections in 3D SPGR and FLAIR sequences], and findings of interictal SPECT using HMPAO and ictal SPECT of brain using Tc-ECD with subtraction ictal SPECT coregistered to interictal SPECT [SISCOS]. All patients with mesial temporal sclerosis underwent a standard anteromedial temporal lobectomy (3.5 cm on the dominant side and 5.5 cm on the nondominant side) with amygdalohippocampectomy, while lesionectomy under electrocorticographic guidance was performed for other lesions involving temporal lobes. All patients were evaluated using the Mini International Neuropsychiatric Interview [MINI], World Health Organization Five Well-Being Index (1998 version) [WHO-5] scores, Quality of Life in Epilepsy Inventory-10 [QOLIE-10] scale (administered before surgery and at 3 months after surgery), and Hospital Anxiety Depression Scale [HADS] for anxiety and depression (administered before surgery, at 7 days, and at 3 months postsurgery). Early seizure outcome postsurgery was assessed using “modified seizure outcome score”. The MINI is a short and efficient diagnostic interview, which has been validated for use in clinical as well as research settings and specifically in patients with epilepsy [12,13]. The test battery was administered to all patients by a single trained interviewer (SDD). A preliminary study to validate the use of MINI for diagnosis of axis-I DSM-IV disorders was conducted by comparing the MINI scores as assessed by the interviewer (SDD) to those assessed by a psychiatrist (SKK), and excellent interobserver agreement in diagnosis was shown. The MINI-based diagnosis for axis-I DSM-IV disorders was comparable to the present mental state examination done by the psychiatrist. The WHO-5 is a validated patient self-reported screening questionnaire for assessing depression in primary care [14,15]. A raw score of less than or equal to 13, percentage scores of 52 or less, or a score of less than 1 on any of the individual questions is suggestive of poor well-being and is an indication for further evaluation for depression [14,15]. The HADS [16] is also a validated

instrument for the assessment of anxiety as well as depression in various medical disorders and consists of a symptom-based questionnaire which gives scores for depression and anxiety, with scores of 0–7 considered as normal, 8–10 as borderline, and ≥11 considered abnormal or “caseness”. A score of ≥11 is an indication for further assessment for anxiety or depression [16]. The QOLIE-10 is a validated instrument for the assessment of quality of life in patients with epilepsy [17,18]. It is a modified shorter version of the original QOLIE-89 instrument, which is lengthy and cumbersome to use. It has one item each from five of the seven QOLIE-89 scales [Seizure Worry, Emotional Worry, Energy/Fatigue, Cognition, and Overall QOL], two items from the Medication Effects Scale, and three items from the Social Function Scale to provide individual questions for driving, social, and work limitations [17,18]. The demographic and other details of the study group were tabulated on Microsoft Excel worksheets and checked for keyboard errors. Statistical analysis was carried out using SPSS software version 12.0. The point prevalence of any psychiatric disorder, depression, and anxiety was calculated for the studied population before surgery and at 3 months postsurgery. The frequency of new onset of such disorders, as well as improvement in psychiatric disorders postsurgery, was also calculated. Paired sample correlations were carried out using Student's t-test to compare mean WHO-5, QOLIE-10, and HAD scores before and three months after surgery. We applied McNemar's test to evaluate for any significant overall difference in proportions of patients with versus without psychiatric disorder, as observed preoperatively versus 3 months postoperatively. A binomial logistic regression model was used to evaluate predictors of an axis-I psychiatric disorder (present or absent) at three months postsurgery among patients with temporal lobe epilepsy from among the variables age (years), gender (male or female), education (undergraduate or graduate), seizure frequency (number of seizures per week), seizure duration (in years), number of antiepileptic drugs per day, side of seizure focus (right or left), modified seizure outcome score (based on scores 0–10 as in Supplementary Table 3), QOLIE-10 score, and psychiatric disease prior to surgery (present or absent). 3. Results We studied 50 patients (21 females, 29 males) with age ranging between 16 and 50 years (mean: 26.1 ± 8.7) and seizure duration ranging between 3 and 30 years (mean: 9.94 ± 5.73 years) [Table 1]. Among the studied patients, 45 (90.0%) had a seizure frequency of less than 3 per month, while the rest had a seizure frequency of one per week or more. Most of the patients were on two or three antiepileptic drugs for more than two years. The epileptic focus was lateralized to the right side in 30 (60%) and to the left side in 20 (40%). The commonest pathology on biopsy was mesial temporal sclerosis (80%). Other lesions consisted of cortical dysplasia, dysembryonic neuroepithelial tumor, gliosis, and cavernoma [Table 1]. Twenty-four (48%) patients did not have any current axis-I disorder before surgery, while 26 patients (52%) had an associated axis-I psychiatric disorder along with epilepsy at baseline. Among them, a depressive disorder was present in 13 (26%), and an anxiety disorder was seen in 14 (28%), while psychosis, obsessive–compulsive disorder, and posttraumatic stress disorder were seen in 2 (4%) patients each. An axis-I disorder was found in 30 (60%) patients on repeat evaluation at three months postsurgery, out of which a depressive disorder was seen in 14 (28.0%), an anxiety disorder was seen in 14 (28.0%), and psychosis was found in three (6%) patients, while posttraumatic stress disorder, hypomania, and obsessive–compulsive disorder were found in two (4%) patients each [Table 2]. Four (8%) patients developed de novo psychogenic nonepileptic seizures postsurgery as confirmed through VEEG. Among these four patients, two had generalized anxiety disorder, and one had psychosis, while one had no coexistent axis-I disorder. On further analysis, it was observed that 10 (20.0%) patients developed a de

S. Desai et al. / Epilepsy & Behavior 32 (2014) 29–33 Table 1 Demographic and clinical characteristics of individuals undergoing epilepsy surgery for medically refractory temporal dyscognitive seizures [n = 50]. Characteristics Age (years): Mean (SD) Range Gender: Male Female Education: ≤Middle school High school Graduate Postgraduate Occupation: Student Service Shopkeeper Teacher Housewife Not working Seizure duration: Mean (SD) Range Seizure frequency: ≤3/month 1–2/week 3–5/week ≥1/day Number of AED/day: 2 3 4 Seizure focus and surgery side: Right Left Pathology: Mesial temporal sclerosis Gliosis Dysembryonic neuroepithelial tumor Cortical dysplasia Cavernoma Ganglioglioma

Number (percentage) 26.10 (8.70) 16–50 29 (58.0) 21 (42.0) 7 (14.0) 18 (36.0) 24 (48.0) 1 (2.0) 20 (40.0) 12 (24.0) 4 (8.0) 3 (6.0) 8 (16.0) 3 (6.0) 9.94 (5.73) 3–30 25 (50.0) 16 (32.0) 4 (8.0) 5 (10.0) 27 (54.0) 22 (44.0) 1 (2.0) 30 (60.0) 20 (40.0) 40 (80.0) 1 (2.0) 3 (6.0) 3 (6.0) 2 (4.0) 1 (2.0)

novo psychiatric disorder postsurgery, while 6 (12%) had improvement in their psychiatric disorder postsurgery [Table 2]. On assessing seizure outcome in the early postsurgery period (first 3 months post-surgery), 34 (68%) patients had no seizures post-surgery,

31

5 (10%) patients had seizures only in the first week postsurgery or related to drug omission, 6 (12%) patients had occasional nondisabling partial seizures, and 2 (4%) had disabling seizures even after surgery [see Supplementary Table 3]. On assessing the effect of epilepsy surgery on quality of life, the mean QOLIE-10 scores improved from 23.78 before surgery to 17.80 at 3 months after surgery, while the mean WHO-5 scores improved from 72.94 to 78.49 [Table 4]. Overall, a 5-point improvement in QOLIE-10 scores was seen in 24 (48%) patients at 3 months postsurgery. The mean HAD scores for depression did not change significantly at 7 days or 3 months postsurgery, but HAD anxiety scores showed a significant increase at 7 days postsurgery, which improved over the next 3 months [see Supplementary Table 4]. On evaluation for any difference in proportions of patients with and without psychiatric disorder preoperatively versus postoperatively, using McNemar's test, no significant difference was identified [see Supplementary Table 7]. Binomial regression analysis suggested that high seizure frequency prior to surgery and high scores on the modified seizure outcome scale postsurgery were significant predictors of postsurgery psychiatric disorders [see Supplementary Table 5]. None of the clinical characteristics could predict the development of de novo psychiatric disorders postsurgery [see Supplementary Table 6]. 4. Discussion This prospective study, conducted with the objective of assessing the frequency and type of DSM-IV axis-I disorders during the early postoperative phase among patients undergoing epilepsy surgery, shows that while 52% of the patients enrolled had an axis-I psychiatric disorder prior to surgery, this frequency increased to 60% at 3 months postoperatively, 20% of which had developed a de novo psychiatric condition. A similar prevalence of psychiatric comorbidity, prior to epilepsy surgery, has been reported in other studies (20%–85%) [10,11,19]. Most of these studies either used patient symptom-based scales to evaluate the patients or structured interviews like Structured Clinical Interview for DSM-IV disorders [SCID] and Schedules for Assessment in Neuropsychiatry [SCAN], which take about 2 h to be administered and are tiresome for the patients. We used the MINI, a shorter version of a clinical interview, which is easier to administer, and detected a similar percentage of such disorders in our patients. On follow-up assessment at 3 months postsurgery, we found that there was an 8% increase in the prevalence of axis-I psychiatric disorders.

Table 2 Prevalence of current DSM-IV axis-I disorders in patients undergoing epilepsy surgery for medically refractory temporal dyscognitive seizures and their relationship to surgery [n = 50]. DSM-IV axis-I disorder type

Presurgical assessment [number (percentage)]

3 months postsurgerya [number (percentage)]

De novo onset postsurgery

Improvement postsurgery

Depressive disorder Depression Dysthymia Anxiety disorder General anxiety disorder Agoraphobia Social phobia Panic disorder Obsessive–compulsive disorder Posttraumatic stress disorder Psychotic disorder Mania or hypomania Bulimia or anorexia nervosa No axis-I psychiatric disorder Any axis-I disorderb Paroxysmal nonepileptiform seizure-like symptoms [PNES]c

13 (26.0) 9 (18.0) 4 (8.0) 14 (28.0) 5 (10.0) 6 (12.0) 7 (14.0) 1 (2.0) 2 (4.0) 2 (4.0) 2 (4.0) 0 0 24 (48.0) 26 (52.0) 0

14 (28.0) 11 (22.0) 3 (6.0) 14 (28.0) 10 (20.0) 0 (0.0) 4 (8.0) 1 (1.6) 2 (4.0) 0 3 (6.0) 2 (4.0) 0 20 (40.0)a 30 (60.0) 4 (8.0)

5 (10.0)

2 (4.0)

5 (10.0)

5 (10.0)

0 0 1 (2.0) 2 (4.0) 0

0 0

10 (20.0) 4 (8.0)

6 (12.0) 0

Two patients with de novo mania/hypomania postsurgery also had anxiety; 1 patient with de novo psychosis postsurgery also had depression. a One patient died of ischemic stroke at 2 months postsurgery. b Disorders not mutually exclusive of each other. c Paroxysmal nonepileptic seizure {not an axis-I disorder but included here}.

0

32

S. Desai et al. / Epilepsy & Behavior 32 (2014) 29–33

Most studies assessing psychiatric comorbidity in epilepsy surgery have assessed the patients after a period of two or more years after epilepsy surgery and, therefore, this finding of higher prevalence of psychiatric morbidity has not been observed by these authors, and they mainly report improvement in psychiatric symptoms postsurgery [5,8,20]. A transient worsening of psychiatric symptoms might be missed if the patients are evaluated after a long postoperative period, while such worsening can be a significant contributor to many aspects of quality of life and ability to cope during the stressful perioperative period. Although an 8% increase in axis-I diagnoses appears to be small, it represents a significant clinical problem in epilepsy surgery programs, especially in those patients in whom symptoms arise de novo. Two other studies which evaluated patients at a similar time period postsurgery as our study also observed increased psychiatric symptoms and emotional lability in patients, thereby supporting our findings [11,21]. The study by Wrench et al. had a heterogeneous population consisting of both temporal and extratemporal epilepsies and evaluated patients using the Austin CEP interview, which predominantly assesses for depression or anxiety-related symptoms and for psychosocial wellbeing [21]. We used the MINI, which assesses all defined axis-I DSM-IV psychiatric disorders and not anxiety and depression only. Hospital anxiety and depression scores obtained preoperatively, at seven days postsurgery, and at three months postsurgery showed significant increase in anxiety scores at seven days postsurgery followed by improvement three months after surgery. This finding in our study is similar to that observed in a study by Ring et al. who also observed that there was an increase in anxiety symptoms in the immediate period postsurgery, which decreased over the following 3 months [11]. This can be explained by the anxiety associated with a major surgery, expectations of life after surgery, fear of complications of surgery, headache, fear of seizures and failure of surgery, and fear of postoperative memory loss. Apart from testing for anxiety and depression, patients were also evaluated for other axis-I disorders. Two patients in our study with a history suggestive of interictal psychosis prior to surgery had worsening of psychotic symptoms postsurgery, while one additional patient developed de novo psychosis postsurgery. Psychosis consisted of schizophreniform episodes with paranoid and depressive features in all the cases. None of these three patients required hospitalization to control the symptoms, and all of them had improvement with olanzapine in a dosage of 5–10 mg/day. These are too small numbers to draw any significance in relation to seizure rates/HAD scores or laterality of surgery. In a series of 320 patients evaluated postsurgery for psychiatric disorders, 11 patients developed psychosis in the postsurgery period, and these consisted of patients with bilateral preoperative EEG abnormalities or smaller amygdala on the nonoperated side [22]. While there was no patient with preexisting manic disorder before surgery, two of our patients developed de novo hypomania after surgery. Both the patients with hypomania postsurgery had right temporal lobe pathology, one of which had mesial temporal sclerosis, while the other had a dysembryonic neuroepithelial tumor [DNET]. Both of them reported feeling very active and energetic, having reduced sleep at night, excessive talkativeness, and being elated with their seizure-free state postsurgery with the feeling of getting rid of a block on their mind, and making ambitious plans for the future but without any associated mood swings [to suggest bipolar disorder] or psychosis. These hypomanic states were controlled by counseling and did not require any mood stabilizer. This state could have been induced by the epilepsy surgery being perceived by the patients as an exciting event which was ridding them of epilepsy and its associated stigma and freeing them from the uncertainty related to seizures. Similar findings have been reported earlier [23–26], but detailed reporting of other axis-I disorders cannot be found in most other series, which, generally, focus only on the prevalence of anxiety or depression. Though both these patients had right temporal surgery, it could just be a matter of chance and not related to the occurrence of hypomania postsurgery.

Four (8%) patients developed de novo psychogenic nonepileptic seizures postsurgery as confirmed through VEEG. Other series describing new-onset psychogenic seizures have proposed low IQ, associated psychiatric disorders, and major surgical complications as risk factors for their development [27–29]. In our series, the number of patients was too low (only four) to draw any meaningful conclusions about the risk factors for their occurrence. Another important feature, which has been observed in most studies, is that after epilepsy surgery, some patients have improvement in their symptoms, while some patients develop a psychopathology de novo after surgery. In our study, we found that 20% of the patients developed a de novo psychiatric disorder postsurgery, while 12% of the patients had improvement in their psychiatric symptoms. Thus, overall, in our study 32% of the patients had a change in their psychiatric comorbidity postsurgery. Similar observations have been reported by most other studies which assess postsurgery psychiatric symptoms [5,7,8,11,20,23,30–32]. Changes in the psychiatric states of patients in the postsurgery period can often surprise neurologists; while in some, preexisting disorders may improve serendipitously, in some, de novo psychiatric disorders may arise postsurgery. However, the factors which determine which patients would improve and that patients would worsen after epilepsy surgery are still not understood. Prediction of postoperative psychiatric disorders has always remained a challenge. We found high frequency of seizures, both prior to surgery as well as postsurgery (higher postoperative modified seizure outcome category), to be a significant predictor of postoperative psychiatric disorder. Similar observations have also been made in other studies assessing predictors of postsurgery psychiatric disorders [8,30,32–35]. Kohler et al. had highlighted the association of fear auras with mood and anxiety disorders after temporal lobectomy [36]. When comparing the WHO-5 as well as HAD anxiety and depression scores between patients who were seizure-free postsurgery and those with continued seizures postsurgery, the latter scored significantly poorly (p b 0.001) suggesting a link between persistence of seizures and psychiatric comorbidity. We did not find any significant relationship between the laterality of the seizure focus and preoperative or postoperative psychiatric disorders. Studies have reported a predominance or trend of left-sided [30,37] or of right-sided [33,38] foci being associated with postoperative depression, while others still have found no association between side of seizure focus and psychiatric disorders [8,29,35]. There is also ample heterogeneity in the methodology and patient population; hence, it is difficult to deduce anything regarding such associations. In a study by Filho et al., presurgery depression or psychosis was associated with higher chances of psychiatric disorders postsurgery [31]. While it would be commonly believed clinically that patients with preoperative psychiatric disorders may have a greater chance of having postoperative psychiatric disorders, this was not found in our study. The reasons for this may be that we had small patient population and we have assessed patients at a short period postsurgery compared to other studies. A longer follow-up of these patients and studies with a large number of patients may better help in understanding this relationship. We also did not find any association between the development of de novo psychiatric disorders and the clinical characteristics of the patients. Multiple mechanisms have been thought to be the cause of the psychiatric comorbidity of surgery for epilepsy. This consists of a complex interplay of biologic and neurochemical effects caused by the removal of areas of the limbic network, the expectations of the patient and family from surgery, and patients' psychosocial adjustment to life after surgery. According to Horowitz and Cohen, patients have to adopt new roles, progress to new adaptations, develop a healthy identity, and give up dependency, passivity, and immature interpersonal styles after an epilepsy surgery [39]. The degree to which patients are successful in bearing this “burden of normality” as termed by Wilson et al., could determine their psychiatric state after epilepsy surgery [40,41]. The patients who already have psychiatric dysfunction

S. Desai et al. / Epilepsy & Behavior 32 (2014) 29–33

presurgery and those who have persisting auras or seizures even after surgery would have more difficulties in this psychosocial, behavioral, and affective adaptation and, hence, may be at greater risk of psychiatric dysfunction, although this was not observed in our study. At the same time, those patients or families who have unrealistic expectations in terms of seizure control and overall life after surgery would be more predisposed to have psychiatric disorders after surgery [42]. We found that the mean QOLIE-10 scores improved from 23.78 to 17.80 (mean difference 5.98) at 3 months postsurgery. This was despite the presence of psychiatric disorders postsurgery. Also, we found that 48% of the patients had a 5-point improvement in QOLIE-10 scores as early as 3 months postsurgery. The mean QOLIE-10 score did not differ significantly between the group with psychiatric disorders and the group without psychiatric disorders. Thus, though psychiatric disorders, predominantly anxiety and depression, are commonly observed in the early postsurgery period, overall, they do not appear to impact the QOLIE-10 score. However, these psychiatric symptoms can have a significant effect on social and familial outcome, which may not be visible in the QOLIE-10 score. Epilepsy surgery outcome studies should also incorporate assessment of psychiatric outcomes, both in the short term as well as in the long term, in addition to the QOLIE-10 assessment due to the nonsensitivity of the QOLIE-10 in assessing the psychiatric outcomes. The fact that we included patients only from our center, with a relatively small patient population, and that the investigators were not blinded are the relative shortcomings of our study. On the other hand, the strengths of this study are that the patient population was homogeneous (only those with temporal lobe epilepsies) and that the patients were assessed by a single assessor for all axis-I psychiatric disorders both prior to and after surgery using a validated, structured, and easyto-perform scale (MINI), and this ensured that the findings observed were indeed de facto.

5. Conclusions Psychiatric comorbidity is observed in nearly half of the patients with refractory temporal lobe epilepsy, with this percentage increasing to 60% following epilepsy surgery, and nearly one-fifth of this group being at risk to develop some psychiatric morbidity, de novo. Though these psychiatric disorders are mild, they may cause significant clinical problems especially when they arise de novo postsurgery. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.yebeh.2013.11.025.

References [1] Manchanda R, Schaefer B, McLachlan RS, et al. Psychiatric disorders in candidates for surgery for epilepsy. J Neurol Neurosurg Psychiatry 1996;61(1):82–9. [2] Savard G, Manchanda R. Psychiatric assessment of candidates for epilepsy surgery. Can J Neurol Sci 2000;27(Suppl. 1):S44–9. [3] Stevens JR. Psychiatric consequences of temporal lobectomy for intractable seizures: 20–30 year follow-up of 14 cases. Psychol Med 1990;20:529–45. [4] Mace CJ, Trimble MR. Psychosis following temporal lobe surgery: a report of 6 cases. J Neurol Neurosurg Psychiatry 1991;54:639–44. [5] Blumer D, Wakhlu S, Davies K, Hermann B. Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications. Epilepsia 1998;39:47S–86S. [6] Anhoury S, Brown RJ, Krishnamoorthy ES, Trimble MR. Psychiatric outcome following temporal lobectomy: a predictive study. Epilepsia 2000;41(12):1608–15. [7] Bladin PF. Psychosocial difficulties and outcomes after temporal lobectomy. Epilepsia 1992;33:898–907. [8] Devinsky O, Barr WB, Vickerey BG, Berg AT, Bazil CW, Pacia SV, et al. Changes in depression and anxiety after resective surgery for epilepsy. Neurology 2005;65:1744–9. [9] Reuber M, Anderson B, Elger CE, et al. Depression and anxiety before and after temporal lobe epilepsy surgery. Seizure 2004;13:129–35.

33

[10] Naylor AS, Rogvi-Hansen BA, Kessing L, Kruse-Larsen C. Psychiatric morbidity after surgery for epilepsy: short-term follow up of patients undergoing amygdalohippocampectomy. J Neurol Neurosurg Psychiatry 1994;57(11):1375–81. [11] Ring HA, Moriarity J, Trimble MR. A prospective study of early postsurgical psychiatric associations of epilepsy surgery. J Neurol Neurosurg Psychiatry 1998;64:601–4. [12] Sheehaan D, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-4 and ICD-10. J Clin Psychiatry 1998;59(Suppl. 20):22–33. [13] Jones, et al. Clinical assessment of axis 1 psychiatric morbidity in chronic epilepsy: a multicenter investigation. J Neuropsychiatry Clin Neurosci 2005;17:172–9. [14] Primack BA. The WHO-5 Wellbeing index performed the best in screening for depression in primary care. ACP J Club 2003;139(2):48. [15] Henkel V, Mergl R, Kohnen R, Maier W, Hans-Jürgen M, Heger U. Identifying depression in primary care: a comparison of different methods in a prospective cohort study. BMJ 2003;326:200–1. [16] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–70. [17] Cramer1 JA, Perrine* K, Devinsky* O, Meador K. A brief questionnaire to screen for quality of life in epilepsy: the QOLIE-10. Epilepsia 37(6): 577–582. [18] Cramer JA, Arrigo C, Van Hammée G, Bromfield EB. Comparison between the QOLIE-31 and derived QOLIE-10 in a clinical trial of levetiracetam. Epilepsy Res 2000;41(1):29–38. [19] Jensen I, Larsen JK. Mental aspects of temporal lobe epilepsy. Follow-up of 74 patients after resection of a temporal lobe. J Neurol Neurosurg Psychiatry 1979;42:256–65. [20] Glosser G, Zwil AS, Glosser DS, O'Connor MJ, Sperling MR. Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy. J Neurol Neurosurg Psychiatry 2000;68(1):53–8. [21] Wrench J, Wilson SJ, Bladin PF. Mood disturbance before and after seizure surgery: a comparison of temporal and extratemporal resections. Epilepsia 2004;45(5):534–43. [22] Shaw P, Mellers J, Henderson M, Polkey C, David AS, Toone BK. Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors. J Neurol Neurosurg Psychiatry 2004;75(7):1003–8. [23] Carran MA, Kohler CG, O'Connor MJ, Bilker WB, Sperling MR. Mania following temporal lobectomy. Neurology 2003;61(6):770–4. [24] Mace CJ, Trimble MR. Psychosis following temporal lobe surgery: a report of six cases. J Neurol Neurosurg Psychiatry 1991;54(7):639–44. [25] Manchanda R, Miller H, McLachlan RS. Post-ictal psychosis after temporal lobectomy. J Neurol Neurosurg Psychiatry 1993;56(3):277–9. [26] Kanemoto K. Hypomania after temporal lobectomy: a sequela to the increased excitability of the residual temporal lobe? J Neurol Neurosurg Psychiatry 1995;59(4):448–9. [27] Ney Gershon C, William BB, Carline N, Decker R, Schaul N. New onset psychogenic seizures after surgery for epilepsy. Arch Neurol 1998;5:726–30. [28] Krahn LE, Rummans TA, Sharbrough FW, Jowesy SG, Cascino GD. Pseudoseizures after epilepsy surgery. Psychosomatics 1995;36(5):487–93. [29] Glosser G, Roberts D, Glosser DS. Nonepileptic seizures after resective epilepsy surgery. Epilepsia 1999;40(12):1750–4. [30] Altschuler L, Pausch R, Delrahi S, Kay J, Crandall P. Temporal lobe epilepsy, temporal lobectomy, and major depression. J Neuropsychiatry Clin Neurosci 1999;11(4):436–43. [31] Filho GM, Mazetto L, Gomes FL, Marinho MM, Tavares IM, Caboclo LO, et al. Presurgical predictors for psychiatric disorders following epilepsy surgery in patients with refractory temporal lobe epilepsy and mesial temporal sclerosis. Epilepsy Res 2012;102(1–2):86–93. [32] Hellwig S, Mamalis P, Feige B, Schulze-Bonhage A, van Elst LT. Psychiatric comorbidity in patients with pharmacoresistant focal epilepsy and psychiatric outcome after epilepsy surgery. Epilepsy Behav 2012;23(3):272–9. [33] Quigg M, Broshek DK, Heidal-Schiltz S, Maedgen JW, Bertram III EH. Depression in intractable epilepsy varies by laterality of focus and surgery. Epilepsia 2003;44(3):419–24. [34] Malmgren K, Starmark JE, Eksdedt G, Rosen H, Sjoberg-Larsson C. Nonorganic and organic psychiatric disorders in patients after epilepsy surgery. Epilepsy Behav 2002;3(1):67–75. [35] Anhoury S, Brown RJ, Krishnamoorthy ES, Trible MR. Psychiatric outcome after temporal lobectomy: a predictive study. Epilepsia 2000;41(12):1608–15. [36] Kohler CG, Carran MA, Bilker W, O'Connor MJ, Sperling MR. Association of fear auras with mood and anxiety disorders after temporal lobectomy. Epilepsia 2001;42(5):674–81. [37] Piazinni A, Canevini MP, Maggiori G, et al. Depression and anxiety in patients with epilepsy. Epilepsy Behav 2001;2:481–9. [38] Perini G, Mendius R. Depression and anxiety in complex partial seizures. Nerv Ment Dis 1984;172:287–90. [39] Horowitz MJ, Cohen FM. Temporal lobe epilepsy: effect of lobectomy on psychosocial functioning. Epilepsia 1968;9:23–41. [40] Wilson SJ, Bladin P, Saling M. The “burden of normality”: concepts of adjustment after surgery for seizures. J Neurol Neurosurg Psychiatry 2001;70:649–56. [41] Wilson SJ, Bladin PF, Saling MM, McIntosh AM, Lawrence JA. The longitudinal course of adjustment after seizure surgery. Seizure 2001;10(3):165–72. [42] Wilson SJ, Saling MM, Kincade P, et al. Patient expectations of temporal lobe surgery. Epilepsia 1998;39(2):167–74.