Prior to any treatment, health professionals should consult with the patient and any close family members and agree that the patient's anxiety is so disabling that treatment is indicated. The type of anxiety experienced by the patient and the relationship between the anxiety and the seizures should be documented. Cooperation between the neurologist or paediatric neurologist and other health professionals, e.g. the district psychiatric centre or a psychologist or psychiatrist in private practice, is often necessary.
In cases of peri-ictal anxiety, the most important measure is improvement of seizure control. There may also be a need to teach the patient specific coping strategies, which must be adapted to the individual.
The International League Against Epilepsy has established guidelines for the treatment of interictal anxiety and depression (24). Cognitive behaviour therapy is the preferred form of treatment for anxiety disorder among the general population. Medication to reduce anxiety should preferably be avoided. Many GPs are skilled in cognitive therapy and/or exposure therapy. However, if there is no choice but to use medication, often in combination with other treatment, selective serotonin reuptake inhibitors (SSRIs) or selective serotonin and norepinephrine reuptake inhibitors (SNRIs), such as sertraline or paroxetine, should be chosen. There has long been widespread fear that SSRI or SNRI drugs may reduce the seizure threshold in epilepsy patients. This fear has been shown to be unfounded as long as doses are maintained at therapeutic levels (25, 26). Higher doses, however, may intensify seizures. One study showed that prolonged use of SSRI drugs can increase epileptogenesis in a kindling model in rats (27). It is unknown whether this has transfer value to humans. Nor is it known whether these drugs have the same anti-depressive and anxiety-reducing effect in epilepsy patients as in psychiatric patients. Unfortunately, no control studies have been conducted in this area. Moreover, in recent years the question has been raised as to whether such drugs increase the risk of suicide, regardless of whether or not the patient had depression prior to treatment with medication. It also appears that a sub-group of patients are disposed to developing serious psychological side effects from antiepileptic drugs. People with epilepsy have a heightened risk of suicide. There are probably multiple, complex reasons for this (28, 29).
Epilepsy patients with anxiety should avoid taking antiepileptic drugs that may have negative psychotropic properties, for example levetiracetam, topiramate, zonisamide and felbamate. In such cases, we recommend the use of medications that can have mood-stabilising and anxiety-reducing properties, such as lamotrigine, carbamazepine, valproate and pregabalin.
Benzodiazepine, lacosamide and pregabalin have particularly anxiety-reducing properties (30, 31), but it is important to recognise that long-term use of benzodiazepine may increase anxiety and that there is the potential for misuse of pregabalin.
In psychopharmacological treatment of epilepsy patients, it is important to be aware that enzyme-inducing antiepileptic drugs (e.g. carbamazepine, phenytoin, phenobarbital) interact with psychopharmacological drugs, thereby reducing the serum concentration of the psychopharmacological drugs. Consequently, it is easier to combine psychopharmacological drugs with newer, non-enzyme-inducing antiepileptic drugs (4).
Epilepsy patients with anxiety have been found to experience pharmacological side effects more often than those without anxiety (32) and to benefit less from both antiepileptic drugs (33) and epilepsy surgery (22).