Addressing the Comorbidity Burden in Epilepsy

Body text: The clinical complexity of epilepsy often extends well beyond seizures. Depression, anxiety, suicidality, cognitive impairment, sleep disturbances, and other comorbidities can meaningfully affect quality of life, yet some remain difficult to identify when patients are reluctant to disclose symptoms or clinicians rely primarily on routine conversation rather than systematic screening.

In this NeurologyLive® Insights series, Jacqueline French, MD, professor of neurology at NYU Grossman School of Medicine, co-director of epilepsy research and epilepsy clinical trials at NYU Langone Health, and chief medical and innovation officer of the Epilepsy Foundation, examines the clinical realities of epilepsy across the disease course. Throughout the series, French provides practical perspectives on improving recognition, classification, diagnosis, and long-term management while accounting for the broader challenges patients and families experience.

In this episode, French explores how clinicians can better identify and address comorbidities alongside seizure management. She discusses the importance of building trust around conversations about depression and suicidality, opportunities to incorporate routine screening into epilepsy care, and the broader range of cognitive, behavioral, gastrointestinal, and sleep-related concerns that may require additional attention, particularly in children with severe epilepsies.

Any patient who arrives to a practitioner with newly diagnosed epilepsy, or with diagnosed epilepsy somewhere along their journey, in addition to identifying and classifying and ensuring that the diagnosis is correct, it's really important to look for comorbidities.

We do fall short in that we feel, as clinicians sometimes, that just talking to the patient, we can know whether they have a mood disorder, we can know whether they have an anxiety disorder, and we can understand if they have cognitive disturbance. But often, that is not the case.

People are very good at masking. In my role as the medical director of the Epilepsy Foundation, I have an opportunity to speak to a lot of people with epilepsy, and a lot of them will express that they have a concern about revealing to their clinician that they have a mood disorder or perhaps that they have suicidal ideation because they feel that will reflect on the way the clinician both interacts with them and perhaps even treats them.

So, the most important thing that a clinician can do, particularly in terms of mood and anxiety disorders, is to really create trust within the relationship between the practitioner and the patient. Also, give an open-ended question that says, "Look, a lot of people with epilepsy suffer from depression, mood disorders, or even thoughts of suicide, and that is actually part of the condition itself. So, you don't have to feel embarrassed, and you don't have to feel concerned. If you have any of these thoughts, or if there are any problems with mood or anxiety, you need to talk to me about it, and we'll discuss it together."

That open-ended question can really open the floodgates and can be extremely useful in regard to having the patient be a little more open with you about their concerns.

Suicidality is a very strong comorbidity in epilepsy. Recently, there was an article from one of my studies that showed that people with treatment-resistant epilepsy have a higher likelihood of having suicidal ideation even before they receive the diagnosis of epilepsy.

So, it's not because they have epilepsy. I think that's a misconception. It's not because they feel like their life is disrupted. Of course, it absolutely is, but there is a biological factor that is involved here, and we don't completely understand it. Certainly, there is a bidirectional biological factor.

If at all possible, it would be absolutely fantastic if every clinician would screen for depression, anxiety, and suicidality. This can be done before somebody even enters the room. It can be a screener that they get beforehand, before they come to the office.

I've been to the office recently for general practitioner checkups, and the general practitioners ask these questions, so there's no reason why neurologists and epileptologists cannot ask these questions as well.

In terms of cognitive comorbidities, we don't usually do neuropsychological testing on everybody who walks in the door. Certainly, when you look at children, the screening for comorbidities goes way beyond what we do in adults. There are going to have to be a lot more screening questions because many of the severe epilepsies, the developmental and epileptic encephalopathies, are associated not only with cognitive disturbances and mood disturbances, but also behavioral disturbances that can be very disruptive to the family.

We're also talking about gastrointestinal disturbances, constipation, diarrhea, nausea, and not eating properly. We're also talking about sleep disturbances. So, there are a lot of additional questions that need to be asked.

Sometimes, depending on whether it's a monogenic epilepsy, there can be a list of comorbidities associated with it that need to be screened for. That individual, that child, may need to be sent for secondary assessment by gastroenterologists and other types of clinicians in order to get proper care.