Antiepileptic drugs and psychopathology of epilepsy: an update

Anti-epileptic drugs (AEDs) continue to be the mainstay of epilepsy treatment, but the benefits of seizure control need to be weighed carefully against possible adverse effects, which can include behavioral problems and psychiatric disorders. In this paper, the associations between AEDs and psychosis, depression and behavioral changes are reviewed. The concept of forced normalization and its clinical counterpart, alternative psychosis, are also discussed. Depression seems to be linked with AEDs potentiating GABAergic neurotransmission in patients with limbic system abnormalities such as hippocampal sclerosis. Psychoses have been described as associated with several of the new AEDs, and they are often seen in a setting in which previously refractory patients suddenly become seizure-free. In general terms, the use of AEDs in monotherapy, adopting slow titration schedules and low doses when possible, can significantly reduce the occurrence of behavioral adverse effects. A previous history of psychiatric disorder or a familial predisposition are important risk factors and should be always considered when choosing the appropriate AED.