Should neurologists treat common psychiatric comorbidities in patients with epilepsy?

Psychiatric comorbidities are common and highly impactful among people with epilepsy, yet they are underrecognized and undertreated due to challenges including shortage of specialty mental health providers and lack of neurologist education to enable management by neurologists. The purpose of this special issue is to address these gaps by providing a practical resource for neurologists to safely manage comorbidities via pharmacotherapy for common comorbidities. In this introductory article, we summarize key categories of psychiatric problems in epilepsy and a broad overview of management strategies. These include reactive psychiatric symptoms, interictal psychiatric disorders, peri-ictal psychiatric episodes, and iatrogenic causes of psychiatric symptoms. Reactive psychiatric symptoms can be addressed via epilepsy education and neurologist acknowledgement of the loss of predictability inherent in epilepsy. Interictal psychiatric disorders can be identified via standardized screening instruments and managed using evidence-based pharmacotherapy with a similar approach to the general population. Peri-ictal psychiatric episodes have a consistent temporal relation to seizure occurrence and are primarily managed via prevention through seizure treatment. Patients with personal or family history of psychiatric disorders are at particular risk for iatrogenic psychiatric effects; neurologists should take care in treatment selection among these individuals and be ready to respond to manage iatrogenic effects if they arise. Management of specific psychiatric conditions are addressed in more depth in topic-focused articles throughout the remainder of the special issue.