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Conventional mood disorders are encountered in many patients with epilepsy, and these include anxiety, depression, dysthymia and panic disorders. Intermittent affective-somatoform symptoms are frequently present in chronic epilepsy and include irritability, depressive moods, anergia, insomnia, atypical pains, anxiety, phobic fears and euphoric moods. Some are present continually but others show marked variation in relation to seizure activity. Prodromal and peri-ictal dysphoria are common.

Both depression and anxiety in epilepsy respond to conventional antidepressant drugs. Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) are routinely given. Fluoxetine is a widely prescribed drug, although it is a powerful CYP3A4 inhibitor and can interact with carbamazepine and other antiepileptics. Other SSRIs commonly used in patients with epilepsy include paroxe-tine and citalopram. Paroxetine does not interact with common antiepileptic drugs. Citalopram may be particularly beneficial in the subgroup of patients with mixed anxiety and depression. ECT is occasionally necessary in unremitting major depression. All the anti-depressant drugs have a mild proconvulsant action, and there is probably little difference between them in this regard. However, in patients with existing epilepsy, if depression is present to the extent that it requires anti-depressant therapy, the benefits of therapy generally greatly outweigh the procon-vulsant risk.

It is a common practice to add an anxiolytic drug during the initial phase of treatment, before the antidepressant can produce its full therapeutic effects. The anxiolytic drug is slowly withdrawn when the action of the antidepressant becomes fully manifest, which may take between 4 and 6 weeks. This practice is particularly helpful because during the initial phases of therapy many antidepressants may provoke rather than control anxiety. Drugs such as clobazam and lorazepam are the drugs usually prescribed. Prophy lactic antidepressants are sometimes given to patients with dysphoria around seizures. Clobazam can be used in shortlived dysphoria occurring around seizures, or in catamenial dysphoric disorders.

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