Psychotherapeutic Interventions

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There are a number of psychotherapeutic treatments that have been demonstrated to be efficacious for anxiety and depression. Psychotherapy appears to be more effective than placebo, and it is often comparable to pharmacotherapy (Michels, 1997). Empirical studies of cognitive-behavioral therapy (CBT) have increased over the past 15 years with a growing body of evidence indicating their utility and efficacy in the management of depression and anxiety. CBT has been recommended as a first line treatment for depression, generalized anxiety disorder, and panic disorder in adults (Haby et al, 2006). As a result of a meta-analysis Haby et al. (2006) reported the effect size for CBT was 0.68 in all three disorders. This is a moderate to large effect size. In children and adolescents, Kendall (1994) and his colleagues (Kendall and Southam-Gerow, 1996 ; Kendall et al, 1997) have demonstrated the efficacy of CBT in reducing symptoms of anxiety in randomized controlled trials, with treatment gains maintained to 1-year and 3-year follow-ups (Kendall, 1994; Kendall and Southam-Gerow, 1996; Kendall et al, 1997).

Despite awareness of the efficacy of psychotherapeutic interventions for depression and anxiety, they have rarely been studied in epilepsy. In a recent Cochrane review of psychological treatments in epilepsy, Ramaratnam e t al. (2005) concluded that due to the limited number of studies and methodological concerns there is not enough evidence to endorse psychological treatments in epilepsy. The authors conducted a focused review of randomized controlled trials of psychological treatments in epilepsy. There were three studies that identified anxiety as measured outcome (Sultana, 1987; Helgeson et al, 1990; Olley et al, 2001) . The results of the studies were mixed; one study found no change (Helgeson et al, 1990), and the other two studies found significant reductions in symptoms of anxiety (Sultana, 1987 ; Olley ;t al, 2001; . The interventions used were psycho-educational programs and relaxation plus behavioral therapy. Depression was the outcome measure in six studies with three studies using an educational approach (Helgeson et al.; 1990; Olley et al.; 2001; May and Pfafflin, 2002), two utilized CBT (Davis, 1984; Tan and Bruni, 1986; and one study used relaxation plus behavior therapy (Sultana, 1987; . Similarly, the results of the interventions were mixed with half reporting no change following the intervention (Tan and Bruni, 1986; Sultana, 1987 ; May and Pfafflin, 2002) and the other half reporting improvement in depressive symptoms (Davis, 1984; Helgeson ;t al, 1990; Olley et al.; 2001).

There is significant discussion in the epilepsy literature regarding the under-recognition and under-treatment of depression, and more recently, anxiety disorders; however, very few psychological intervention studies have been conducted even though it has been demonstrated in the general psychiatric and psychological literature that there are efficacious treatment modalities for both depression and anxiety. Armed with this knowledge, we need to begin to study these treatment modalities using randomized controlled trials in individuals with epilepsy to identify and develop efficacious treatment options in epilepsy.

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