Lexapro for Major Depression in Patients With Epilepsy

Rationale:

Epilepsy is a chronic disorder that adversely affects social, vocational, and psychological
functioning. Despite the variety and complexity of the negative clinical associations with
epilepsy, depression is remarkable in prevalence and related adverse effects on health
status. An estimated 30-50% of persons with refractory epilepsy have major depression, and
depression has a stronger correlation than seizure rate with quality of life. Suicide is one
of the leading causes of death in epilepsy. Available data indicate that depression may
result from underlying brain dysfunction rather than social and vocational disability. Most
patients with depression are not screened systematically for the diagnosis, and are
subsequently not treated. Although the density of serotonin receptors is greatest in limbic
brain regions commonly involved in human epilepsy, such as the mesial temporal and prefrontal
areas, no prior randomized controlled trials have evaluated the efficacy of serotonin
reuptake inhibitors for depression in epilepsy.

Escitalopram may be an ideal SSRI for patients on antiepileptic medications because of the
lack of pharmacokinetic drug interactions, which can be expected, for example, with
fluoxetine or paroxetine.

Study Hypothesis:

Epilepsy patients having major depression will improve significantly over the course of a
12-week trial with escitalopram. Significant improvement will occur in ratings of depressive
symptoms, physical symptoms and measures of psychosocial function and quality of life.

Primary and Secondary objectives:

The primary objective will be to pilot the use of escitalopram for the treatment of major
depression in patients with epilepsy. The secondary objectives will be to determine effect
sizes on scales measuring depressive symptoms, physical symptoms, psychosocial function and
quality of life, and to evaluate safety in the population of patients with epilepsy.

These results will be used to evaluate the possibility of a future double-blind, placebo
controlled RCT of escitalopram for the treatment of major depression in patients with
epilepsy.

Study design:

An open-label design is proposed because this would be the first study of escitalopram for
the treatment of major depression in patients with epilepsy.

Treatment:

Psychiatric evaluations will be done by Dr. Kocsis, who will also monitor subjects for
improvement psychiatrically, as well as for potential adverse events such as agitation,
psychosis, and suicidality. Subjects who are noted to have an exacerbation in their
depression or develop suicidal ideation or mania may have the medication stopped or changed,
based on clinician judgement. SCID assessments will be done by Dr. Bleiberg.

Escitalopram will begin at 10mg. a day. Visits will occur biweekly for 12 weeks. Subjects
with minimal or no response and minimal or no side effects after 4 weeks will have the dose
increased to 20mg. a day. The maximum dose of escitalopram will not exceed the FDA-approved
maximum dose of 20 mg per day.

Safety Monitoring:

Safety monitoring for seizure worsening during the study will consist of the following:

Subjects will be evaluated by the study neurologist prior to starting escitalopram for a
complete seizure history, and a neurologic and general physical examination. Anti-epileptic
drug (AED) levels will be obtained at this baseline visit as well. The seizure count for all
seizure types for the previous month will be documented. A seizure severity score for each
seizure type using the National Hospital Seizure Severity Scale will be documented. Subjects
will be counseled to take all AEDs regularly. After escitalopram is started, subjects will be
seen every 4 weeks (3 visits) by the neurologist for a brief visit, during which an interim
seizure and medical history will be obtained, and a brief neurologic examination will be
performed. Seizure counts and seizure severity will be obtained for each seizure type and
compared to baseline. If there is a doubling of seizure counts compared to baseline of any
seizure type over any month period, the subject will be discontinued from the study and
escitalopram will be discontinued. Any lesser degree of increased seizure frequency or
worsened seizure severity during escitalopram treatment will prompt discontinuation of the
study depending on the judgement of the investigators.

Primary and secondary efficacy measures:

Clinically rated outcomes will be the HAM-D and the CGI, which assess depressive symptoms,
physical symptoms and severity of the depressive syndrome.

Self-rated assessments will include the IDS-SR for depressive symptoms, the SAS-SR for
social/vocational function and the Q-LES-Q for quality of life.

Safety assessments will include hematology, chemistries, AED levels, pregnancy testing and
urine drug screening prior to treatment. Hematology and chemistries, and AED levels will be
repeated at week 12 or termination.

Vital signs and adverse events will be systematically recorded at each visit. Occurrence of
seizures will be systematically logged during the course of the trial.

Anticipated findings:

The Wilcoxon signed-rank test will be applied to the mean scores available at weeks-1 and 0
vs. weeks 10 and 12 for the HAM-D, IDS-SR, SAS-SR and Q-LES-Q respectively. We anticipate
that there will be significant differences in clinician-rated depressive symptoms and
self-rated social function and quality of life from pre- to post-escitalopram treatment.

Inclusion Criteria:

1. Patients will be 20 males or females above the age of 18 with a current major
depressive episode, as defined by DSM-IV and assessed on the MINI, of at least 4 weeks
duration.

2. All subjects must have epilepsy, defined as the recurrence of seizures that are
unprovoked and unpredictable, requiring treatment with an anti-epileptic medication
under the care of a neurologist.

3. Subjects must be stabilized on their antiepileptic drug (AED) regimen for the previous
2 months.

4. If a vagus nerve stimulator is in place, the settings must be unchanged for the
previous 2 months.

5. Patients must be ages 18 - 75 and have a 24 item Hamilton Depression Rating Scale
Score (HAM-D) at intake >/= 20.

6. Subjects must be fluent in English and have the capacity to understand the nature of
the study and sign the written informed consent.

Exclusion Criteria:

1. Axis II diagnosis of antisocial, schizotypal or severe borderline personality
disorder(defined as patients who are high risk for being unable to complete the study
due to hospitalization, suicide attempts, significant self-mutilation, or other
self-injurious or destructive behavior).

2. History of psychosis, mania or hypomania.

3. Subjects with more than 10 seizures per month that involve impairment of
consciousness, such as complex partial or generalized seizures.

4. Subjects unable to count seizures accurately, or do not have a someone in their home
who can count seizures accurately .

5. Unstable medical or neurological disorder (other than epilepsy).

6. Epilepsies related to a progressive neurologic disease such as a brain tumor.

7. Substance abuse including ETOH within the past 6 months.

8. Need for concurrent psychotropic drugs with the exception of AEDs or zolpidem for
sleep.

9. Concurrent or recent (within 3 months) entry into a new psychotherapy.

10. Actively or acutely suicidal.

11. Failure to respond to escitalopram or to two or more other adequate antidepressant
trials in the past year.

12. Pregnancy or lactation.

13. Females of child bearing potential who do not practice adequate contraception.