Current address: Sadat Shamim, 6301 Gaston Avenue, Suite 400 West Tower, Dallas, TX 75214, U.S.A.
Temporal lobe epilepsy, depression, and hippocampal volume
Version of Record online: 19 NOV 2008
Wiley Periodicals, Inc. © 2008 International League Against Epilepsy
Volume 50, Issue 5, pages 1067–1071, May 2009
How to Cite
Shamim, S., Hasler, G., Liew, C., Sato, S. and Theodore, W. H. (2009), Temporal lobe epilepsy, depression, and hippocampal volume. Epilepsia, 50: 1067–1071. doi: 10.1111/j.1528-1167.2008.01883.x
Current address: Gregor Hasler, Department of Psychiatry, University Hospital, 8091 Zürich, Switzerland.
Current address: Clarissa Liew, 1210S Cedar Crest Blvd. Suite 1800, Allentown, PA 18103, U.S.A.
- Issue online: 7 MAY 2009
- Version of Record online: 19 NOV 2008
- Accepted August 14, 2008; Early View publication November 19, 2008.
- Temporal lobe;
Objective: To evaluate the relationship between hippocampal volume loss, depression, and epilepsy.
Background: There is a significantly increased incidence of depression and suicide in patients with epilepsy. Both epilepsy and depression are associated with reduced hippocampal volumes, but it is uncertain whether patients with both conditions have greater atrophy than those with epilepsy alone. Previous studies used depression measures strongly weighted to current state, and did not necessarily assess the influence of chronic major depressive disorder (“trait”), which could have a greater impact on hippocampal volume.
Methods: Fifty-five epilepsy patients with complex partial seizures (CPS) confirmed by electroencephalography (EEG) had three-dimensional (3D)-spoiled gradient recall (SPGR) acquisition magnetic resonance imaging (MRI) scans for hippocampal volumetric analysis. Depression screening was performed with the Beck Depression Inventory (BDI, 51 patients) and with the structured clinical inventory for DSM-IV (SCID, 34 patients). For the BDI, a score above 10 was considered mild to moderate, above 20 moderate to severe, and above 30 severe depression. MRI and clinical analysis were performed blinded to other data. Statistical analysis was performed with Systat using Student’s t test and analysis of variance (ANOVA).
Results: There was a significant interaction between depression detected on SCID, side of focus, and left hippocampal volume. Patients with a diagnosis of depression and a right temporal seizure focus had significantly lower left hippocampal volume. A similar trend for an effect of depression on right hippocampal volume in patients with a right temporal focus did not reach statistical significance.
Conclusions: Our results suggest that patients with right temporal lobe epilepsy and depression have hippocampal atrophy that cannot be explained by epilepsy alone.
The comorbidity of epilepsy and depression is being recognized increasingly (Kanner, 2003). They occur together much more frequently than would be predicted by their frequency in the general population, and the risk for suicide and depression is significantly higher in epilepsy patients (Lambert & Robertson, 1999). The risk of epilepsy is also increased in patients with depression or with a history of attempted suicide (Hesdorffer et al., 2000, 2006). However, it is not clear if this association is because of similar underlying pathologic processes, psychosocial effects, or a combination.
The two diseases may share neuroanatomic localization. Neuroimaging studies in patients with depression as well as epilepsy show volume loss in the hippocampus. Depressed patients have hippocampal volume loss (Bremner et al., 2000; MacQueen et al., 2003), and bilateral reduction in hippocampal gray matter (Seidenberg et al., 2005) that may be worse with more bouts of major depression (Sheline et al., 1996). These findings parallel the hippocampal atrophy found in patients with temporal lobe epilepsy, who can have bilateral hippocampal atrophy, although more severe on the side of the focus. Moreover, volume loss ipsilateral to the seizure focus has been shown to be related to seizure frequency, generalized tonic–clonic seizures, and duration of epilepsy (Kälviäinen et al., 1998; Tasch et al., 1999; Theodore et al., 1999; Spanaki et al., 2000; Fuerst et al., 2003).
A previous study that evaluated volumetric hippocampal changes in comorbid epilepsy and depression used the hospital anxiety depression scale (HADS), which is a dynamic measure of depression, reflecting current mood but not necessarily underlying disease (Baxendale et al., 2005). However, hippocampal volumetric changes may not be present at the first episode of new-onset depression, and, in contrast, may be found in patients with a past history of depression who are not depressed at the time of scan (MacQueen et al., 2003). Therefore, we used a measure of underlying depressive trait, the structured clinical inventory for DSM-IV (SCID) as well as the Beck Depression Inventory (BDI), in order to study the effect of depression on hippocampal volume in patients with temporal lobe epilepsy (TLE).
We studied 55 consecutively evaluated patients (19 women) with temporal lobe epilepsy (mean age: 35 years, range: 18–62 years) with complex partial seizures (CPS), with or without secondary generalization, established by ictal video-electroencephalography (EEG), who had been referred to the National Institute of Neurological Disorders and Stroke (NINDS), Clinical Epilepsy Section for uncontrolled seizures. Patients with extratemporal lobe epilepsy were excluded. Subjects underwent depression screening with BDI (51 patients) and with the SCID (34 patients). Thirty-one patients had both. We categorized patients with bilateral temporal interictal spikes but with all ictal events arising from one side as having a unilateral focus. Bilateral patients had ictal events arising from both temporal lobes.
The SCID was performed by a psychiatrist (GH) and was used to define patients as having a lifetime diagnosis of major depression or not. BDI questionnaires were completed by patients. A score of above 10 was considered mild to moderate, above 20 moderate to severe, and above 30 severe depression. In the context of this study, we used “depressive trait” to indicate a current or past history of depression, and “depressive state” to indicate the presence of depression at the time of evaluation. The patients were taking a wide variety of antiepileptic drugs (AEDs); carbamazepine, lamotrigine, and levetiracetam were the most common. Others included valproic acid, zonisamide, gabapentin, and phenytoin. During the course of the seizure disorder many other AEDs had been tried as well. At the time of evaluation, none of the patients was on antidepressant therapy, but intermittent exposure had occurred in the past. The study was approved by the NINDS Institutional Review Board.
All patients underwent coronal three-dimensional (3D) spoiled gradient recalled (SPGR) acquisition (matrix 256 × 256 with 0.9375 × 0.9375 × 1.5 mm slices, TE: 3, TR: 27, TA:20, FOV 240 mm, Nex:1) MRI scans (GE, Milwaukee, WI, U.S.A.). These were loaded into a Linux-based system and hippocampi manually traced on each slice, and then assembled into 3D volumes. The anterior head of the hippocampus was separated from the amygdala by the appearance of the inferior limb of the lateral ventricle. The hippocampus was traced superiorly around the choroidal fissure, curving laterally along the medial border of the temporal horn, and medially along the gray matter of the hippocampus up to its junction with the parahippocampal gyrus. It was traced posteriorly to include the entire tail, up to and including the gyrus fasciola. We calculated a hippocampal asymmetry index (AI): 2 * (ipsilateral volume − contralateral volume)/(ipsilateral volume + contralateral volume). The more negative the AI, the greater the relative hippocampal volume reduction ipsilateral to the epileptic focus.
Statistical analysis was performed with Systat (Systat Inc., Chicago, IL, U.S.A.) using Student’s t-test and analysis of variance (ANOVA) to compare hippocampal volumes and depression state or trait. MRI volume measurement and clinical data extraction were performed by an investigator blinded to mood status. All MRI analysis was performed by the same reviewer to ensure reproducibility of methods.
Twenty-seven patients had a left temporal lobe epilepsy (LTLE) focus, 23 had a right temporal lobe epilepsy (RTLE), and five had bitemporal foci. Left hippocampal volume was significantly lower in patients with LTLE than in those with RTLE (p < 0.02), and right hippocampal volume significantly lower in those with RTLE than LTLE (p < 0.001) (Table 1). The mean AI did not differ significantly between LTLE (−0.32 ± 0.28) and RTLE patients (−0.22 ± 0.25), although there was a trend toward greater ipsilateral atrophy in LTLE patients. The patients with bitemporal foci had right hippocampal volume of 2,528 ± 617, and left hippocampal volume of 2,508 ± 623, consistent with bilateral atrophy.
|Right hippocampus||Left hippocampus|
|Right temporal focus (n = 23)||2,561 ± 840*||3,069 ± 554**|
|Left temporal focus (n = 27)||3,403 ± 450*||2,549 ± 788**|
|SCID: depressed (n = 15)||2910 ± 684||2,940 ± 606|
|SCID: not depressed (n = 19)||3,153 ± 691||2,902 ± 906|
|BDI: depressed (n = 21)||2,997 ± 821||2,789 ± 606|
|BDI: not depressed (n = 30)||3,024 ± 725||2,861 ± 801|
|Men (n = 36)||2,957 ± 769||2,731 ± 716|
|Women (n = 19)||3,049 ± 717||2,790 ± 779|
Across the entire patient sample, patients with depression on SCID or BDI did not differ in right or left hippocampal volume, or AI, from those with negative depression assessments (Table 1). There was no difference in BDI between RLTE (10.4 ± 10.3) and LTLE (11.9 ± 10.6) patients, or in the proportion depressed on SCID. One-way ANOVA for depression based on BDI compared to right (F-ratio 0.129, p = 0.721) or left (F-ratio 0.710, p = 0.403) hippocampal volumes showed no relationship. Severity of depression based on BDI did not show a relation to hippocampal volumes. Patients with increased MRI signal intensity diagnostic of mesial temporal sclerosis (MTS) on qualitative reading did not have higher BDI, or higher likelihood of positive SCID. There were no significant differences in age at depression onset, duration of illness, or number of episodes between patients with LTLE and RTLE.
Patients positive for depressive trait on SCID had significantly higher BDI (14.2 ± 12.7 vs. 5.5 ± 5.4 p < 0.02) than those negative on SCID. Five patients with current depression on SCID had BDI of 22.8 ± 16.3, compared with 6.9 ± 6.3 (p < 0.01) for those with only a history of depression.
Across the entire sample, there were interaction effects for SCID and focus on hippocampal volume (left: F-ratio 4.37, p < 0.05; right: f-ratio 3.73, 0.05 < p < 0.10). RTLE patients who were depressed on SCID evaluation had significantly lower left hippocampal volumes than those who were not depressed (Spearman correlation coefficient −0.54) (Table 2). There was a trend for depressed RTLE patients to have lower left hippocampal volume. Similar trends were seen when depression was measured by BDI, but this did not reach statistical significance. LTLE patients showed no differences (Table 2).
|Focus (N)||SCID (N)||Right hippocampus||Left hippocampus|
|Right (14)||Nondepressed (8)||2,960 ± 905**||3,425 ± 648*|
|Depressed (6)||2,261 ± 378**||2,852 ± 250*|
|Left (20)||Nondepressed (12)||3,294 ± 485||2,522 ± 898|
|Depressed (8)||3,405 ± 438||2,952 ± 811|
There was no difference between men and women in right or left hippocampal volume (Table 1). Five of 13 women tested, and 14 of 21 men, were depressed on SCID (chi-square 2.59: p = 0.11), but there was no difference in BDI. Women were overrepresented among patients with LTLE (13 of 28) compared to RTLE (4 of 23) (chi-square 4.79: p < 0.02). However, there were no interaction effects between gender and SCID, or gender and focus, on hippocampal volume. There was a weak inverse relationship between depression duration and left hippocampal volume (r2 = 0.18, f-ratio 2.95).
We found significantly lower left hippocampal volume (and a strong trend for right hippocampal volume) in depressed compared to nondepressed patients with RTLE. In contrast, there was no effect in patients with LTLE. Our results parallel a previous report that found greater hippocampal symmetry associated with higher depression levels in the right MTS patients, suggesting a smaller left hippocampus and thus greater bilateral atrophy associated with depression (Baxendale et al., 2005). A study using several scales, including the BDI, found that right MTS was related to increased scores (Nees et al., 2001). However, our study suggests that the underlying depressive trait, detected on SCID, as well as the current mood state, measured by BDI or Hospital Anxiety and Depression Scale (Baxendale et al., 2005), may influence hippocampal volume.
The vagaries of sampling in a consecutively acquired clinical series might explain our finding a significant relation between hippocampal volume and depression in RTLE alone. However, we were unable to find any explanatory clinical parameters. Although the gender distribution differed, there were no differences in right or left hippocampal size between men and women, or any interactions between gender and focus. Overall, the proportion of depressed patients in RTLE and LTLE groups was similar.
We found about 40% of our patients had positive findings on SCID or BDI. The rate of reported depression in epilepsy ranges from 20–55%; in a community study, female gender and low socioeconomic status were associated with increased depression risk (Ettinger et al., 2004). In a series from several epilepsy centers that excluded surgery patients, 22% of an unselected cohort had a mood disorder (Jones et al., 2005). In a large single center series collected over 11 years, 33% of patients had current or past depression on clinical evaluation; there was no difference between temporal and extratemporal lobe epilepsy, or between patients with RTLE or LTLE (Adams et al., 2008). Consistent with our results, MTS was not associated with increased risk for depression. Forty-four percent of 37 patients with refractory TLE had a history of depression, associated with length of epilepsy, but not laterality or MTS (Briellmann et al., 2007). One study (Quiske et al., 2000) not confirmed by subsequent work from the same group suggested an association of MTS with depression (Helmstaedter et al., 2004).
Our finding of an association between depression and reduced left- but not right-sided volume in the RTLE patients could be attributed to sample size. Moreover, RTLE patients already have significant right hippocampal atrophy that may make an additional effect of depression hard to detect. Detection of the effect in RTLE but not LTLE is harder to explain, but, intriguingly, has been suggested by two other studies (Nees et al., 2001; Baxendale et al., 2005). Right temporal lobe and hemispheric resections have been associated with the development of postresection depression (Kohler et al., 1999; Quigg et al., 2003). Right temporal resections tend to be more extensive, often involving greater subcortical tissue loss than left temporal resections. However, more recent reports from a multicenter trial have not confirmed this association (Devinsky et al., 2005). There may be some evidence for lateralized limbic affective processing. Patients with RTLE onset before age 5 had impaired recognition of facial emotion (McClelland et al., 2006). In a study of contextual fear condition, right but not left hippocampus was activated (Alvarez et al., 2008).
Our study has several limitations. The sample size was small, especially when divided by seizure focus laterality. We did not have a formal mechanism for establishing cumulative antidepressant exposure. Moreover, the wide variety of AEDs patients were taking at the time of the study, or had taken formerly, makes it extremely difficult to assess their potential effect on hippocampal volume.
Our findings should be seen in the context of the reported association of primary depression with reduced hippocampal volume; the left hippocampus may be more affected than the right (Sheline et al., 1996; Bremner et al., 2000; MacQueen et al., 2003) Some investigators have failed to find an association, whereas others report that factors such as a history of child abuse might be important; suggestions that hypercortisolemia might lead to hippocampal atrophy, a process with potential relevance for epilepsy as well, have not been confirmed (Geuze et al., 2005). Some data suggest patients with epilepsy have impaired dexamethasone suppression of corticotropin-releasing hormone, induced cortisol, and adrenocorticotrophin release (Zobel et al., 2004). Data from MRI and positron emission tomography studies in primary depressive disorders as well as epilepsy with depression suggest that volume loss and dysfunction may be widespread (Bromfield et al., 1992; Victoroff et al., 1994; Drevets, 1999; Rajkowska et al., 1999; Salzberg et al., 2006; Zetzsche et al., 2006; Richardson et al., 2007). It may be that the additional hippocampal volume loss, as well as more widespread findings, seen in patients with depression as well as epilepsy is the result, rather than the cause, of the mood disorder.
The study was supported by the Division of Intramural Research, National Institutes of Neurological Disorders and Stroke.
We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.
W.H. Theodore owns General Electric stock. None of the other authors reports any conflict of interest.
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