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Introduction 

Introduction
Author(s):

Andrea E. Cavanna

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The good physician is concerned not only with turbulent brain waves but with disturbed emotions

William G. Lennox and Charles H. Markham (1953)

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs, as they are used to treat both epilepsy and psychiatric disorders. [ … ] Regrettably, both psychiatrists and neurologists are not well versed in the antiepileptic drugs literature that comes from each other's specialty.

Kenneth R. Kaufman (2011)

Antiepileptic drugs are among the most commonly prescribed medications by both neurologists and psychiatrists, as they exert a number of effects that extend far beyond their anticonvulsant properties. There is growing evidence that each antiepileptic drug is characterized by a specific behavioural profile: for example, the mood stabilizing properties demonstrated by valproate, carbamazepine, and lamotrigine have been recognized as useful psychotropic effects, resulting in regulatory indications for treating patients with bipolar affective disorder. The Behavioural Neurology of Antiepileptic Drugs provides the first clinically oriented reference book on the use of antiepileptic drugs with a focus on their behavioural effects in both patients with epilepsy and patients with primary psychiatric conditions.

This book aims to be a pocket-sized guide to assist neurologists in the use of antiepileptic drugs when treating patients with epilepsy and associated behavioural problems (ictal anxiety, post-ictal psychosis, interictal dysphoric disorder, to cite but a few). Needless to say, psychiatrists treating patients with affective, anxiety, and psychotic disorders will also find this compendium on the behavioural aspects of antiepileptic drugs a useful tool for their clinical practice. The book is organized alphabetically by antiepileptic drug for easier information gathering, enabling physicians to use the text as a standalone reference in busy clinical settings, such as specialist epilepsy clinics or general psychiatry ward rounds.

Particular care has been taken in covering the breadth of medications used in modern epilepsy and psychiatry practice, including each drug’s indications, contra-indications, side-effects, and important interactions. The underlying pharmacology is also presented to provide a quick refresher and background on the underlying mechanisms. Practical aspects related to prescribing and therapeutic drug monitoring are covered following the most up-to-date evidence-based guidance. However, it is important to note that most recommendations on clinical practice in the field of behavioural symptoms in epilepsy are empirical, as data based on methodologically sound research are often lacking. Each drug monograph closes with a section providing a visual overall rating in terms of antiepileptic indications, behavioural tolerability, interactions in polytherapy, and psychiatric use, again drawing on the existing evidence. A selected reference list is included to provide the reader with the primary sources for clinically relevant information presented in a concise way within each chapter. Coherence is maintained by the use of a universal template for each drug, with consistency in both required information and writing style.

It was felt that a new agile and up-to-date book was acutely needed to fill the gap between existing neuropharmacology textbooks (which focus mainly on the anticonvulsant effects of antiepileptic drugs) and, often out-of-date, monographs (which summarize antiepileptic drugs’ psychiatric indications for the psychiatry audience). This book’s practical approach and pocket size makes it a particularly useful resource for medical practitioners working with adult patients in the United Kingdom, although its unique cross-disciplinary features make it a valuable reference for the global audience.

Inevitably, while striving to achieve the best compromise between comprehensiveness and conciseness, important omissions and inaccuracies will have occurred, and this will not have escaped the attention of more learned readers. The alphabetical list of antiepileptic drugs is far from being exhaustive; voluntary omissions encompass, for example, drugs that are more rarely prescribed, drugs for paediatric use, and drugs with a restricted market because of specific warnings. These factors have provided the rationale for the exclusion of a number of pharmacological agents, including acetazolamide, felbamate, retigabine, stiripentol, and tetracosactide (adrenocorticotropic hormone or ACTH). Moreover, it is important to note that this book was written with a specific readership (i.e. behavioural neurologists) in mind; this explains why the text does not cover a number of important topics, such as emergency medications used for the treatment of status epilepticus, psychopharmacology, and behavioural therapy of psychiatric disorders in co-morbidity with epilepsy. Likewise, more invasive procedures, such as epilepsy surgery have not been included in a manual focusing on the behavioural aspects of antiepileptic drugs. These aspects of epilepsy care fall outside the remits of specialists in behavioural neurology. The relatively high prevalence of behavioural symptoms in patients with epilepsy is a serious and very complex problem, with important implications in terms of health-related quality of life. It has been suggested that one potential solution is for neurologists is to begin therapeutic interventions for uncomplicated behavioural symptoms, including non-refractory mood and anxiety disorders that are not co-morbid with suicidal risk, personality disorders, substance abuse, bipolar disorder, or psychotic disorder. The first important step in the behavioural neurologist’s intervention is the optimization of antiepileptic treatment in patients with epilepsy and co-morbid behavioural symptoms. Hopefully, the borderlands between neuropharmacology and psychopharmacology chartered in this book will offer unique insights and precious resources to treating clinicians who prioritize health-related quality of life as a therapeutic outcome for their patients. It does not appear anachronistic to refer to Lennox and Markham’s 1953 statement that the patient with epilepsy ‘is not just a nerve-muscle preparation; he is a person’ as a guiding principle for the medical science of the new millennium.

Birmingham (UK), February 2017