I am extremely indebted to my Columbia University colleague, Dr. Martha Morrell, for her stewardship of this month's issue of CNS Spectrums. Four of the five articles this month deal with epilepsy, its causes, modern treatments, and potential adverse outcomes of treatment. When I became editor of CNS Spectrums last year, one of my goals was to involve more neurologists in shaping the journal's content. A distinguishing aspect of this goal is to present cutting-edge information of value to both psychiatrists and neurologists. We are, after all, the clinicians and scientists most involved with diseases of the central nervous system, and we even share the same specialty board association. More importantly, however, there have recently been calls for better coordination of training and information between psychiatry and neurology. Dr. Eric Kandel, the recent Nobel Prize winner in physiology, has stated that in some ways the separation of psychiatry and neurology is artificial and impedes both fields. While I do not personally favor a complete merger of the two specialties, I do hope that CNS Spectrums will be one forum for bringing them closer together.

The clinical manifestation of epileptic seizures may vary widely from patient to patient, depending on the region of the brain involved. Over the centuries, many seizure classific systems have been used, and the current most widely used classification system is that of the International League Against Epilepsy (ILAE). The ILAE system divides seizures into those of partial onset and those of generalized onset, depending on whether the initial clinical manifestations indicate that one cortical region or both hemispheres are involved at the onset of the seizure. Partial seizures are then divided into simple partial seizures, in which a fully conscious state is retained, or complex partial seizures, in which consciousness is impaired. A more recent classification system based purely on symptom features and signs has been proposed, and this system may provide advantages for localization, and especially for surgical evaluation. Epilepsy is a condition characterized by recurrent unprovoked seizures. Epilepsy may be idiopathic, cryptogenic, or symptomatic. Idiopathic epilepsies are generally genetic, and while man such syndromes have been described, advances in molecular genetics will undoubtedly reveal many more syndromes in near future. Cryptogenic epilepsies are those in which an underlying cause is suspected, but the etiology remains undetected. Epilepsies for which there is an underlying structural cause or major metabolic derangement are considered symptomatic. Common causes and diagnostic evaluation are described in this article.

During the past 10 years, there has been a welcome influx of novel agents for the treatment of epilepsy. Many show advantages compared to older agents, including better adverse effect profiles and lack of drug-drug interactions. The sheer number of agents now available makes distinction among them confusing at times. Agents differ in spectrum of action, pharmacokinetic profile (affecting dosing schedule and drug interactions), and titration time. This review highlights the differences between the various new agents and the more traditional antiseizure drugs. Evidence for the widespread use of these compounds outside their indication, particularly for diseases other than epilepsy, is reviewed as well.

Lennox-Gastaut syndrome (LGS) is a severe form of childhood epilepsy that is usually refractory to medical management. When medications fail, alternative therapies are considered. Among these are two surgical options: corpus callosotomy and vagus nerve stimulation (VNS). Safety and efficacy are two important factors to consider when selecting an appropriate treatment. VNS is safer than callosotomy, but its efficacy is more difficult to assess. Available studies evaluate its effectiveness using a mixed population of patients (some with prior epilepsy surgery), a multitude of VNS settings, and variable endpoints. To estimate the efficacy of VNS in patients with LGS, a review of the medical literature and the VNS Patient Registry was performed. Within the limits of this type of study, the results showed that VNS appears equally as effective as callosotomy. Because VNS has a lower potential for adverse events, these results suggest that VNS should be considered first in appropriately selected patient.

Women with epilepsy are at risk for reproductive health dysfunction. Sex-steroid hormone abnormalities have been reported in women with epilepsy, but it has been difficult to determine whether these abnormalities are due to epilepsy-related hypothalamic-pituitary axis dysfunction, or to pharmacokinetic actions of antiepileptic drugs (AEDs). Sex-steroid hormones were evaluated in 84 reproductive-aged women with epilepsy receiving an AED in monotherapy, and in 20 nonepileptic controls. Estrone, free testosterone, and androstenedione were significantly lower in subjects receiving enzyme-inducing AEDs than in nonepileptic controls. Free testosterone was significantly elevated in subjects receiving valproate compared to nonepileptic controls. Subjects with epilepsy receiving gabapentin or lamotrigine were no different from the nonepileptic controls in any of the endocrine variables. Subjects with epilepsy who are receiving AEDs that alter cytochrome P450 enzymes are at risk for significant abnormalities in sex-steroid hormones. In contrast, subjects receiving AEDs that do not alter cytochrome P450 enzymes show no differences in sex-steroid hormones compared with nonepileptic controls. With new AEDs available that do not alter cytochrome P450 enzymes, physician selection of therapy should consider not only seizure control, but also potential effects on reproductive physiology.

Antidepressant treatments have evolved over the last 20 years, and many new drugs with complex mechanisms of action are available. It has become apparent that mechanism of action is significant in terms of treatment impact. We may have some capacity to predict the potential outcomes of treatment based on what drugs we use. Depression management requires elaborate assessment in order to keep track of treatment progress and know how to move through the sequences of therapy. Many patients with depression who are treated with antidepressants do not experience full remission, and a large number of patients who do recover eventually relapse. Remission as a treatment goal is difficult to achieve. One of the reasons why remission rates are low is that the currently available treatment choices are implemented improperly. Also, our understanding of the neurobiology of depression is still in the early stages. As we gain more knowledge about what this disorder truly entails, we will be able to achieve better treatment outcomes, and we can hope that remission will become the standard of care in treating patients with depression.

Subjective cognitive complaints of women exposed to intimate partner violence (IPV) and nonabused women were examined using the Cognitive Difficulties Scale (CDS). Cognitive complaints were compared among victims of IPV with a lifetime diagnosis of posttraumatic stress disorder (PTSD) (PTSD+; n=20), victims of IPV without lifetime PTSD (PTSD-; n=21), and a nonabused comparison group (n=22). The results indicated that both the PTSD+ and PTSD- groups had significantly higher levels of self-perceived cognitive difficulties than nonabused women. Furthermore, PTSD symptom severity was found to be positively correlated with self-perceived cognitive difficulties (r=.47). Further research is needed to determine whether cognitive complaints are associated with exposure to IPV, with the subsequent development of PTSD, or with other not yet understood factors. Furthermore, additional work is needed to resolve whether cognitive complaints are accompanied by objective evidence of cognitive dysfunction in victims of IPV.