27 Depression
Depression is not just feeling sad. It is a medical condition that affects how a person thinks, feels, and functions, and it is much more common in children and adolescents with epilepsy than in the general population. Up to half of children with epilepsy will experience depression at some point in their lives1. The good news is that depression responds well to treatment, and recognising it early makes a real difference.
27.1 Why is depression so common in epilepsy?
The connection between epilepsy and depression is deeper than the emotional burden of living with a chronic illness, though that burden is real. Epilepsy and depression share overlapping brain circuits, particularly in the limbic system, the temporal lobe, and the prefrontal cortex2. This means that for some children, depression is part of the same neurological picture as the epilepsy itself, not simply a reaction to it.
The timing of mood changes relative to seizures can vary, and understanding this helps you and your doctor figure out what is going on and what treatment is needed. Some children experience irritability, anxiety, or low mood in the hours or days before a seizure. During a seizure, sadness or fear can occasionally be a seizure symptom itself, a feeling that arises directly from abnormal electrical activity in the brain. In the hours after a seizure, depression, tearfulness, and low energy are very common, and these are distinct from a depressive disorder. Finally, persistent low mood, loss of interest, and other symptoms that occur independently of seizures, between episodes, represent what we mean by a depressive disorder requiring its own treatment.
27.2 What does depression look like in children?
Depression in children and adolescents often looks quite different from the picture most people imagine. Many depressed children do not appear sad at all. They appear irritable, angry, or simply flat. Some signs to watch for include irritability or angry outbursts that seem out of proportion, loss of interest in activities they used to enjoy, and withdrawing from friends and family. Changes in sleep are common, either difficulty falling asleep or sleeping much more than usual. Appetite and weight may change. School performance may decline, or your child may begin refusing to go to school. They may seem persistently tired, talk negatively about themselves, or make hopeless statements like “nothing will ever get better.” Physical complaints without a clear medical cause, such as headaches, stomachaches, or nausea, are also common3.
If your child says anything that suggests they are thinking about hurting themselves or do not want to be alive, take this seriously. Contact your doctor, epilepsy team, or a mental health provider the same day. If you believe your child is in immediate danger, go to the nearest emergency department or call 988 (Suicide and Crisis Lifeline).
27.3 Depression and suicide risk in epilepsy
People with epilepsy have a two-to-four times higher risk of suicide compared to the general population, and this risk is higher in children with temporal lobe epilepsy and in those who are also depressed or impulsive4. This is a serious finding, and it is one of the main reasons early recognition and treatment of depression in epilepsy matters so much.
Anti-seizure medications deserve a mention here. In 2008, the FDA issued a warning that some ASMs carry a small increase in suicidal thoughts based on clinical trial data5. This does not mean your child’s medication should be stopped. Uncontrolled seizures carry far greater risks. It does mean this is something to monitor, and to discuss openly with your epilepsy team.
If you have concerns about your child’s safety at home, practical steps include keeping medications in a locked box and, if firearms are present, ensuring they are stored unloaded and locked with ammunition stored separately.
27.4 Treatment
27.4.1 Talking therapies
Cognitive Behavioural Therapy (CBT) is the best-studied psychological treatment for depression in children and adolescents6. CBT works by helping your child identify thought patterns that keep them stuck, for example the tendency to assume the worst, or to interpret neutral events as proof that they are a failure, and to replace these with more balanced ways of thinking. It is typically structured, goal-oriented, and time-limited, often 12 to 20 sessions.
For younger children, or when family dynamics are contributing to low mood, the therapist may work directly with parents. This approach, called Parent Management Training, can help everyone in the family communicate in a more consistent and supportive way.
27.4.2 Medications
When depression is moderate to severe, or when therapy alone has not been enough, antidepressant medication is often recommended. The first-line medications for depression in children are Selective Serotonin Reuptake Inhibitors (SSRIs), including fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro). Multiple studies have found that SSRIs do not increase seizure frequency, and some evidence suggests they may have mild anti-seizure properties in certain cases7.
In 2004, the FDA issued a warning that antidepressants may increase suicidal thoughts in children and adolescents, based on clinical trial findings8. No completed suicides were reported in any of those trials, and untreated depression carries significantly greater risk of harm than treated depression. The recommendation is close monitoring, especially in the first weeks after starting or adjusting medication, not avoidance of treatment.
Antidepressants for a child with epilepsy should be prescribed and monitored by a child and adolescent psychiatrist, working in coordination with your epilepsy team.
27.5 What you can do at home
There are meaningful things you can do alongside professional treatment. Maintaining predictable daily routines provides a scaffold when mood is low. Depression encourages withdrawal, so gently encourage contact with friends, even in small doses. Acknowledging your child’s feelings without trying to fix or minimize them goes further than reassurance; “I can see this is really hard for you” lands better than “you have so much to be grateful for.” Physical activity, even light exercise, has a meaningful effect on mood. And it is worth watching your own wellbeing too. Parental depression is a risk factor for depression in children, and seeking support for yourself is not a luxury. It is part of caring for your child.