Madam, Dr. Sheerani 1 , in his review article, Development of a comprehensive.. (JPMA 2005;53:32-37), aptly described the steps needed to develop an epilepsy surgery programme in Pakistan. We agree that a neurosurgical facility specializing in epilepsy is a need of the hour to deal with the huge burden of intractable epilepsy in Pakistan. 2 It is important to realize that an epilepsy surgery programme requires a joint effort by multiple medical disciplines and we aim to highlight the crucial role played by a psychiatrist in such a setting. Psychiatric illnesses are often co morbid with epilepsy and depression is the most common psychiatric illness in epileptics. These psychiatric co-morbid disorders are more common in refractory epilepsy-the group ideally chosen to undergo surgery. There is a well recognized bidirectional relationship between depression and epilepsy that is easily missed in neurological and neurosurgical settings. 3 A detailed psychiatric history is therefore an important component of the preoperative evaluation.

The epilepsy surgery team needs to work in liaison with a psychiatrist even after the procedure. Psychiatric complications such as psychosis4; dysphoria and overt depression have been identified following temporal lobectomies.A psychiatrist intervening at this stage can help the patient with antidepressants that effectively treat psychiatric sequelae of chronic epilepsy. 5

Though neuropsychological studies were mentioned in the phase 2 evaluation1, they can never be a substitute for neuropsychiatric studies. Neuropsychological studies provide data on cognitive performance unlike a neuropsychiatric evaluation which should document the presence and type of psychiatric illness, its course, relationship to epileptic disorder and the need to begin psychotropic medication postoperatively.

Omar Aftab, Haider Naqvi*
Medical Student 2006, Department of Psychiatry*,
Aga Khan University, Karachi.

1. Sheerani M. Development of a Comprehensive epilepsy surgery programme in Pakistan J Pak Med Assoc 2005;55:32-7.

2. Aziz H, Akhtar SW, Hasan KZ. Epilepsy in Pakistan: stigma and psychosocial problems. A population-based epidemiologic study. Epilepsia 1997;38:1069-73.

3. Kanner AM, Balabanov A. Depression and epilepsy: how closely related are they? Neurology 2002;58 (Suppl 5):S27-39.

4. Shaw P, Mellers J, Henderson M, Polkey C, David AS, Toone BK. Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors. J Neurol Neurosurg Psychiatry 2004;75:1003-8.

5. Blumer D,Wakhlu S, Davies K, Hermann B. Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications. Epilepsia 1998;39;478-86.