The presence and clinical implications of depression in a community population of adults with epilepsy

Psychosocial predictors of depression and anxiety in patients with epilepsy: a systematic review

BACKGROUND

People with epilepsy (PWE) have a high chance of experiencing depression and anxiety disorders over their lifetime. However, those most at risk are unknown. Psychosocial variables have been suggested as potentially important risk factors. A systematic review was conducted in order to critically assess available evidence regarding the psychosocial predictors of depression and anxiety in adults with epilepsy.

METHODS

Electronic databases searched were MEDLINE, PsycINFO and Web of Science. Studies were included if they assessed depressive or anxiety symptoms using a validated questionnaire, and controlled for the role of potentially important epilepsy factors. Eleven studies were identified and assessed for research standards using the Quality Index Scale (QIS).

RESULTS

Ten of the eleven studies found at least one significant predictor of depression and all six studies that assessed anxiety found one or more significant predictors.

LIMITATIONS

Overall QIS score was only 7.5 out of 15, indicating significant design limitations of many included studies. There was also large variability between studies in measures used to assess psychosocial variables.

CONCLUSION

Studies did not support the importance of attributional theory and stigma in the development of depression in epilepsy. There was inconsistent support for the role of illness representations but likely support for the role of stress and self-efficacy. Consistent support was found for the role of coping strategies and perceived social support. Given that psychosocial factors are potentially modifiable, a better understanding of their role in the development of depression in people with epilepsy is urgently needed to guide effective treatments.

Finding a better drug for epilepsy: antiinflammatory targets

This monograph summarizes one of the sessions of the XI Workshop on Neurobiology of Epilepsy (WONOEP), and provides a critical review of the current state of the field. Speakers and discussants focused on several broad topics: (1) the coexistence of inflammatory processes encompassing several distinct signal-transduction pathways with the epileptogenic process; (2) evidence for the contribution of specific inflammatory molecules and processes to the onset and progression of epilepsy, as well as to epilepsy-related morbidities including depression; (3) the complexity and intricate cross-talk of the pathways involved in inflammation, and the discrete, often opposite roles of a given mediator in neurons versus other cell types. These complexities highlight the challenges confronting the field as it aims to define inflammatory molecules as promising targets for epilepsy prevention and treatment.

Prevalence and clinical characteristics of epilepsy in the South of Spain

PURPOSE

Epilepsy is a common neurological disorder found in all societies. There are extensive epidemiologic studies of different European areas. However, not much information about the South-West of Europe exists. In Málaga, Health Care is free and there are only two public hospitals with Neurological Services that assist Eastern or Western areas depending on the case. The purpose is to estimate the epidemiology in Málaga through a hospital-based study and compare it to the other European studies.

METHODS

Review on the hospital data base and gathering of consecutive patients with a diagnosis of active epilepsy served by the Epilepsy outpatient clinic in Virgen de la Victoria Hospital throughout a year.

RESULTS

2 281 patients fulfilled the criteria and 515 patients were recruited in order to study the epidemiologic characteristics. Male gender and focal onset seizures predominate (75.5%). Medium age 40. 58% of patients have been seizure-free in the last year. Known etiology in half of the patients. 54% of patients are treated with monotherapy. Valproic acid is the commonest drug. Other epidemiologic and demographic important data are provided. Data are analysed and compared to other European studies.

CONCLUSIONS

Prevalence rate in Western Málaga is 4.79 cases/1000 inhabitants. Characteristics of the sample are similar to those of other European studies. Although this is a hospital-based study, the particular characteristics of the Health Care System in our region enable us to gather real data concerning epidemiology and prevalence.

Determinants of quality of life in patients with refractory focal epilepsy who were not eligible for surgery or who rejected surgery

The aim of the study was to assess the determinants of quality of life (QOL) in adult patients with refractory focal epilepsy who were not eligible for surgery or who rejected surgery after presurgical evaluation. The QOLIE-31, the Hospital Anxiety and Depression Scale and PESOS questionnaire were mailed in 2009 to all adult patients who had been evaluated for suitability for epilepsy surgery between 2001 and 2007 in the Bethel Epilepsy Center and had been deemed not eligible for surgery or had decided against surgery. Questionnaires were sent by post to 359 patients: 172 (47.9%) replied, and of these, 125 patients were eligible for this study. The remaining 47 patients were excluded mainly because they did not fulfill the criteria of refractory epilepsy. Out of the included 125 patients, 106 were considered to be poor surgical candidates for medical reasons, and 19 had decided against surgery. The mean follow-up was 4.1±2.1 years. In the past 6 months, 13.9% of the patients were seizure free, 12 of them (9.6%) were seizure free for one year, 10.7% had 1-2 seizures, 11.5% had 3-5 seizures, 27.0% had one or more seizures a month, 23.0% had one or more seizures a week, and 13.9% had one or more seizures a day. Patient-perceived changes in their seizures since presurgical evaluation were rated by 15.6% of the patients as 'improved significantly', by 28.7% as 'improved', by 46.7% as 'no change', by 6.6% as 'deteriorated' and by 2.5% as 'significantly deteriorated'. Quality of life in patients with refractory epilepsy was much lower compared to operated patients from our center. Multivariate analysis of QOL showed that depression and anxiety are strong predictors but not exclusively. Furthermore, tolerability and efficacy of AEDs are significant predictors of most QOLIE-31 subscales. Employment, seizure frequency, patient-perceived change in their seizures, number of AEDs and the degree of comorbidity appeared as predictors for some aspects of QOL as well. When excluding anxiety and depression, the most important predictors of QOL were tolerability of AEDs and employment. For other aspects of QOL, efficacy of AEDs, gender, number of AEDs, degree of comorbidity and a certificate of disability were additional predictors. The results of the multivariate analysis did not essentially change when seizure-free patients were excluded.

CONCLUSION

Quality of life in non-operated patients with refractory epilepsy is significantly lower than in operated patients from the same center. Besides depression and anxiety, patient-rated tolerability and efficacy of AEDs, seizure frequency and employment are the main determinants of QOL.

Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives

The clinical manifestations of depression in people with epilepsy (PWE) are pleomorphic, often associated with anxiety symptoms and anxiety disorders. The ongoing debate of whether the clinical presentation of depression in PWE is unique to this neurologic disorder is reviewed. Comorbid depression can impact the recruitment of PWE for pharmacologic trials with antiepileptic drugs (AEDs). Yet, the impact of depression on the response of the seizure disorder to pharmacotherapy with AEDs and its impact on worse adverse events may bias the interpretation of the trial findings, particularly when depressed patients are included in the AED trials. PWE have a greater suicidal risk than the general population. This risk is mediated by multiple factors, and recent data from the FDA have imputed a potential pathogenic role to all AEDs. The recognition of patients at risk is reviewed. Yet, the validity of the FDA data has been questioned, and the status of this controversial question is analyzed. As in the case of epilepsy, depression and pain syndromes have a relatively high comorbidity. The negative impact of depression on pain is reminiscent of that of depression in PWE; furthermore, the high comorbidity may be also associated with the existence of common pathogenic mechanisms. Neurologists and in particular, epileptologists establish the diagnosis of psychogenic non-epileptic seizures (PNES) in whom a comorbid depressive disorder is very often identified. The role of depression in the course of PNES and its treatment are discussed. Scarce data are available on the treatment of depression in PWE. Thus, clinicians have had to adopt data from patients with primary depressive disorders. We outline a consensus strategy on the identification and treatment of depressive disorders in adult and pediatric patients with epilepsy.

Screening symptoms of depression and suicidal ideation in people with epilepsy using the Beck depression inventory

OBJECTIVE: To measure the severity of symptoms of depression and suicidal ideation in people with epilepsy (PWE) before and after epilepsy surgery using the Beck Depression Inventory (BDI). We aimed to determine the factors associated to depression in PWE. METHODS: PWE, regardless of epilepsy type, seizure type, duration or frequency of seizures, and AEDs were investigated. The sample (n=468) was divided into two groups: pre-operatory (n=346) and pos-operatory (n=122). RESULTS: Before epilepsy surgery female gender, unemployment and high seizure frequency were associated factors for the occurrence of symptoms of depression. After epilepsy surgery, the only factor associated to high level of depression symptoms was the lack of seizure remission. Suicidal ideation was associated to seizure frequency before and after epilepsy surgery. CONCLUSION: Our results confirm the generally held view that depression is common in PWE and provide further insight to the association of depression with certain socio-demographic and seizure-related factors before and after epilepsy surgery.

Prevalence of psychiatric comorbidities in temporal lobe epilepsy in a Southern Brazilian population

A great prevalence of psychiatric disorders in epilepsy is well demonstrated, although most studies have used unstructured psychiatric interviews for diagnosis. Here we present a study evaluating the prevalence of psychiatric comorbidities in a cohort of Southern Brazilian patients with temporal lobe epilepsy (TLE) using a structured clinical interview. We analyzed 166 patients with TLE regarding neuropsychiatric symptoms through the Structured Clinical Interview for DSM-IV. One hundred-six patients (63.9%) presented psychiatric comorbidities. Mood disorders were observed in 80 patients (48.2%), anxiety disorders in 51 patients (30.7%), psychotic disorders in 14 (8.4%), and substance abuse in 8 patients (4.8%) respectively. Our results agree with literature data where most authors detected mental disorders in 10 to 60% of epileptic patients. This wide variation is probably attributable to different patient groups investigated and to the great variety of diagnostic methods. Structured psychiatric interviews might contribute to a better evaluation of prevalence of psychiatric comorbidities in TLE.

Help-seeking and treatment preferences for depression in epilepsy

Depression among people with a diagnosis of epilepsy is common, underrecognized, and undertreated, yet the reasons for this are unclear. In this study people with a diagnosis of epilepsy recruited from primary care were mailed a questionnaire covering help seeking for psychological distress, treatment preferences for depression, and current symptoms of depression using the Patient Health Questionnaire-2 (PHQ2). Eighty-six people with epilepsy responded to the survey and 44% of the sample reported they would not seek help if they were feeling stressed, worried, or low and it was affecting their daily lives. Almost 40% of the participants screened positive for current depression and PHQ2 scores were statistically unchanged over an average of 8.6 months. The most popular treatment for depression was advice from a general practitioner or from family and friends. The majority of respondents felt speed of treatment should take priority over receiving preferred treatment for depression care.

Psychiatric comorbidity, quality of life and social support in epileptic patients

BACKGROUND

Epilepsy is accompanied by many psychiatric disorders and continues to be a disease that disturbs the functioning and quality of life (QOL) of patients.

AIMS

To assess the frequency of psychiatric disorders occurring in epileptic patients, determine depression and anxiety levels, and compare the results with healthy controls. The effect of epilepsy on QOL and the effects of social support on epilepsy were also assessed.

METHODS

50 epileptic patients and 50 controls were compared using the Structured Clinical Interview for DSM-IV (SCID-I), Beck Depression Inventory, Beck Anxiety Scale, Multi-dimensional Scale of Perceived Social Support (MSPSS) and the World Health Organization Quality of Life Assessment-Brief (WHOQOL-Brief).

RESULTS

44% of epileptic patients had psychiatric disorders, with depression being the most common diagnoses (28%). In terms of psychiatric comorbidity, there was a significant difference between the groups. The depression and anxiety scores of epileptic patients were significantly higher and there was no difference between the groups in terms of MSPSS scores. Psychological and physical subscale scores of WHOQOL-Brief were significantly lower in epileptic patients. In the epileptic group, a multi-variate analysis of covariance demonstrated that depression was a significant covariate for physical and psychological domains, anxiety was a significant covariate for psychological domain, social support was a significant covariate for social and environmental domains, and age of epilepsy onset was a significant covariate for physical domain of QOL.

CONCLUSION

Epilepsy needs multi-dimensional analysis because of its chronic nature, frequently accompanying psychiatric disorders, its negative effects on QOL and the important role social support plays. The clinicians' handling of patients at an early stage can play an important role in preventing the negative results of epilepsy.

Depression and anxiety in a community sample with epilepsy in Brazil

OBJECTIVE

To estimate the frequency of depression/anxiety and to establish the social, epilepsy and psychiatric characteristics in individuals with epilepsy.

METHOD

A cross-sectional study was employed to evaluate 153 subjects with epilepsy who were identified in a previous community-based survey. First, a structured interview was conducted, followed by a psychiatric evaluation. Subjects with depression were compared to those without, and subjects with anxiety were compared to those without.

RESULTS

The prevalence of anxiety and depression was 39.4 and 24.4%, respectively. Both were associated with low schooling (OR 3.8, 95% CI 1.6 to 9.0 and OR 2.8, 95% CI 1.2 to 6.5 for depression and anxiety, respectively), lifetime suicidal thoughts (OR 4.4, 95% CI 1.9 to 10.3 and OR 3.6, 95% CI 1.7 to 7.7) and lifetime suicide attempts (OR 9.3, 95% CI 2.6 to 32.8 and OR 6.9, 95% CI 1.8 to 26.4).

CONCLUSION

The high rates of depression and anxiety reinforced the need for recognition and treatment of mental disorders in epilepsy.

Depression screening for patients with epilepsy in a primary care setting using the Patient Health Questionnaire-2 and the Neurological Disorders Depression Inventory for Epilepsy

Depression among people with a diagnosis of epilepsy is under-recognized. General practitioner (GP) screening for depression using a new scale developed specifically for patients with epilepsy, the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), has not before been reported. The aims were to examine the process of GP screening for depression in patients with epilepsy employing the widely used Patient Health Questionnaire-2 (PHQ-2) and the NDDI-E; to determine the impact of screening on GP-recognized depression; and to ascertain depression predictors. Patients were screened via their GPs. A subset of participants underwent clinical interview to assess screener accuracy. Use of either instrument almost doubled the proportion of GP-recognized depression. Ninety-four percent of those interviewed found screening acceptable. More recent and frequent seizures predicted screening positive. The results suggest that screening for depression in patients with epilepsy via GPs improves detection of depression and is acceptable to interviewed patients.

Psychiatric symptomatologies and disorders related to epilepsy and antiepileptic medications

INTRODUCTION

Psychiatric comorbidities (such as depression, anxiety, psychosis, inattention, obsession, personality traits, aggression and suicide) are frequent in patients with epilepsy and have a significant impact on medical management and quality of life.

AREAS COVERED

A literature search was performed in MEDLINE for epidemiological, longitudinal, prospective, double-blind clinical trial studies published between 1990 and 2011 using the following words: epilepsy, antiepileptic drugs (AEDs), behavioral/emotional/psychiatric comorbidities, suicide and aggression. In this review, the author discusses: i) the characterization and prevalence of behavioral disturbances associated with epilepsy, ii) variables correlated with behavioral comorbidities which include: psychosocial-, clinical- and treatment-related variables, iii) the complex mechanisms of behavioral comorbidities associated with epilepsy, which include both psychosocial (functional) and organic; the process of epileptogenesis, neuronal plasticity, abnormalities in hypothalamic-pituitary axis and neurotransmitters and pathways are fundamental determinants, iv) the negative psychotropic effects of AEDs and their mechanisms and v) the suggested biopsychosocial model of management (pharmacological and non-pharmacological).

EXPERT OPINION

The relationship between psychiatric disorders and epilepsy has relevant therapeutic implications which should be directed towards a comprehensive biopsychosocial approach that focuses on the whole person rather than simply on the disease process.

Post-traumatic epilepsy: an overview

Post-traumatic seizures (PTS) and post-traumatic epilepsy (PTE) are complications from traumatic brain injury (TBI). PTE refers to recurrent and unprovoked PTS that occur at least 1 week after TBI. Seizures during the first week after TBI are considered provoked, an acute complication from head injury, while seizures occurring 1 week after TBI are considered a manifestation of PTE and if only a single seizure occurs it is known as late PTS. EEG and neuroimaging help in the diagnosis of PTE. Predictors for PTE include TBI severity, presence of intracranial bleeding and early PTS. Several clinical trials have demonstrated that antiepileptic drugs are effective in reducing the frequency of acute PTS, but do not appear to alter the natural history of late PTS or PTE.

Suicidal thoughts in epilepsy: a community-based study in Brazil

Epilepsy has been associated with increased risk of suicide; however, few studies have examined the relationship between epilepsy and suicidal behavior. The aims of this study were to evaluate the frequency of suicidal behavior in people with epilepsy and to identify characteristics that are associated with suicidal ideation in epilepsy. Of 171 people with epilepsy identified in a previous survey, 139 were included. A structured interview was conducted, and a second psychiatric evaluation was scheduled for those who agreed. The frequencies of suicidal thoughts, plans, and attempts during lifetime were 36.7, 18.2, and 12.1%, respectively. The following conditions were strongly associated with suicidal thoughts: anxiety (OR=3.3, 95% CI=1.4-7.5, P=0.001), depression (OR=4.8, 95% CI=1.9-12.5, P=0.001), and two or more standardized psychiatric diagnoses (OR=21.6, 95% CI=4.4-105.9, P<0.0001). Although specific characteristics of epilepsy were found to be related to suicidal thoughts, psychiatric diseases also play an essential role.

Influence of population and general practice characteristics on prescribing of minor tranquilisers in primary care

Prevalence of generalised anxiety disorders is widespread in Great Britain. Previous small-scale research has shown variations in minor tranquiliser prescribing, identifying several potential predictors of prescribing volume.

OBJECTIVE

This study aimed to investigate the relationship between general practice minor tranquiliser prescribing rates and practice population and general practice characteristics for all general practices in England.

METHODS

Multiple regression analysis of minor tranquiliser prescribing volumes during 2004/2005 for 8,291 English general practices with general practice and population variables obtained from the General Medical Services (GMS) statistics, Quality and Outcomes Framework (QOF), 2001 Census and 2004 Index of Multiple Deprivation (IMD).

RESULTS

The highest rates of minor tranquiliser prescribing were in areas with the greatest local deprivation while general practices situated in areas with larger proportions of residents of black ethnic origin had lower rates of prescribing. Other predictors of increased prescribing were general practices with older general practitioners and general practices with older registered practice populations.

CONCLUSION

Our findings show that there is wide variation of minor tranquilisers prescribing across England which has implications regarding access to treatment and inequity of service provision. Future research should determine the barriers to equitable prescribing amongst general practices serving larger populations of black ethnic origin.

A population-based study of risk of epilepsy after hospitalization for traumatic brain injury

PURPOSE

This study was undertaken to determine the risk of developing posttraumatic epilepsy (PTE) within 3 years after discharge among a population-based sample of older adolescents and adults hospitalized with traumatic brain injury (TBI) in South Carolina. It also identifies characteristics related to development of PTE within this population.

METHODS

A stratified random sample of persons aged 15 and older with TBI was selected from the South Carolina nonfederal hospital discharge dataset for four consecutive years. Medical records of recruits were reviewed, and they participated in up to three yearly follow-up telephone interviews.

RESULTS

The cumulative incidence of PTE in the first 3 years after discharge, after adjusting for loss to follow-up, was 4.4 per 100 persons over 3 years for hospitalized mild TBI, 7.6 for moderate, and 13.6 for severe. Those with severe TBI, posttraumatic seizures prior to discharge, and a history of depression were most at risk for PTE. This higher risk group also included persons with three or more chronic medical conditions at discharge.

DISCUSSION

These results raise the possibility that although some of the characteristics related to development of PTE are nonmodifiable, other factors, such as depression, might be altered with intervention. Further research into factors associated with developing PTE could lead to risk-reducing treatments.

Individual, seizure-related, and psychosocial predictors of depressive symptoms among people with epilepsy over six months

Depression is the most frequently diagnosed psychiatric disorder among people with epilepsy. A variety of risk factors for depression among people with epilepsy have been identified; however, few studies have examined these risk factors over time. The primary purpose of this study was to explore the relationship between demographic characteristics, seizure-related factors, and psychosocial factors and depressive symptoms over 6 months. Three hundred and nineteen adults with epilepsy completed three surveys at 3-month intervals. Multiple linear regression was used with the baseline variables to predict depressive symptoms at baseline, 3 months, and 6 months. Employment status, social support, and stigma emerged as predictors of depressive symptoms at all three time points. Other factors that predicted depression symptoms in one or two time points were self-management, financial strain, and activity restriction due to seizures. The results indicate that multiple factors influence depressive symptoms among people with epilepsy.

The contribution of seizures to psychosocial ill-health

Persons with a chronic health condition may be disadvantaged compared to others, though the precise pattern of disadvantage will vary from one condition to another. Persons with epilepsy have been shown to be at increased risk of both psychological morbidity and social disadvantage. Various clinical characteristics of epilepsy have been linked to these psychosocial risks, primary among which is seizure frequency: studies linking seizure frequency to psychosocial ill-health are reviewed here. Given the apparently powerful influence of seizure frequency, it is unsurprising that psychosocial health trajectories in epilepsy are very closely linked to its clinical course-but the relationship is not a completely linear one. Recent research has begun to unravel factors other than seizure frequency which appear promoting or protective of psychosocial ill-health. The need for a more nuanced approach to understanding the causes of psychosocial ill-health is highlighted, as is an important distinction between epilepsy as biomedically defined disease and as socially defined illness.

Self-reported memory problems in everyday activities in patients with epilepsy treated with antiepileptic drugs

OBJECTIVE

The goal of this study was to assess everyday memory complaints in a large cohort of patients with epilepsy treated with antiepileptic drugs and to determine demographic, clinical, and emotional state factors associated with patients' self-perception of memory disturbances.

METHODS

This cross-sectional epidemiological study was carried out in routine clinical practice using the Questionnaire of Memory Efficiency (QME) and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Six hundred sixty-one patients were recruited. The time since epilepsy diagnosis was 17.3 years (SD=12.5); the number of seizures in the past year 13.8 (SD=4.8); the proportion of patients free of seizures in the last year 42.5%; the proportion of patients with partial seizures 73.2%; and the proportion of patients on monotherapy 56.3%. Total QME score was 110.0 (SD=18.6). Depression and anxiety scores and polytherapy explained 38.7% of the QME variance.

CONCLUSIONS

Subjective memory functioning in this cohort of patients with epilepsy was relatively good. Complaints expressed by these patients are explained mainly by the presence of depressive and anxiety symptoms.

Anxiety and depression symptoms in patients with diabetes

AIMS

To identify the prevalence and major determinants of anxiety and depression symptoms in patients with diabetes.

METHODS

A cross-sectional study of 2049 people with Types 1 and 2 diabetes, selected from patients experiencing three different models of care in Ireland: (i) traditional mixed care; (ii) hospital/general practitioner (GP) shared care; (iii) structured GP care. Anxiety and depression symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). Analyses were conducted primarily using logistic regression with adjustment for relevant confounders.

RESULTS

The overall response rate was 71% (n = 1456). Based on the HADS, there was evidence of high levels of anxiety and depression symptoms in patients with diabetes; 32.0% (95% confidence interval = 29.5-34.6%) exceeded the HADS cut-off score of 'mild to severe' anxiety and 22.4% (95% confidence interval = 20.2-24.7%) exceeded the HADS cut-off score of 'mild to severe' depression. Diabetes complications, smoking, uncertainty about glycaemic control and being an ex-drinker or a heavy drinker were risk factors for both higher anxiety and depression scores in multivariate analysis. Female gender and poor glycaemic control were risks factors associated only with higher anxiety scores. Higher socio-economic status and older age were protective factors for lower anxiety and depression scores. Type of diabetes, insulin use, marital status and models of care were not significant predictors of anxiety and depression scores.

CONCLUSIONS

The prevalence of anxiety and depression symptoms in patients with diabetes is considerably higher than in general population samples. These data serve as a benchmark for the prevalence of anxiety and depression symptoms in patients with diabetes.

Stress, anxiety, depression, and epilepsy: investigating the relationship between psychological factors and seizures

OBJECTIVE

The goal of the study described here was to examine the interrelationship between psychological factors (anxiety, stress, and depression) and seizures.

METHODS

In this longitudinal cohort study, data on anxiety, depression, perceived stress, and seizure recency (time since last seizure) and frequency were collected at two time points using standard validated questionnaire measures. Empirically based models with psychological factors explaining change in (1) seizure recency and (2) seizure frequency scores across time were specified. We then tested how these psychological factors acted together in predicting seizure recency and frequency. Our data were used to test whether these models were valid for the study population. Latent variable structural equation modeling was used for the analysis.

RESULTS

Four hundred thirty-three of the 558 individuals who initially consented to participate provided two waves of data for this analysis. Stress (beta=0.25, P<0.01), anxiety (beta=0.30, P<0.01), and depression (beta=0.30, P<0.01) all predicted change in seizure recency. However, it was depression that mediated the relationship of both anxiety and stress with modeled change in seizure recency (beta=0.19, P<0.01) and seizure frequency (beta=0.30, P<0.01) over time.

CONCLUSION

Depression mediates the relationship between stress and anxiety and change in seizure recency and seizure frequency. These findings highlight the importance of depression management in addition to seizure management in the assessment and treatment of epilepsy in an adult population.

Prevalence of self-reported epilepsy, health care access, and health behaviors among adults in South Carolina

Behavioral Risk Factor Surveillance System data from South Carolina for 2003-2005 were used to determine epilepsy prevalence and prevalence variation by demographic subgroups, and to compare health insurance coverage, health care visits, and health-related behaviors among persons with epilepsy and the general population. Two percent of respondents reported they had ever been told by a doctor that they had epilepsy, and 1% reported active epilepsy. Almost half of those with active epilepsy reported a seizure in the prior 3 months. More than one-third of respondents with active epilepsy reported that there was a time in the past 12 months when they needed to see a doctor but could not because of cost. Persons with epilepsy were more likely to smoke and have less physical activity. Persons with epilepsy need better access to health care, as well as interventions focused on smoking cessation and increased physical activity.

Quality-of-life trajectories in epilepsy: a review of the literature

The potential psychosocial sequelae of epilepsy are well-documented, but it cannot be assumed that trajectories for quality of life (QOL) of people with epilepsy will inevitably follow its clinical course. In this article, we draw on available literature to suggest likely QOL trajectories associated with epilepsy and the broad range of disease-, patient-, and other-focused factors that appear important in determining them. We conclude that both the likely shape and time frame for QOL trajectories associated with particular clinical scenarios can be delineated, but that their shape can be altered by a much wider range of factors than those represented as epilepsy disease progression. We identify contributory factors currently relatively unexplored and highlight implications for treatment and areas for future research.

Health disparities in epilepsy: how patient-oriented outcomes in women differ from men

Epilepsy is a chronic disorder with multiple effects on biological, social, and psychological health. Many of these effects differ between men and women, but only sparse research has specifically addressed the relevance and importance of the differences. Available evidence suggests that men and women with epilepsy have differing rates of employment and driving, and women with epilepsy have increased risk for specific mood disorders such as post-partum depression. National surveys of physicians indicate that many physicians providing care for women with epilepsy have limited knowledge of fundamental concerns such as interactions between antiepileptic drugs and oral contraceptives, and their potential teratogenic effects. Further research and clinical implementation of improved gender-specific care is needed to optimize outcomes for women with epilepsy.

Psychopathology in children and adolescents with epilepsy: an investigation of predictive variables

This epidemiological study was aimed at determining the prevalence of behavioral and emotional problems in a UK community-based population of children and adolescents with epilepsy aged 4-17 using a postal questionnaire survey. The intent was to identify, through this survey, those epilepsy-related and demographic factors predictive of the presence of psychopathology and diminished health-related quality of life, and to distinguish whether such factors differ for differing types of psychopathology. Outcomes were measured using the Strengths and Difficulties Questionnaire (SDQ), Moods and Feelings Questionnaire (MFQ), Impact of Paediatric Epilepsy Scale (IPES), and Quality of Life in Epilepsy Inventory for Adolescents (QOLIE-AD-48). Information was obtained from main carers for 56 children (25 males and 31 females, mean age=12 years, SD=3 years 9 months, range=5-17). Parent report identified that 23 (47.9%, 95% confidence interval [CI] 34.5-61.7%) children met psychiatric caseness criteria and 32 (61.5%, 95% CI 48-73.5%) had chronic distress and social impairment. Regression analyses identified seizure severity as a risk factor for emotional problems and depression (odds ratio [OR]=1.09, P<0.05), whereas cognitive impairment was associated with behavioral problems, specifically conduct problems (OR=14.0, P<0.05), hyperactivity/inattention (OR=9.4, P<0.01), and peer problems (OR=28.5, P<0.01). Cognitive impairment and high seizure frequency were significantly related to increased IPES scores (R(2)=0.33, P<0.001) and diminished QOLIE-AD-48 scores (R(2)=0.39, P<0.01). In conclusion, children with epilepsy experience considerable psychopathology and reduced quality of life. Epilepsy-related factors appear more closely associated with emotional well-being, and cognitive factors with behavior problems.

Psychological well-being of people with epilepsy in Norway

The subjective well-being of people with epilepsy has been studied extensively, but only sparingly in Norway. In 2005, members of the Norwegian Epilepsy Association responded to a short version of the Hopkins Symptom Check List ("psychological distress") and to a version of the Self-Anchoring Striving Scale, also termed the Cantril Ladder ("life satisfaction"). In this article, the relationships between responses to the two questionnaires (the two outcome variables) and seizure frequency, medication side effects, comorbidity, and surgery, as well as demographic variables such as age, sex, marital status, occupational status, education, and place of residence, are addressed. The analyses demonstrate clear effects of seizure frequency (P<0.001) and medication side effects (P<0.001) on both outcome variables. People with no comorbidity (no additional diagnoses) reported less psychological distress (P<0.001) and greater satisfaction with life (P<0.05) than those who reported additional diagnoses. The factor having the strongest impact on the psychological well-being of these people was medication side effects.

Psychiatric events in epilepsy

Psychiatric events are thought to be more frequent in people with epileptic seizures than in the general population. However, inter-ictal psychiatric events attributable to epilepsy remain controversial. The aim of the present study was to evaluate the occurrence of psychiatric events in a population of fairly unselected patients with epilepsy and in the general population, and the correlation between psychiatric complaints and selected demographic and disease characteristics. The survey was part of a multicentre prospective cohort study of everyday life risks conducted in eight European countries and comparing referral children and adults with epilepsy referred to secondary/tertiary centers to age- and sex-matched non-epileptic controls. Nine hundred and fifty-one patients with epilepsy and 909 controls were studied. Each patient and his/her control received a diary to record any accident or illness, with severity, circumstances, causes, consequences, and (for the cases) the possible relation to a seizure. The follow-up period ranged between 1 and 2 years. Fifty-eight psychiatric events occurred in 25 patients (2.6%) and 88 in 19 controls (2.1%). Housewives (9.3%) and unemployed persons (4.1%) were mostly affected. No correlation was found between psychiatric events, demographic and disease characteristics. Our results suggest that people with epilepsy if unselected are not at higher risk for psychiatric disorders than the general population.

A community study of the presence of anxiety disorder in people with epilepsy

Anxiety represents a major problem for people with epilepsy, and it is important to understand why it arises and how to reduce its potential debilitating and adverse effects. The aim of this study was to determine the prevalence of anxiety in a community-identified sample of people with epilepsy and to identify which demographic and clinical factors are most closely associated with anxiety and which factors predict the presence of anxiety among people with epilepsy. Adults with epilepsy in the community (n=515) were identified through primary care records and sent validated questionnaires, which included the Hospital Anxiety and Depression Scale (HADS). The mailout also included items on demographic and clinical variables. The prevalence of anxiety (HADS score >11) in this sample was 20.5% (95% CI: 16.9-24.1%) and was associated with a current history of depression, perceived side effects of antiepileptic medication, lower educational attainment, chronic ill health, female gender, and unemployment. It was not associated with the duration of epilepsy. The findings from this study suggest that anxiety disorders in a community population with epilepsy are most strongly predicted by factors independent of epilepsy-related variables, with the exception of patient-reported side effects. It is important to be aware of these factors when evaluating an individual with epilepsy.

Psychiatric comorbidity in epilepsy: a population-based analysis

PURPOSE

The estimated prevalence of mental health disorders in those with epilepsy in the general population varies owing to differences in study methods and heterogeneity of epilepsy syndromes. We assessed the population-based prevalence of various psychiatric conditions associated with epilepsy using a large Canadian national population health survey.

METHODS

The Canadian Community Health Survey (CCHS 1.2) was used to explore numerous aspects of mental health in persons with epilepsy in the community compared with those without epilepsy. The CCHS includes administration of the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects. Age-specific prevalence of mental health conditions in epilepsy was assessed using logistic regression.

RESULTS

The prevalence of epilepsy was 0.6%. Individuals with epilepsy were more likely than individuals without epilepsy to report lifetime anxiety disorders or suicidal thoughts with odds ratio of 2.4 (95% CI = 1.5-3.8) and 2.2 (1.4-3.3), respectively. In the crude analysis, the odds of lifetime major depression or panic disorder/agoraphobia were not greater in those with epilepsy than those without epilepsy, but the association with lifetime major depression became significant after adjustment for covariates.

CONCLUSIONS

In the community, epilepsy is associated with an increased prevalence of mental health disorders compared with the general population. Epilepsy is also associated with a higher prevalence of suicidal ideation. Understanding the psychiatric correlates of epilepsy is important to adequately manage this patient population.

The personal and financial impact of repetitive or prolonged seizures on the patient and family

Individuals with epilepsy consistently report diminished quality of life. The clinical characteristics of seizures and the unpredictable nature of seizure occurrences are some factors that affect quality of life. Prolonged or repetitive seizures can impose psychologic comorbidities, social issues, and lifestyle restrictions that can affect quality of life of patients and their caregivers and family members, who also bear the considerable indirect costs of seizures, including time away from work or school, and even loss of employment. The availability and use of an at-home medication to terminate prolonged or repetitive seizures or in seizure emergencies improves quality of life for patients and their families. Fewer visits to the emergency department are associated with a reduction in the financial burden to families and the health care system. This article discusses factors that contribute to the personal and financial impact of prolonged seizures on adult and pediatric patients, their families, and caregivers.

Anticonvulsants in sports: ethical considerations

OBJECTIVE

Antidoping codes in sport are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. Although the World Anti-Doping Code (WADC) permits anticonvulsants in general, harmonization of antidoping permits an international sport federation (IF) to prohibit specific medications within that IF. The anticonvulsants levetiracetam, tiagabine, and lamotrigine may pose ethical dilemmas and could be considered violations of antidoping codes.

METHOD

This study is a literature review with analysis.

RESULTS

Lamotrigine, with antiglutamatergic and sodium channel properties, is FDA-approved for maintenance treatment of bipolar disorder, in addition to its use in the treatment of major depression, anxiety disorders, and schizophrenia. Tiagabine, a selective GABA reuptake inhibitor, has mood-stabilizing and anxiolytic properties. Levetiracetam, whose unique mechanism involves the modulators beta-carboline and zinc, has anxiolytic and mood-stabilizing properties. Anxiolytics, antidepressants, and antipsychotics are banned in archery; under strict liability, all three anticonvulsants violate WADC/IF for that specific sport and could result in disqualification unless therapeutic use exemptions (TUEs) are obtained. Ethical issues regarding the use of anticonvulsants by athletes and the need to obtain TUEs are addressed.

CONCLUSION

The WADC with harmonized IF policies are meant to prevent doping by athletes, but not appropriate medical treatment. When anticonvulsants have other psychotropic properties, ethical issues arise. Athletes should list all medications taken with diagnoses, obtain TUEs as indicated, and contact the appropriate IF or Olympic organization to determine the status of the proposed medication (banned, restricted, nonbanned). Further, clinicians should be knowledgeable regarding these issues when treating athletes.

Effect of lamotrigine on depressive symptoms in adult patients with epilepsy

In this investigation, the effects of lamotrigine versus placebo on depressive symptoms in patients with epilepsy were prospectively assessed. This investigation was a secondary analysis of a randomized, double-blind, placebo-controlled, parallel-group study in which adult patients received adjunctive lamotrigine (n=32) or placebo (n=38) for a 7-week dose escalation phase, followed by a 12-week maintenance phase, for primary generalized tonic-clonic (PGTC) seizures. Mood symptoms were assessed with the Beck Depression Inventory, second edition (BDI-II), the Profile of Mood States (POMS), and the Cornell Dysthymia Rating Scale-Self-Report (CDRS). Mean (SD) BDI-II scores at screening reflected mild depressive symptoms and were similar between groups (lamotrigine 18.3 (12.1), placebo 16.8 (12.0)). At the end of the maintenance phase, mean (SD) improvement from baseline was greater with lamotrigine than placebo with respect to BDI-II score (lamotrigine 8.9 (7.6), placebo 1.7 (8.5), P=0.01) and POMS total score (lamotrigine 32.0 (30.4), placebo 6.5 (32.3), P=0.03) and numerically greater with lamotrigine than placebo for CDRS score (lamotrigine 7.3 (7.8), placebo 4.1 (13.9), P=0.50). Among the subset of patients with at least mild depression (BDI-II score10), mean improvement from baseline was numerically, but not statistically significantly, greater with lamotrigine (11.5, n=13) than placebo (3.1, n=18) (P=0.054). Median percentage reductions in seizure frequency were significantly greater with lamotrigine than placebo during the escalation phase, the maintenance phase, and the escalation and maintenance phases combined for PGTC seizures and all generalized seizures. However, improvement in seizure frequency was not correlated with improvement in mood (r=0.1, P=ns). Compared with placebo, lamotrigine improved mood symptoms independently of seizure reduction in patients with generalized seizures. Lamotrigine may be useful in treating patients with epilepsy and comorbid depressive symptoms.

Quality of life and comorbid medical and psychiatric conditions in temporal lobe epilepsy

Patients with epilepsy frequently report dissatisfaction with their quality of life (QOL), and there is considerable interest in understanding the factors and mechanisms associated with this perception. To date, investigation has focused on the potential contribution of seizure variables (e.g., seizure control) and psychiatric conditions to QOL, but there has not been an examination of the potential role of comorbid medical conditions. Information was gathered concerning current medical and psychiatric conditions for 93 patients with temporal lobe epilepsy, and their relationship with QOL was examined. The numbers of medical and psychiatric conditions were distinct and significant predictors of QOL satisfaction, and both were stronger correlates than seizure-related factors and demographic variables. The implications of these findings for the treatment and management of patients with epilepsy are discussed.