The influence of comorbid depression on quality of life for people with epilepsy

Fluoxetine accelerates epileptogenesis and magnifies disease severity in a rat model of acquired epilepsy

OBJECTIVE

Many people with epilepsy experience comorbid anxiety and depression, and antidepressants remain a primary treatment for this. Emerging evidence suggests that these agents may modulate epileptogenesis to influence disease severity. Here, we assessed how treatment with the selective serotonin reuptake inhibitor (SSRI) antidepressant fluoxetine impacts epileptogenic, behavioral, and pathological sequelae following status epilepticus.

METHODS

Male Wistar rats received kainic acid to induce status epilepticus (SE) or vehicle (sham). Animals then received either fluoxetine (10 mg/kg/day) or vehicle for 8 weeks via subcutaneous osmotic pump. Video-electroencephalography was recorded continuously until behavioral testing at day 56, including assessments of anxiety- and depression-like behavior and spatial cognition. Postmortem immunocytochemistry studies examined mossy fiber sprouting.

RESULTS

Fluoxetine treatment significantly accelerated epileptogenesis following SE, reducing the average period to the first spontaneous seizure (from 32 days [vehicle] to 6 days [fluoxetine], p < .01). Also, fluoxetine exposure magnified the severity of the resultant epilepsy, increasing seizure frequency compared to vehicle (p < .01). Exposure to fluoxetine was associated with improved anxiety- and depression-like behaviors but significantly worsened cognition. Mossy fiber sprouting was more pronounced in fluoxetine-treated rats compared to vehicle (p < .0001).

SIGNIFICANCE

Our studies demonstrate that, using a model exhibiting spontaneous seizures, epileptogenesis is accelerated and magnified by fluoxetine, an effect that may be related to more severe pathological neuroplasticity. The differential influence of fluoxetine on behavior indicates that different circuitry and mechanisms are responsible for these comorbidities. These findings suggest that caution should be exercised when prescribing SSRI antidepressants to people at risk of developing epilepsy.

Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Adults with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient-clinician decision-making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross-cultural applicability. The essential outcomes included many non-seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient-centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts.

Mood disorders in adults with epilepsy: a review of unrecognized facts and common misconceptions

Epilepsy is one of the most common neurologic conditions. Its clinical manifestations are not restricted to seizures but often include cognitive disturbances and psychiatric disorders. Prospective population-based studies have shown that people with epilepsy have an increased risk of developing mood disorders, and people with a primary mood disorder have an increased risk of developing epilepsy. The existence of common pathogenic mechanisms in epilepsy and mood disorders may explain the bidirectional relation between these two conditions. Recognition of a personal and family psychiatric history at the time of evaluation of people for a seizure disorder is critical in the selection of antiseizure medications: those with mood-stabilizing properties (e.g., lamotrigine, oxcarbazepine) should be favoured as a first option in those with a positive history while those with negative psychotropic properties (e.g., levetiracetam, topiramate) avoided. While mood disorders may be clinically identical in people with epilepsy, they often present with atypical manifestations that do not meet ICD or DSM diagnostic criteria. Failure to treat mood disorders in epilepsy may have a negative impact, increasing suicide risk and iatrogenic effects of antiseizure medications and worsening quality of life. Treating mood disorders in epilepsy is identical to those with primary mood disorders. Yet, there is a common misconception that antidepressants have proconvulsant properties. Most antidepressants are safe when prescribed at therapeutic doses. The incidence of seizures is lower in people randomized to antidepressants than placebo in multicenter randomized placebo-controlled trials of people treated for a primary mood disorder. Thus, there is no excuse not to prescribe antidepressant medications to people with epilepsy.

Tetramethylpyrazine contributes to the neuroprotection in a rodent epileptic model of pentylenetetrazole-induced kindling

OBJECTIVES

In this study, tetramethylpyrazine (TMP) was evaluated for its therapeutic potential as an alternative therapy for epileptogenesis and its associated comorbidities in rats.

METHODS

The sub-convulsant dose of pentylenetetrazole (PTZ) (35 mg/kg, intraperitoneally) was injected on alternative days to produce kindling for 32 days and observed for seizure score percent of kindled animals in each group. After kindling, the animals were evaluated in models of anxiety, memory and predictive of depression. The neuroprotective effect of TMP was assessed by estimating the biochemical parameters in the cortex and hippocampus of the brain. Histopathological alterations were also observed in the cortex and hippocampus (CA1, CA3 and DG).

KEY FINDINGS

The administration of TMP reduced the seizure score and percentage of kindled animals dose-dependently. Furthermore, TMP significantly improved the behavioural parameters measured in the predictive models of depression but not in the anxiety and cognitive performances of the animals. The oxidative-nitrosative stress, excitotoxicity, neuroinflammation and histological alterations in the brain induced by PTZ were significantly mitigated by administering the TMP high dose of 60 mg/kg.

CONCLUSION

In conclusion, the TMP attenuated the depression behaviour in the PTZ-induced kindled rats, and reduced the oxidative-nitrosative stress, excitotoxicity, neuroinflammation and histological alterations of the brain.

Directionality of the Association Between Epilepsy and Depression: A Nationwide Register-Based Cohort Study

BACKGROUND AND OBJECTIVES

Epilepsy and depression share a bidirectional relationship; however, its magnitude and long-term temporal association remain to be elucidated. This study investigates the magnitude and long-term association between epilepsy and depression, comparing with the risks of the 2 disorders after another chronic medical illness (asthma).

METHODS

In a nationwide register-based matched cohort study, we identified all individuals who received a first diagnosis of epilepsy, depression, and asthma from January 1, 1980, to December 31, 2016. We used a Cox regression model to estimate the risk of epilepsy after depression and vice versa and the risk of epilepsy or depression after asthma, compared with healthy references matched on age and sex, adjusting for medical comorbidity, substance abuse, and calendar time. Results were stratified by epilepsy subtype. We furthermore investigated the risk of admission with acute seizures for persons with epilepsy who became depressed.

RESULTS

In a population of 8,741,955 individuals, we identified 139,014 persons with epilepsy (54% males, median age at diagnosis 43 years [inter quartile range (IQR) 17-65 years]), 219,990 persons with depression (37% males, median age at diagnosis 43 years [IQR 29-60 years]), and 358,821 persons with asthma (49% males, median age at diagnosis 29 years [IQR 6-56 years]). The adjusted hazard ratio (aHR) of depression after epilepsy was 1.88 (95% CI 1.82-1.95), and the aHR of epilepsy after depression was 2.35 (95% CI 2.25-2.44). The aHR of depression after asthma was 1.63 (95% CI 1.59-1.67) and that of epilepsy after asthma, 1.48 (95% CI 1.44-1.53). The risk of depression was highest in the few years preceding and after an epilepsy diagnosis, and vice versa, but remained elevated during the entire follow-up period for both directions of the association. There was no evidence of a stronger association with depression for any epilepsy subtype. Receiving a diagnosis of depression subsequent to an epilepsy diagnosis was associated with a 1.20-fold (95% CI 1.07-1.36) increased HR of acute hospital admission with seizures.

DISCUSSION

We identified a long-term bidirectional relationship between depression and epilepsy in a large-scale cohort study. Risk estimates were higher than those of epilepsy or depression after asthma.

Co-morbid mental health conditions in people with epilepsy and association with quality of life in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Comorbid mental health conditions are common in people with epilepsy and have a significant negative impact on important epilepsy outcomes, although the evidence is mostly from high-income countries. This systematic review aimed to synthesise evidence on the association between comorbid mental health conditions and quality of life and functioning among people with epilepsy living in low- and middle income countries (LMICs).

METHODS

We searched PubMed, EMBASE, CINAHL, Global Index medicus (GID) and PsycINFO databases from their dates of inception to January 2022. Only quantiative observational studies were included. Meta-analysis was conducted for studies that reported the same kind of quality of life and functioning outcome. Cohen's d was calculated from the mean difference in quality-of-life score between people with epilepsy who did and did not have a comorbid depression or anxiety condition. The protocol was registered with PROSPERO: CRD42020161487.

RESULTS

The search strategy identified a total of 2,101 articles, from which 33 full text articles were included. Depression was the most common comorbid mental health condition (33 studies), followed by anxiety (16 studies). Meta-analysis was conducted on 19 studies reporting quality of life measured with the same instrument. A large standardized mean effect size (ES) in quality of life score was found (pooled ES = -1.16, 95% confidence interval (CI) - 1.70, - 0.63) between those participants with comorbid depression compared to non-depressed participants. There was significant heterogeneity between studies (I2 = 97.6%, p < 0.001). The median ES (IQR) was - 1.20 (- 1.40, (- 0.64)). An intermediate standard effect size for anxiety on quality of life was also observed (pooled ES = -0.64, 95% CI - 1.14, - 0.13). There was only one study reporting on functioning in relation to comorbid mental health conditions.

CONCLUSION

Comorbid depression in people with epilepsy in LMICs is associated with poor quality of life although this evidence is based on highly heterogeneous studies. These findings support calls to integrate mental health care into services for people with epilepsy in LMICs. Future studies should use prospective designs in which the change in quality of life in relation to mental health or public health interventions across time can be measured.

Cognitive decline and quality of life after resective epilepsy surgery

OBJECTIVES

The objectives of this study were to examine the association between cognitive decline and quality of life (QoL) change in a large sample of individuals with drug-resistant epilepsy who underwent resective surgery and to examine whether the association between cognitive decline and QoL is differentially affected by seizure classification outcome (Engel Class 1 vs. 2-4) or side of surgery (left vs. right hemisphere).

MATERIALS AND METHODS

The sample comprised 224 adults (ages ≥ 18) with drug-resistant focal epilepsy treated with resective surgery who underwent comprehensive pre-operative and post-operative evaluations including neuropsychological testing and the Quality of Life in Epilepsy Inventory - 31 between 1991 and 2020. Linear mixed-effects models were fit to examine subject-specific trajectories and assess the effects of time (pre- to post-operative), cognitive decline (number of measures that meaningfully declined), and the interaction between time and cognitive decline on pre- to post-operative change in QoL.

RESULTS

Increases in QoL following resection were observed (B = -10.72 [SE = 1.22], p < .001; mean difference between time point 1 and time point 2 QoL rating = 8.11). There was also a main effect of cognitive decline on QoL (B = -.85 [SE = .27], p = .002). Follow-up analyses showed that the number of cognitive measures that declined was significantly associated with post-surgical QoL, (r = -.20 p = .003), but not pre-surgical QoL, (r = -.04 p = .594), and with pre-to post-surgery raw change in QoL score, (r = -.18 p = .009). A cognitive decline by time point interaction was observed, such that those who had greater cognitive decline had less improvement in overall QoL following resection (B = .72 [SE = .27], p = .009). Similar results were observed within the Engel Class 1 outcome subgroup. However, within the Engel Class 2-4 outcome subgroup, QoL improved following resection, but there was no main effect of cognitive decline or interaction between cognitive decline and time point on QoL change. There was no main effect of resection hemisphere on overall QoL, nor were there interactions with hemisphere by time, hemisphere by cognitive decline, or hemisphere by time by cognitive decline.

CONCLUSIONS

Quality of life improves following epilepsy surgery. Participants who had cognitive decline across a greater number of measures experienced less improvement in QoL post-operatively overall, but there was no clear pattern of domain-specific cognitive decline associated with change in QoL. Our results indicate that cognitive decline in a diffuse set of cognitive domains negatively influences post-operative QoL, particularly for those who experience good seizure outcomes (i.e., seizure freedom), regardless of the site or side of resection.

Knowledge of epilepsy, quality of life, and psychiatric comorbidities in Lebanese adults with epilepsy

INTRODUCTION

People with epilepsy (PWE) face a variety of psychosocial challenges. A lack of knowledge of epilepsy, a high level of depression and anxiety and a low quality of life (QoL) are among the major problems that affect most PWE. The objective of this study was to examine the association of sociodemographic characteristics, clinical factors and knowledge of epilepsy with the level of QoL, and the presence of psychiatric comorbidities.

METHOD

A cross-sectional study was conducted in Lebanon. The PWE were recruited from neurologists' clinics in Beirut and its suburbs. A questionnaire translated into Arabic was used and composed of four parts: sociodemographic factors, clinical characteristics, psychosocial characteristics (QoL, psychiatric disorders), and knowledge epilepsy scale. Backward logistic regression models were developed, the associations were estimated by odds ratio (OR), and the level of significance was set at p ≤ 0.05.

RESULTS

Four hundred and four PWE were recruited in this study. About a half of PWE had controlled epilepsy (46.3 %) and 40.3 % had epilepsy for less than 5 years. The QoL was low for 38.6 % of PWE and 30.2 % had psychiatric comorbidities. More than half of PWE had a good level of knowledge (71.5 %). Controlled epilepsy (OR = 1.8; 95 %CI: 1.2-2.9), and good knowledge about epilepsy (OR = 5.5; 95 %CI: 3.4-9.1) were associated with better QoL. Patients on polytherapy with anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9), experienced side effects of anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9) and with psychiatric comorbidities (OR = 0.6; 95 %CI: 0.3-0.9) had a lower QoL. A high number of nonpsychiatric comorbidities (OR = 2.5; 95 %CI: 2.0-3.1) and a polytherapy increased the risk of having psychiatric comorbidities (OR = 1.8; 95 %CI: 1.1-2.8).

CONCLUSIONS

Good knowledge of epilepsy and the absence of psychiatric comorbidities are important predictors of good QoL in Lebanese PWE. Educational programs are needed to reduce misconceptions about epilepsy and improve mental health of PWE.

Interictal Heart Rate Variability as a Biomarker for Comorbid Depressive Disorders among People with Epilepsy

Depressive disorders are common among people with epilepsy (PwE). We here aimed to report an unbiased automatic classification of epilepsy comorbid depressive disorder cases via training a linear support vector machine (SVM) model using the interictal heart rate variability (HRV) data. One hundred and eighty-six subjects participated in this study. Among all participants, we recorded demographic information, epilepsy states and neuropsychiatric features. For each subject, we performed simultaneous electrocardiography and electroencephalography recordings both in wakefulness and non-rapid eye movement (NREM) sleep stage. Using these data, we systematically explored the full parameter space in order to determine the most effective combinations of data to classify the depression status in PwE. PwE with depressive disorders exhibited significant alterations in HRV parameters, including decreased time domain and nonlinear domain values both in wakefulness and NREM sleep stage compared with without depressive disorders and non-epilepsy controls. Interestingly, PwE without depressive disorder showed the same level of HRV values as the non-epilepsy control subjects. The SVM classification model of PwE depression status achieved a higher classification accuracy with the combination of HRV parameters in wakefulness and NREM sleep stage. Furthermore, the receiver operating characteristic (ROC) curve of the SVM classification model showed a satisfying area under the ROC curve (AUC: 0.758). Intriguingly, we found that the HRV measurements during NREM sleep are particularly important for correct classification, suggesting a mechanistic link between the dysregulation of heart rate during sleep and the development of depressive disorders in PwE. Our classification model may provide an objective measurement to assess the depressive status in PwE.

Minimum clinically important difference (MCID) of the personal impact of epilepsy scale (PIES)

INTRODUCTION

The Personal Impact of Epilepsy Scale (PIES) assesses patient functional status in subscales of (1) seizure impact, (2) medication effects, (3) mood & social status, and (4) overall quality of life. This study was designed to determine the Minimal Clinically Important Change (MCID) in PIES subscale and total scores that demonstrate improvement.

METHODS

To ascertain the correspondence of PIES score change and clinical status change (improved, same, worse) in each PIES subscale and total score, we used two distinct retrospective anchor-based assessments of clinical status (patient self-assessment and trained rater assessment) across two clinic visits. Mean PIES scores were compared between clinical status groups, controlling for days between visits and initial clinical status. Personal Impact of Epilepsy Scale score change was quantified for each group to determine MCID. A small prospective proof-of-concept study was conducted in a separate subject group.

RESULTS

Patient self-report anchor analysis demonstrated lower (better) PIES scores in the "improved" group vs the "worse" group on the mood & social subscale (p < .001) and total score (p = .002), with a similar trend on the seizure subscale (p = 0.056). Clinical rater anchor analysis demonstrated lower PIES scores in the "improved" vs "worse" group in the mood & social subscale (p = .029) and a trend in total score (p = .082). For the "improved" group, the reduction in PIES scores between visits averaged across both anchor analyses was 8.14% for subscales and 8.67% for total score.

DISCUSSION/CONCLUSION

Reduction of 8% on a PIES subscale or total score indicates meaningful improvement in patient clinical status, and is designated the MCID for this instrument. Personal Impact of Epilepsy Scale can be useful in day-to-day clinical care and as an outcome metric in clinical research.

Multimodal Quality of Life Assessment in Post-9/11 Veterans With Epilepsy: Impact of Drug Resistance, Traumatic Brain Injury, and Comorbidity

BACKGROUND AND OBJECTIVES

Epilepsy is defined by the occurrence of multiple unprovoked seizures, but quality of life (QOL) in people with epilepsy is determined by multiple factors, in which psychiatric comorbidities play a pivotal role. Therefore, understanding the interplay between comorbidities and QOL across epilepsy phenotypes is an important step towards improved outcomes. Here, we report the impact of QOL across distinct epilepsy phenotypes in a cohort of post-9/11 veterans with high rates of traumatic brain injury (TBI).

METHODS

This observational cohort study from the Veterans Health Administration included post-9/11 Veterans with epilepsy. A process integrating an epilepsy identification algorithm, chart abstraction, and self-reported measures was used to classify patients into one of four groups: 1. Epilepsy controlled with medications, 2. Drug resistant epilepsy (DRE), 3. Post-traumatic epilepsy (PTE), or 4. Drug resistant post-traumatic epilepsy (PT-DRE). Summary scores for six QOL measures were compared across the groups, adjusting for age, sex, and number of comorbidities.

RESULTS

A total of 529 survey respondents with epilepsy were included in the analysis: 249 controls (i.e., epilepsy without DRE or PTE), 124 with DRE, 86 with PTE, and 70 with PT-DRE. Drug resistant epilepsy was more common in those with PTE compared with non-traumatic epilepsy (45% vs. 33%, odds ratio 1.6 (95% CI: [1.1-2.4], p=0.01)). Patients with PTE and PT-DRE had significantly more comorbid conditions in health records than those with nontraumatic epilepsy. Those with both PTE and DRE reported the lowest QOL across all six measures, and this persisted after adjustment for comorbidities, and in further linear analyses.

DISCUSSION

Among those with PTE, DRE prevalence was significantly higher than for non-traumatic epilepsies. PTE was also associated with higher burden of comorbidity, and worse overall QOL compared to those with non-traumatic epilepsies. People with PTE are distinctly vulnerable to the comorbidities associated with TBI and epilepsy. This at-risk group should be the focus of future studies aimed at elucidating the factors associated with adverse health outcomes and developing anti-epileptogenic therapies.

Dysphoria and Irritability-Diagnostic Pitfalls in the Assessment of Interictal Dysphoric Disorder in Epilepsy

This article aims to review the concept of epilepsy-specific psychiatric disturbance, Interictal Dysphoric Disorder (IDD), focusing on issues related to its core symptoms and methodological pitfalls. In the psychiatric literature, an epilepsy-specific pleomorphic mood disorder has been long recognized and described as IDD, a condition characterized by eight symptoms, which are grouped into four labile depressive symptoms, two labile affective symptoms, and two specific symptoms. The existence of IDD is still a matter of debate because of several methodological issues. The main features of IDD, such as dysphoria and irritability, lack precise and clear definition. This review article explores the different definitions and approaches towards both terms described in the psychiatric literature and the rationale for modifying the diagnostic process of IDD.

Relationships among illness representations and depressive symptom severity in predominantly African-American and Caribbean-American people with epilepsy

Objective: Depression is the most common psychiatric comorbidity among people with epilepsy (PWE) and tends to be more prevalent among people of color (POC) and those with intractable seizures. However, the extent to which illness-related perceptions are associated with depressive symptom severity among POC with intractable seizures is unclear. Method: This cross-sectional study examined relationships among illness representations and self-rated depressive symptoms in 55 PWE (M Age = 41; 61.8% female) with intractable seizures (M seizures per month = 2) who identified as Black/African-American (52.7%), Black/Caribbean-American (27.3%), and/or Hispanic/Latino (21.8%). Epilepsy-related illness perceptions were assessed with the Illness Perception Questionnaire-Revised and depression was measured via the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Results: Nearly half of the sample (41.8%) scored above the NDDI-E depression cut-off. PWE endorsing more severe depressive symptoms indicated that their epilepsy had more negative consequences, was hard to comprehend, was insufficiently controlled by treatment, and had a negative emotional impact (p's ≤ 0.02). Controlling for sex, these four illness representations accounted for 48% of the variance in depression severity. Interestingly, participants with probable major depressive episodes were more likely to endorse several psychological causes of seizures compared to non-depressed PWE. Conclusions: Worse depression symptom severity was associated with negative illness perceptions and a tendency to attribute one's epilepsy to psychological causes. Future research is needed to understand how the relationship between negative illness perceptions and depression symptoms unfold over time and whether interventions aimed at modifying illness representations reduce psychological distress in diverse PWE.

Anxiety symptoms are the strongest predictor of quality of life in temporal lobe epilepsy

PURPOSE

It is established that the severity of depressive and anxiety symptoms is associated with poorer quality of life (QOL) in persons with drug-resistant epilepsy. We aimed to verify the presence of subsyndromic depressive episodes (SDEs) and subsyndromic anxiety episodes (SAEs) in persons with temporal lobe epilepsy with hippocampal sclerosis (TLE-HS) compared to healthy controls and to determine the impact of depressive and anxiety symptoms on patients' QOL.

METHODS

We prospectively evaluated 35 persons with TLE-HS and 90 healthy controls. QOL was assessed by the Epilepsy Surgery Inventory (ESI) and QOL in Epilepsy Inventory-31 (QOLIE-31). The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI-X) were used to assess symptoms, and SDEs and SAEs diagnosis were made considering the total scores of BDI (<9) and STAI-Trait (<49), respectively.

RESULTS

Persons with TLE-HS had higher symptoms on BDI, STAI-S, and STAI-T. They have 3.011 greater odds of presenting SDEs and 7.056 times odds, SAEs. The depressive and anxiety symptoms, added in the model with epilepsy-related factors, accounted for a significant increase in the variance in several aspects of QOL. Anxiety-trait symptoms are the most critical individual determinant of the QOL.

CONCLUSION

Our results demonstrated that persons with TLE-HS had greater odds of presenting SDE and SAE than healthy controls. Besides, there was a relationship between anxiety and depressive symptoms and worse QOL in TLE-HS. It is essential to be aware of psychiatric symptoms, even though these symptoms do not meet the criteria to be considered a "disorder."

Evaluation of reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E)

INTRODUCTION

Major depression is common among people with epilepsy (PWE), but it is underdiagnosed. The aim of the present study was to assess the reliability and validity of the Persian version of the Neurological Disorders Depression Inventory for Epilepsy (P-NDDI-E) as a screening tool for major depression in patients with epilepsy.

METHOD

A total of 210 patients suffering from epilepsy have been assessed using the NDDI-E and the Beck Depression Inventory-II (BDI-II) with no difficulty in understanding or answering the Persian version of the questionnaire. Patients identified as depressed under BDI-II underwent a psychiatric evaluation to confirm depression according to 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) criteria.

RESULT

According to the BDI-II and the ICD-10 criteria, major depression was diagnosed in 75 patients (32% men, 68% women). Cronbach's α coefficient was 0.826, suggesting a very good internal consistency. The receiver operating characteristic analysis showed an area under the curve of 0.90 (95% confidence interval [CI] = 0.86-0.94, standard error [SE]: 0.02, p < 0.001). A cutoff of ≥14 resulted in an 83% sensitivity, an 80% specificity, a 70.1% positive predictive value, and an 88.6% negative predictive value. A significant and positive correlation between the P-NDDI-E and the BDI-II was shown (Spearman's ρ = 0.604, p < 0.001).

DISCUSSION

The P-NDDI-E could be used as a reliable and valid instrument in detecting major depression in PWE.

Comorbid depression and its associated factors in patients with epilepsy treated with single and multiple drug therapy: A cross-sectional study from Himalayan country

INTRODUCTION

Depressive disorder is the most common psychiatric comorbidity in individuals with epilepsy (IWE) and is associated with a significant negative impact with increased morbidity and mortality rate. However, the magnitude of comorbid depression in such patients in the Nepalese setting is still poorly understood. Therefore, we aimed to determine the magnitude of depression in individuals diagnosed as having epilepsy and further examine the influencing factors associated with it.

METHODS

This cross-sectional observational study was conducted from April 2018 to September 2018 at Nepal Epilepsy Center, Lazimpat, Kathmandu, Nepal. One hundred and forty-two eligible subjects were enrolled for analysis. The core outcome variable evaluated in this study was depressive disorder, whereas age, gender, types of epilepsy, frequency of seizures, duration of epilepsy, and drug use were evaluated as covariates. The mean ages of the patients were 31.45 ± 12.05 years, and 87 (61.3%) were male. The prevalence of depression was found to be 31% (95% confidence interval [CI]; lower limit: 23.39% and upper limit: 38.60%), with majority subjects had a mild type of depression, and 63.63% (95% CI; lower limit: 55.05% and upper limit: 70.94%). The frequency of drug use remained a significant predictor for depression in individuals with epilepsy (P = 0.002), and the odds of having depression in individuals receiving polytherapy were 3.82 higher than in those receiving monotherapy (95%: 1.61-9.05, P = 0.002).

CONCLUSION

Our study indicated a high rate of depression in a substantial number of IWE in the Nepalese setting. Polytherapy emerged as an independent predictor for depression. The high coexistence of depression in this vulnerable population and an increased risk for comorbid in polytherapy necessitate incorporating depression screening and proper treatment into the existing epilepsy program. Furthermore, revising treatment guidelines on comorbid depression to reduce polytherapy and encouraging health education on epilepsy to reduce stigma may also be warranted.

Network Dysfunction in Comorbid Psychiatric Illnesses and Epilepsy

The episodic nature of both epilepsy and psychiatric illnesses suggests that the brain switches between healthy and pathological states. The most obvious example of transitions between network states related to epilepsy is the manifestation of ictal events. In addition to seizures, there are more subtle changes in network communication within and between brain regions, which we propose may contribute to psychiatric illnesses associated with the epilepsies. This review will highlight evidence supporting aberrant network activity associated with epilepsy and the contribution to cognitive impairments and comorbid psychiatric illnesses. Further, we discuss potential mechanisms mediating the network dysfunction associated with comorbidities in epilepsy, including interneuron loss and hypothalamic–pituitary–adrenal axis dysfunction. Conceptually, it is necessary to think beyond ictal activity to appreciate the breadth of network dysfunction contributing to the spectrum of symptoms associated with epilepsy, including psychiatric comorbidities.

Assessing the personal impact of epilepsy in a population-based cohort of Veterans

PURPOSE

Epilepsy impacts patient lives in multidimensional ways. Although previous work has investigated epilepsy impact on health status, little is known about the overall quantified impact of epilepsy in Veterans. Our goal was to describe the impact of epilepsy on Veterans' lives using the Personal Impact of Epilepsy Scale (PIES) and determine the patient and clinical characteristics most strongly correlated with epilepsy impact. We described cohort characteristics and developed regression models to determine which characteristics were most strongly associated with PIES subscale (seizure, medication, comorbidity) scores and quality of life (QOL).

RESULTS

Approximately 36% of those who were invited responded to the survey. Of the 438 respondents included in the analyses, roughly 50% were aged 45-64 years (35% >65; 14% 18-44); 19% were women. Almost 90% had previously received care by an epilepsy specialist, 37% of which was in Veterans Health Administration (VHA) and 38% in both VHA and community. The PIES scores were moderately low (mean: 88.68, [standard deviation (SD) = 63.24]; 300 total). The PIES overall and subscale scores were significantly lower for older Veterans with epilepsy (VWE) (>65) compared with younger (18-44 years) and middle-aged (45-64 years) VWE [p < 0.001], indicating that older Veterans had a lower epilepsy impact overall, and for seizures, medication, and comorbidity. The younger and middle-aged VWE had a significantly higher proportion with psychiatric diagnosis compared with older VWE [p < 0.001]. There was a trend for significance for the overall PIES scores by gender, with women having total higher (worse) scores (mean = 93.10, SD = 69.68) than men (mean = 74.39, SD = 59.97), which was driven by a statistically higher score on the seizure subscale for women (mean = 27.66, SD = 27.97) compared with men (mean = 19.29, SD 25.35; p = 0.04). Regression models revealed that frequent seizures (>1/month, >2/month) and diagnoses of dementia significantly predicted higher (more negative) Seizure Severity PIES score [all p < 0.05]. Frequent seizures (>1/month), number of antiepileptic drugs (AEDs), and diagnosis of dementia predicted negative impact, and older age predicted positive impact for medication subscale. Frequent seizures (>1/month) and diagnoses of depression and dementia predicted negative mood and social impact [all p < 0.05]. Seizure frequency (>2/month) was the only variable that significantly predicted lack of excellent QOL [p < 0.05]. Effects for gender were not significant after controlling for other variables.

CONCLUSIONS

Findings were similar to a prior study of generic health outcomes in younger and older VWE using the 36-Item Short Form Survey (SF-36). Seizure frequency was consistently associated with negative impact of epilepsy in all age groups. While dementia and other diagnosed health conditions also contributed to epilepsy impact, older VWE had significantly lower PIES scores even after controlling for physical conditions and dementia. Lower (better) scores for comorbidity and medication scales in older VWE may be due to fewer diagnosed psychiatric comorbidities and psychiatric medication that have similar cognitive impact as AEDs, and which may also interact with AEDs. Implementation of patient self-management programs to improve seizure control may reduce epilepsy impact for Veterans and reduce Veterans Affairs (VA) healthcare utilization. The PIES may also be useful to measure outcomes of self-management interventions.

Trends in prevalence and treatment of depressive symptoms in adult patients with epilepsy in the United States

OBJECTIVE

Depressive symptoms are a common comorbidity among adults with epilepsy (AWE). Prior estimates regarding prevalence and treatment of depressive symptoms in AWE have been largely based on samples of tertiary care cohorts that may not be generalizable. We aimed to provide a representative population estimate of the prevalence and treatment of depressive symptoms over time in AWE in the United States as measured by a validated depression screen.

METHOD

Data from the Medical Expenditure Panel Survey (MEPS) were analyzed from 2004 to 2015 to determine the prevalence of "screen positive" depressive symptoms (SPDS) among AWE as evaluated by the Patient Health Questionnaire-2 (PHQ-2). We defined pharmacotherapy for depressive symptoms as the prescription of any antidepressant, antipsychotic, anxiolytic, or central nervous system stimulant for the "Clinical Classification Code" of mood disorders within the year sampled, and psychotherapy as any outpatient or office-based visit for "mood disorders" for that year sampled. We analyzed temporal trends and explanatory variables for treatment using the Cochran-Armitage test and logistic regression, respectively.

RESULTS

Our sample included 2024 AWE, representing 1,736,023 patients nationwide. This included 517 AWE with SPDS (AWE-SPDS), representing 401,452 AWE, and 1507 AWE who screened negative for depressive symptoms (AWE-SNDS), representing 1,334,571 AWE. The prevalence of SPDS was 23.1% (95% confidence interval [CI]: 20.6%-25.8%). Women (odds ratio [OR]: 1.40, 95% CI: 1.05-1.87), patients ages 35-49 (OR: 1.83, 95% CI: 1.23-2.72; compared with patients ages 18-34), and patients with Charlson Comorbidity Index ≥1 (OR: 1.92, 95% CI: 1.41-2.61) had higher odds of SPDS. There was no significant change in depressive symptoms' prevalence or treatment in AWE between the epochs of 2004-2006 and 2013-2015.

CONCLUSIONS

Despite a quarter of AWE in the United States with SPDS, fewer than half received treatment. This indicates a need for improved efforts to screen AWE for depression and treat appropriately.

Prevalence of depression and associated factors among epileptic patients at Ilu Ababore zone hospitals, South West Ethiopia, 2017: a cross‑sectional study

BACKGROUND

Depression is one of the most common and overwhelming mental disorder in patients with epilepsy. Despite its high prevalence, depression continues to be under-recognized and undertreated. This study aimed to assess the prevalence of depression and its associated factors among epileptic patients attending the outpatient department of Ilu Ababore zone hospitals, Southwest Ethiopia, 2017.

METHODS

Institution-based cross-sectional study was carried out among 402 individual with epilepsy. The participants were selected using systematic random sampling technique. Depression was measured using Beck's Depression Inventory II. Oslo 3 Social Support Scale was used to assess social support. Perceived Stress Scale was used to assess the stress level of epileptic patients. The data were entered into Epi Info version 7 and analyzed by the SPSS version 20 software. We computed bivariate and multivariate binary logistic regressions to assess factors associated with depression. Statistical significance was declared at p-value < 0.05.

RESULTS

A total of 402 study participants were interviewed with a response rate of 96.2%. The prevalence of depression was found to be 48.1%. In the final multivariate analysis, educational status [unable to read and write (AOR = 4.01,95% CI = 3.82, 8.28), primary (AOR = 3.43, 95% CI = 3.12,9.29), secondary (AOR = 2.01, 95% CI = 1.89,7.24)], high perceived stress (AOR = 3.21, 95% CI = 2.70, 8.41), poor social support (AOR = 2.04, 95% CI = 1.42, 2.78), onset of illness < 6 year (AOR = 2.40, 95%CI = 2.10,7.91), seizure frequency of [1-11 per year (AOR = 2.34, 95% = 1.41, 4.36), ≥ 12/year (AOR = 3.49, 95% CI = 3.43, 6.40)], and polytherapy (AOR = 2.73, 95%CI = 2.52, 7.14) were independent predictors of depression among epileptic patients at p-value < 0.05.

CONCLUSION AND RECOMMENDATION

Overall, the prevalence of depression was found to be high. Having lower educational status, early onset of illness, poor social support, high perceived stress, high seizure frequency, and polytherapy were factors statistically associated with depression. Clinicians need to give emphasis to epileptic patients with high perceived stress, low educational status, and poor social support. An early depression-focused regular screening for epileptic patient should be carried out by trained health professionals. Linkage with mental health service providers also needs to be considered.

Mechanisms of Psychiatric Comorbidities in Epilepsy

Psychiatric illnesses, including depression and anxiety, are highly comorbid with epilepsy (for review see Josephson and Jetté (Int Rev Psychiatry 29:409-424, 2017), Salpekar and Mula (Epilepsy Behav 98:293-297, 2019)). Psychiatric comorbidities negatively impact the quality of life of patients (Johnson et al., Epilepsia 45:544-550, 2004; Cramer et al., Epilepsy Behav 4:515-521, 2003) and present a significant challenge to treating patients with epilepsy (Hitiris et al., Epilepsy Res 75:192-196, 2007; Petrovski et al., Neurology 75:1015-1021, 2010; Fazel et al., Lancet 382:1646-1654, 2013) (for review see Kanner (Seizure 49:79-82, 2017)). It has long been acknowledged that there is an association between psychiatric illnesses and epilepsy. Hippocrates, in the fourth-fifth century B.C., considered epilepsy and melancholia to be closely related in which he writes that "melancholics ordinarily become epileptics, and epileptics, melancholics" (Lewis, J Ment Sci 80:1-42, 1934). The Babylonians also recognized the frequency of psychosis in patients with epilepsy (Reynolds and Kinnier Wilson, Epilepsia 49:1488-1490, 2008). Despite the fact that the relationship between psychiatric comorbidities and epilepsy has been recognized for thousands of years, psychiatric illnesses in people with epilepsy still commonly go undiagnosed and untreated (Hermann et al., Epilepsia 41(Suppl 2):S31-S41, 2000) and systematic research in this area is still lacking (Devinsky, Epilepsy Behav 4(Suppl 4):S2-S10, 2003). Thus, although it is clear that these are not new issues, there is a need for improvements in the screening and management of patients with psychiatric comorbidities in epilepsy (Lopez et al., Epilepsy Behav 98:302-305, 2019) and progress is needed to understand the underlying neurobiology contributing to these comorbid conditions. To that end, this chapter will raise awareness regarding the scope of the problem as it relates to comorbid psychiatric illnesses and epilepsy and review our current understanding of the potential mechanisms contributing to these comorbidities, focusing on both basic science and clinical research findings.

Implementation of quality measures and patient-reported outcomes in an epilepsy clinic

OBJECTIVE

To see if systematic collection of patient-reported epilepsy quality measures can identify opportunities to improve care, and to examine the associations between these measures and physical and mental health.

METHODS

We developed a patient-reported questionnaire for medication adherence, seizure frequency, medication side effects, and driving that included the Patient-Reported Outcome Measurement Information System-10 (PROMIS-10) (physical and mental health). We offered it to all adult patients seen twice in an epilepsy clinic (January 2017-January 2018). The questionnaire was available on the web as well as a tablet provided at appointment check-in. We used the first completed questionnaire to explore the relationship between patient-reported care quality and measures of physical and mental health.

RESULTS

A total of 610 unique patients (15% of the total encounters) completed a survey. Respondents were comparable to nonrespondents. Respondents reported gaps in care or opportunities for quality improvement in 48.4% (n = 295) of the encounters. Of patients who reported at least 1 seizure per month over the previous 3 months, 55.2% (n = 100) reported problems with adherence, 30.0% (n = 131) reported having problems believed to be adverse reactions to anticonvulsants, and 15.2% (n = 41) reported driving. In addition, respondents who reported either seizures over the recent 3 months, nonadherence to treatment due to cost, or anticonvulsant-associated adverse effects had consistently worse physical and mental health (all p < 0.05).

CONCLUSIONS

Systematic collection of epilepsy quality measures endorsed by the American Academy of Neurology can identify opportunities for quality improvement. Measures of epilepsy care quality predict outcomes that matter to patients.

Obstacles in the treatment of common psychiatric comorbidities in patients with epilepsy: What is wrong with this picture?

The aim of this special issue is to highlight a major problem that plagues the management of patients with epilepsy (PWE): the failure to identify and treat relatively frequent psychiatric comorbidities, in particular, depression and anxiety disorders. The causes are multiple, starting from the neurologists' failure to investigate the existence of these common comorbidities during the initial evaluation or even throughout the course of treatment of these patients. Does this phenomenon reflect a lack of curiosity, ignorance, or both? The problem is compounded by the limited or lack of access to treatment once the psychiatric comorbidity has been identified. This special issue tries to analyze the causes of this very serious problem that not only has serious implications in the comprehensive management of PWE but also raises serious questions on the lack of communication between neurologists and psychiatrists… truly a "bizarre phenomenon". This article is part of the Special Issue "Obstacles of Treatment of Psychiatric Comorbidities in Epilepsy".

A pilot study of combined endurance and resistance exercise rehabilitation for verbal memory and functional connectivity improvement in epilepsy

Memory impairment is common in persons with epilepsy (PWE), and exercise may be a strategy for its improvement. In this pilot study, we hypothesized that exercise rehabilitation would improve physical fitness and verbal memory and induce changes in brain networks involved in memory processes. We examined the effects of combined endurance and resistance exercise rehabilitation on memory and resting state functional connectivity (rsFC). Participants were randomized to exercise (PWE-E) or control (PWE-noE). The exercise intervention consisted of 18 supervised sessions on nonconsecutive days over 6 weeks. Before and after the intervention period, both groups completed self-report assessments (Short Form-36 (SF-36), Baecke Questionnaire (BQ) of habitual physical activity, and Profile of Mood States (POMS)), cognitive testing (California Verbal Learning Test-II (CVLT-II)), and magnetic resonance imaging (MRI); PWE-E also completed exercise performance tests. After completing the study, PWE-noE were offered cross-over to the exercise arm. There were no differences in baseline demographic, clinical, or assessment variables between 8 PWE-noE and 9 PWE-E. Persons with epilepsy that participated in exercise intervention increased maximum voluntary strength (all strength tests p < 0.05) and exhibited nonsignificant improvement in cardiorespiratory fitness (p = 0.15). Groups did not show significant changes in quality of life (QOL) or habitual physical activity between visits. However, there was an effect of visit on POMS total mood disturbance (TMD) measure showing improvement from baseline to visit 2 (p = 0.023). There were significant group by visit interactions on CVLT-II learning score (p = 0.044) and total recognition discriminability (d') (p = 0.007). Persons with epilepsy that participated in exercise intervention had significant reductions in paracingulate rsFC with the anterior cingulate and increases in rsFC for the cerebellum, thalamus, posterior cingulate cortex (PCC), and left and right inferior parietal lobule (IPL) (corrected p < 0.05). Change in CVLT-II learning score was associated with rsFC changes for the paracingulate cortex (r_S = -0.67; p = 0.0033), left IPL (r_S = 0.70; p = 0.0019), and right IPL (r_S = 0.71; p = 0.0015) while change in d' was associated with change in cerebellum rsFC to angular/middle occipital gyrus (r_S = 0.68; p = 0.0025). Our conclusion is that exercise rehabilitation may facilitate verbal memory improvement and brain network functional connectivity changes in PWE and that improved memory performance is associated with changes in rsFC. A larger randomized controlled trial of exercise rehabilitation for cognitive improvement in PWE is warranted.

Quality of life in adults enrolled in an open-label study of cannabidiol (CBD) for treatment-resistant epilepsy

Treatment-resistant epilepsy (TRE) is associated with low quality of life (QOL). Cannabidiol (CBD) may improve QOL, but it is unclear if such improvements are independent of improvements in seizure control. Our aim was to compare QOL at baseline and after 1 year of treatment with CBD. We hypothesized that QOL would improve independent of changes in seizure frequency (SF) or severity, mood, or adverse events. We assessed QOL using Quality of Life in Epilepsy-89 (QOLIE-89) in an open-label study of purified CBD (Epidiolex®) for the treatment of TRE. All participants received CBD, starting at 5 mg/kg/day and titrated to 50 mg/kg/day in increments of 5 mg/kg/day. We collected QOLIE-89 in adult participants at enrollment and after 1 year of treatment, or at study exit if earlier. We analyzed if the change in QOLIE-89 total score could be explained by the change in SF, seizure severity (Chalfont Seizure Severity Scale, CSSS), mood (Profile of Moods States, POMS), or adverse events (Adverse Event Profile, AEP). Associations among the variables were assessed using bivariate tests and multiple regression. Fifty-three participants completed enrollment and follow-up testing, seven at study termination. Mean QOLIE-89 total score improved from enrollment (49.4 ± 19) to follow-up (57 ± 21.3; p = .004). We also saw improvements in SF, POMS, AEP, and CSSS (all p ≤ .01). Multivariable regression results showed QOLIE-89 at follow-up associated with improvements in POMS at follow-up (p = .020), but not with AEP, CSSS, or SF (p ≥ .135). Improvement in QOL after treatment with CBD is associated with better mood but not with changes in SF, seizure severity, or AEP. Cannabidiol may have beneficial effects on QOL and mood that are independent of treatment response.

Depression and quality of life among African Americans with epilepsy: Findings from the Managing Epilepsy Well (MEW) Network integrated database

Depression and worse quality of life (QOL) are significantly associated with epilepsy. However, limited descriptive data on depression and quality of life among African Americans with epilepsy are available. This study sought to describe the prevalence of depression among African Americans with epilepsy participating in self-management studies and to examine the relationship between depression and QOL. Using data from the Managing Epilepsy Well (MEW) research network, a subgroup of African Americans with epilepsy were selected for the analytic sample. Descriptive statistics indicated the prevalence of depression (Patient Health Questionnaire-9 [PHQ-9]) and reports of epilepsy-specific QOL (Quality of Life in Epilepsy-10 [QOLIE-10]) in the sample. Multiple linear regression examined the relationship between depression and QOL while controlling for sociodemographic characteristics and seizure frequency. The prevalence of depression (PHQ-9 ≥; 10) was 47.7%. Quality of life was the only variable significantly associated with depressive symptoms in multivariable analyses, suggesting that depressive symptoms have a stronger relationship with QOL than seizure frequency. With the high levels of depression and the significant relationship with QOL, regular screening of depression is needed among African Americans with epilepsy. Self-management programs that improve mood may also play an important role in improving the lives of African Americans with epilepsy.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures

RATIONALE

Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups?

METHODS

We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores.

RESULTS

The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES.

CONCLUSIONS

Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

Depressive Symptom Severity in Individuals With Epilepsy and Recent Health Complications

Identifying relationships between depression severity and clinical factors may help with appropriate recognition and management of neuropsychiatric conditions in persons with epilepsy (PWE). Demographic characteristics, epilepsy variables, and medical and psychiatric comorbidities were examined from a baseline randomized controlled trial sample of 120 PWE. Among demographic characteristics, only inability to work was significantly associated with depression severity (p = 0.05). Higher 30-day seizure frequency (p < 0.01) and lower quality of life (p < 0.0001) were associated with greater depression severity. Comorbid bipolar disorder (p = 0.02), panic disorder (p < 0.01), and obsessive-compulsive disorder (p < 0.01) were correlated with worse depression severity. The literature supports our findings of correlations between worse depression, seizure frequency, and lower quality of life. Less well studied is our finding of greater depression severity and selected psychiatric comorbidities in PWE.

Depression among epileptic patients and its association with drug therapy in sub-Saharan Africa: A systematic review and meta-analysis

Background

Despite the high prevalence of epilepsy in sub-Saharan Africa and the established relationship between depression and epilepsy, the extent of comorbid epilepsy and depression in the region is still poorly understood. The objective of this systematic review and meta-analysis is to address this gap in the literature by determining the pooled prevalence of depression among epileptic patients in sub-Saharan Africa.

Methods

A systematic desk review and electronic web-based search of PubMed, Google Scholar, EMBASE, PsycINFO and the World Health Organization’s Hinari portal (which includes the SCOPUS, African Index Medicus, and African Journals Online databases) conducted from December 2, 2017 to February 30, 2018, identified peer-reviewed, original research articles and doctoral dissertations using pre-defined quality and inclusion criteria. Relevant data were extracted and descriptive summaries of the studies presented in tabular form. The I² statistic was used to assess heterogeneity across studies. Funnel plot asymmetry and Egger’s tests were used to check for publication bias and the methodological quality of the included studies were assessed using the scale developed by Hoy and colleagues. The pooled prevalence of comorbidity at a 95% confidence interval (CI) was determined by applying a trim and fill analysis in a random-effects model.

Results

Our search identified 167 studies, of which 14 original research articles and two doctoral dissertations reporting on case-control and cross-sectional studies were eligible for inclusion in the final analysis. The pooled estimate of prevalence of depression among patients with epilepsy was 32.71% (95% CI: 25.50–39.91%). Regional sub-group analysis found that the pooled prevalence in East Africa was 34.52% (95% CI: 23.53–45.51%) and 29.69% (95% CI: 22.7–36.68%) in Southern and West Africa. The odds of depression among epileptic patients receiving polytherapy were 2.65 higher than in those receiving monotherapy (95% CI: 1.49–4.71, I² = 79.1%, p < 0.05).

Conclusion

Our findings indicate high comorbidity in sub-Saharan Africa and suggest that it may be more prevalent there than elsewhere. Comorbidity is statistically associated with polytherapy in the studies reviewed. Given the high levels of comorbidity in the region, more attention should be paid to incorporating depression screening and treatment into existing epilepsy programs and to revising treatment guidelines on comorbid depression to reduce polytherapy.

Beyond depression: The impact of executive functioning on quality of life in patients with temporal lobe epilepsy

OBJECTIVE

Individuals with temporal lobe epilepsy (TLE) often experience diminished quality of life (QoL). Although comorbid depression is one of the most recognized predictors of poor QoL in TLE, impairments in verbal memory (VM) and executive functioning (EF), have also been identified as risk factors, independent of other biological and psychosocial factors. In this study, we examine the contribution of depression, VM, and EF to QoL in 52 well-characterized medically-refractory TLE patients.

METHODS

Quality of life was assessed with the Quality of Life in Epilepsy (QOLIE-31) questionnaire and depression symptomatology was evaluated with the Beck Depression Inventory-II (BDI-II). Tests of VM included the California Verbal Learning Test-Second Edition and the Wechsler Memory Scale-Third Edition, Logical Memory and Verbal Paired Associates subtests. Tests of EF included the D-KEFS Category Switching and Color Word Interference Tests, and the Trail Making Test. Using these measures, a principal component (PC) was derived for VM and for EF. Hierarchical multiple linear regression analysis was used to evaluate the unique contributions of BDI-II Score, VM PC, and EF PC to the QOLIE-31 Total Score, while controlling for important clinical and demographic variables. Post-hoc analyses were also performed to examine the contribution of each variable to specific QOLIE subscales.

RESULTS

Of the clinical variables, only number of antiepileptic drugs contributed to QOLIE scores. As expected, severity of depressive symptoms was the most significant predictor of QOLIE Total Score, explaining 43.4% of the variance in total QoL. The VM PC did not contribute to the QOLIE Total Score. Rather, our EF PC emerged as an important predictor of QoL, explaining an additional 5% of the variance, after controlling for clinical variables, depression severity, and VM performance.

SIGNIFICANCE

These findings suggest that a combination of clinical, affective, and cognitive factors influence QoL in patients with TLE. Designing interventions with careful attention to depression and EF may be needed to optimize QoL in patients with refractory TLE and potentially other epilepsy syndromes.

Antiepileptic and psychiatric medication in a nationwide cohort of patients with glioma WHO grade II-IV

INTRODUCTION

Glioma is the most common intracranial primary brain tumor. Patients with glioma often suffer from epilepsy, anxiety and depression. Aims of this study were to identify risk factors for drug-treated anxiety and depression, and to determine the use of psychiatric medication in a national glioma cohort.

METHODS

Data from the Cancer Registry of Norway on all persons diagnosed with glioma WHO grade II-IV 2004-2010 were linked with data from the Norwegian Prescription Database. Cox regression analysis was used to assess risk factors for drug-treated anxiety and depression. Standardized incidence ratios were calculated for psychiatric medication dispensed to glioma patients and compared to the general population.

RESULTS

The glioma cohort consisted of 1056 males and 772 females. Of the 1828 patients, 565 had glioma grade II-III, and 1263 had grade IV. The patients with glioma grade II-III who were treated with levetiracetam had an increased risk for drug-treated anxiety compared to patients without levetiracetam; hazard ratio 2.8 (95% confidence interval 1.7-4.9). Female gender increased the risk for drug-treated anxiety compared to males in patients with glioma grade IV; hazard ratio 1.5 (95% confidence interval 1.2-2.0). Antidepressants were less frequently dispensed to patients with glioma grade II-III and epilepsy than to the general population.

CONCLUSIONS

Patients with glioma grade II-III on levetiracetam had an increased risk for drug-treated anxiety. The subgroup of patients with glioma grade II-III and epilepsy received less antidepressants than the general population.

Care Needs and Health Care Burden of Persons With Epilepsy Receiving Home Care Services

The purpose of this study was to describe the characteristics of persons with epilepsy (PWE) receiving home care services. A cross-sectional study was conducted comparing the characteristics of PWE with those without epilepsy (comparison group). PWE were more likely to have mental health issues and functional, mobility, and cognitive impairments; to receive a variety of psychotropic medications; to experience psychosocial issues such as isolation and conflicts in their relationships; to have caregivers experiencing psychological distress; and to be economically disadvantaged necessitating making economic trade-offs in their care. Epilepsy is associated with caregiver distress and has an impact on health resource utilization. Future studies are needed to identify strategies to improve the quality of care and life of PWE.

Increased risk of hospital admission for mood disorders following admission for epilepsy

OBJECTIVE

To determine if epilepsy admissions, compared to admissions for other medical causes, are associated with a higher readmission risk for mood disorders.

METHODS

The Nationwide Readmissions Database is a nationally representative dataset comprising 49% of US hospitalizations in 2013. In this retrospective cohort study, we used ICD-9-CM codes to identify medical conditions. Index admissions for epilepsy (n = 58,278) were compared against index admissions for stroke (n = 215,821) and common medical causes (n = 973,078). Readmission rates (per 100,000 index admissions) for depression or bipolar disorders within 90 days from discharge for index hospitalization were calculated. Cox regression was used to test for associations between admission type (defined in 3 categories as above) and readmission for depression or bipolar disorder up to 1 year after index admission, in univariate models and adjusted for age, sex, psychiatric history, drug abuse, income quartile of patient's zip code, and index hospitalization characteristics.

RESULTS

The adjusted hazard ratio (HR) for readmission for depression in the epilepsy group was elevated at 2.80 compared to the stroke group (95% confidence interval [CI] 2.39-3.27, p < 2 × 10^-16), and 2.09 compared to the medical group (95% CI 1.88-2.32, p < 2 × 10^-16). The adjusted HR for readmission for bipolar disorder in the epilepsy group was elevated at 5.84 compared to the stroke group (95% CI 4.56-7.48, p < 2 × 10^-16), and 2.46 compared to the medical group (95% CI 2.16-2.81, p < 2 × 10^-16).

CONCLUSION

Admission for epilepsy was independently associated with subsequent hospital readmission for mood disorders. The magnitude of elevated risk in this population suggests that patients admitted with epilepsy may warrant targeted psychiatric screening during their hospital admission.

Who are the individuals diagnosed with epilepsy using the Public Health System in the city of Pelotas, southern Brazil?

The aim of this study was to describe sociodemographic, clinical, behavioral, nutritional, and health-related variables from people with epilepsy. A descriptive observational study was carried out in the city of Pelotas, southern Brazil. Sociodemographic, clinical, behavioral, nutritional, and health-related variables were collected. A univariate analysis was performed, calculating the measures of central tendency for continuous variables and proportions for categorical ones. The sample consisted of 101 people, age ranging from 12 to 75years, mostly male (50.5%) and white (59.4%). Only 37.2% from the sample was employed, and the average income was R$ 788.00 Brazilian Reais (US$ 245.90 at the moment of the interview). From all the subjects, 65.6% was in treatment with monotherapy, 62.9% presented more than 15 seizures during the life, 67.3% showed active epilepsy, 64.6% were physically inactive, 52.5% presented normal body mass index, and 50% showed generalized seizures. The most used antiepileptic drug was the carbamazepine. The average score of depression was 12.6±4.1 points and 34.6% showed severe depressive symptoms (equal or higher than 15 points). The mean score of trait and state anxiety was 12.2±3.6 and 15.1±3.4 points, respectively (ranging from 6 to 24 points). The mean score of quality of life and stress was 63.2±18.2 (ranging from 0 to 100 points) and 21.2±7.1 points (ranging from 0 to 40 points), respectively. Considering the medication side effects, the mean score was 42.4±8.9 points, 38.5% showing high rates (higher than 45 points), and only 16% showing good sleep quality. In conclusion, these results are important to improve understanding of these individuals' disease and to subsidize the specific public policies in countries of low and middle income.

Neuronal Nitric Oxide Synthase Contributes to PTZ Kindling-Induced Cognitive Impairment and Depressive-Like Behavior

Epilepsy is a chronic neurological disease which is usually associated with psychiatric comorbidities. Depsression and cognition impairment are considered to be the most common psychiatric comorbidities in epilepsy patients. However, the specific contribution of epilepsy made to these psychiatric comorbidities remains largely unknown. Here we use pentylenetetrazole (PTZ) kindling, a chronic epilepsy model, to identify neuronal nitric oxide synthase (nNOS) as a signaling molecule triggering PTZ kindling-induced cognitive impairment and depressive-like behavior. Furthermore, we identified that both hippocampal MAPK and PI3K/AKT signaling pathways were activated in response to PTZ kindling, and the increased MAPK and PI3K/AKT signaling activation was paralleled by increased level of reactive oxygen species (ROS) in the hippocampus. However, the PTZ kindling-induced MAPK, PI3K/AKT signaling activities and the ROS level were attenuated by nNOS gene deficiency, suggesting that nNOS may act through ROS-mediated MAPK and PI3K/AKT signaling pathways to trigger cognition deficit and depressive-like behavior in PTZ-kindled mice. Our findings thus define a specific mechanism for chronic epilepsy-induced cognitive impairment and depressive-like behavior, and identify a potential therapeutic target for psychiatric comorbidities in chronic epilepsy patients.

Factors affecting quality of life in Hungarian adults with epilepsy: A comparison of four psychiatric instruments

PURPOSE

We investigated the impact of 19 factors on life quality in Hungarian patients with epilepsy. Wellbeing was evaluated by several inventories to investigate the impact of factors in more detail.

METHODS

A cross-sectional study was performed in 170 patients. Wellbeing was evaluated with the WHO-5 Well-being Index (WHOQOL-5), Diener Satisfaction with Life Scale (SwLS), and the Quality of Life in Epilepsy-31 Questionnaire (Qolie-31). We investigated their association with demographic characteristics, general health status, epilepsy, and its treatment. The impact of these factors on illness perception (Illness Perception Questionnaire, IPQ) was also studied.

RESULTS

The four measures correlated highly significantly. In addition, the predictive power of factors was comparable with the four inventories as evaluated by Multiple Regression. Factors explained 52%, 41%, 63% and 46% in the variance of WHOQOL-5, SwLS, Qolie-31, and IPQ scores, respectively. However, associations with particular factors were instrument-specific. The WHOQOL-5 was associated with factors indicative of general health. SwLS scores were associated with health-related and several demographic factors. Neither showed associations with epilepsy-related factors. All four categories of factors were associated with Qolie-31 and IPQ scores. Factors had an additive impact on IPQ, but not on Qolie-31.

SIGNIFICANCE

Our findings reveal interactions between the method of life quality assessment and the factors that are identified as influencing life quality. This appears to be the first study that analyses the factors that influence illness perception in epilepsy patients, and suggests that the IPQ may become a valuable tool in epilepsy research.

Are physical activity levels associated with better health outcomes in people with epilepsy?

The aim of the study was to investigate the association of physical activity in three categories (inactive, insufficiently active and active) with health outcomes in people with epilepsy. The dependent variables and the instruments used in the study were: a) quality of life - measured by Quality of Life in Epilepsy-31 for adults and Quality of Life in Epilepsy for Adolescents, b) side effects of medication - measured by Adverse Events Profile, c) depression - measured by Neurological Disorders Depression Inventory for Epilepsy, and d) state and trait anxiety - measured by State-Trait Anxiety Inventory. Physical activity levels were analyzed using the International Physical Activity Questionnaire (IPAQ) for adults in the commuting and leisure domains and Physical Activity Questionnaire for Adolescents (PAQ-A). Simple and multiple linear regression was used in the statistical analysis. The cross-sectional study with one hundred and one individuals was conducted in Pelotas/RS, Brazil, at the Neurology Clinic of the Faculty of Medicine of the Federal University of Pelotas. In the crude analysis, physical activity was positively associated with quality of life (p<0.001) and negatively associated with depression (p=0.046), state of anxiety (p=0.014), trait of anxiety (p=0.015) and side effect of medication (p=0.01). In addition, physical activity levels explained 10% of the quality of life (R²=0.10). In the adjusted analysis, physical activity remained associated with side effect of medication (p=0.014) and was not associated with trait anxiety (p=0.066). However, quality of life showed a positive linear trend (p=0.001) while depression (p=0.033) and anxiety state (p=0.004) showed a negative trend according to physical activity levels. Physical activity was associated with health outcomes, and can be a nonpharmacological treatment in people with epilepsy for improving health and life conditions.

Psychiatric comorbidities in new onset epilepsy: Should they be always investigated?

The new definition of epilepsy establishes that epilepsy is not only a disorder presenting with epileptic seizures but it can be often associated with cognitive and psychiatric comorbidities. In fact, the prevalence of psychiatric comorbidities is relatively high in patients with epilepsy (PWE), as one in three patients will have experienced a psychiatric disorder in the course of their life, with mood and anxiety disorders being the most frequent. Psychiatric comorbidities often precede the onset of the seizure disorder, and affect the life of these patients and the course of the seizure disorder at several levels, including a worse tolerance of pharmacotherapy with antiepileptic drugs (AEDs), in particular the development of iatrogenic psychiatric symptoms from pharmacologic and surgical treatments, an increased mortality risk, a worse quality of life and higher economic burdens of the patient, family and society as a hole. Accordingly, psychiatric comorbidities should be recognized at the time of the initial evaluation of every PWE and their treatment needs to be incorporated within the overall therapeutic plan. This question is addressed in this article.

To what extent does depression influence quality of life of people with pharmacoresistant epilepsy in Argentina?

INTRODUCTION

Depression is the most frequent psychiatric co-morbidity in patients with epilepsy. Lifetime prevalence of depression is reported more frequently in temporal lobe epilepsy and is estimated at 35%. This co-morbidity appears to be related with various mechanisms. The aim of this study was to determine the quality of life (QoL) of patients with pharmacoresistant epilepsy with and without co-morbid depression in an Argentinean population.

METHODS

Patients admitted to the video-EEG monitoring unit during the period 2010-2013 went through a standardized psychiatric assessment using SCID-I (Structured Clinical Interview for Axis I diagnoses of DSM-IV), BDI II (Beck Depression Inventory) GAF (Global assessment of functioning), and Q LES Q-SF (for quality of life). Patients were divided in two groups: with and without depression (according to DSM-IV). Sociodemographic data, BDI II scores, GAF, and quality of life (QoL) were compared between the two groups. Comparisons were made using Student's t-test and Mann-Whitney U test. Frequency distributions were compared by Chi-square test. Spearman correlation coefficients were determined.

RESULTS

Seventy-seven patients with pharmacoresistant epilepsy were eligible for this study, 41 patients were included in the group with depression (mean BDI II 15.93), and 36 in the group without depression (mean BDI II 3.36) (p=0.001). The overall QoL was significantly lower in the group with depression compared to the group without depression (p<0.01). The most affected areas were: physical health (p=0.013), mood (p=0.006), course activities (referring to school as well as to hobbies or classes outside of school) (p=0.003), leisure time activities (p=0.011), social activities (p=0.047), general activities (p=0.042), and medication (p=0.022). Severity of depression according to BDI II had a negative correlation with overall QoL (r - 0.339, p<0.01). No correlations were found between seizure frequency, QoL and BDI II.

CONCLUSION

Patients with pharmacoresistant epilepsy and co-morbid depression reported worst QoL. Depression disrupts daily functioning (leisure, social functioning) and is a negative influence for subjective perception of health and medication. Interdisciplinary treatment should be considered (neurology-psychiatry-psychotherapy).

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it

Purpose of review

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions.

Recent findings

Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations.

Summary

Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

Impact of seizure frequency reduction on health-related quality of life among clinical trial subjects with refractory partial-onset seizures: A pooled analysis of phase III clinical trials of eslicarbazepine acetate

BACKGROUND

Subjects who received eslicarbazepine acetate (ESL) as adjunctive therapy experienced significantly greater seizure frequency reduction (SFR) than placebo in three phase III, randomized, double-blind trials. This analysis compared changes in health-related quality of life (HRQOL) between treatment responders and non-responders across the pooled, per-protocol population (N=842) using the validated Quality of Life in Epilepsy Inventory-31 (QOLIE-31).

METHODS

QOLIE-31 scores were calculated for Total Score (TS) and seven subscales; higher scores indicate better HRQOL. Mean changes from baseline were calculated. Analysis of covariance examined least square mean (LSM) differences in final scores between responders (≥50% and ≥75% SFR) and non-responders. Clinical significance was based on established minimal clinically important differences (MCIDs).

RESULTS

Mean changes were greater among responders for TS (5.2 versus 1.4 for ≥50% SFR; 7.5 versus 1.9 for ≥75% SFR) and all subscales. Additionally, the percentage of subjects with changes meeting or exceeding MCIDs was higher among responders for TS (48.4% versus 33.9% for ≥50% SFR; 56.9% versus 35.8% for ≥75% SFR) and all subscales. Responders had significantly higher final scores for TS (LSM difference=4.0 for ≥50% SFR; LSM difference=5.7 for ≥75% SFR) and all subscales except emotional well-being at ≥50% SFR. LSM differences exceeded MCIDs at ≥75% SFR for TS and five of seven subscales, and two subscales at ≥50% SFR. In a subgroup analysis with placebo removed, LSM differences were larger overall.

SIGNIFICANCE

In clinical trials of adjunctive ESL, higher levels of SFR were associated with greater improvements in HRQOL.

Psychogenic Explanations of Physical Illness

In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.

Medicinal-Induced Behavior Disorders

Commonly used medications can have neuropsychiatric and behavioral effects that may be idiosyncratic or metabolic in nature, or a function of interactions with other drugs, toxicity, or withdrawal. This article explores an approach to the patient with central nervous system toxicity, depending on presentation of sedation versus agitation and accompanying physical signs and symptoms. The effects of antihypertensives, opioids, antibiotics, antiepileptic agents, steroids, Parkinson's disease medications, antipsychotics, medications for human immunodeficiency virus infection, cancer chemotherapeutics, and immunotherapies are discussed. A look at the prevalence of adverse reactions to medications and the errors underlying such occurrences is included.

Depression correlates with quality of life in people with epilepsy independent of the measures used

PURPOSE

A number of studies have suggested that depressed mood is one of the most important predictors of quality of life (QoL) in patients with epilepsy. However, the QoL measure used in previous studies was limited to the Quality of Life in Epilepsy (QOLIE) scales. It could be questioned whether correlation of QOLIE with measures of depression is influenced by the properties of the instruments used rather than being a valid effect. By using visual analogue scales, the current study aimed to clarify whether depression and QoL are truly correlated in patients with epilepsy.

METHODS

Data from a sample of 261 outpatients with epilepsy attending the Epilepsy Clinics of the Atkinson Morley Outpatient Department, St George's Hospital in London, were analyzed. Patients were screened using the European Quality-of-Life scale (EQ-5D-3L) which includes an overall visual analogue score (EQ-VAS), the Emotional Thermometer (ET7), the Beck Depression inventory-II (BDI-II), the Hospital Anxiety and Depression scale (HADS), and the Major Depression inventory (MDI).

RESULTS

Depression was found to significantly correlate with EQ-VAS score with r coefficient ranging from 0.42 to 0.51 and r(2) coefficients ranging between 0.18 and 0.26. In addition, we identified patients who were depressed according to DSM-IV criteria (MD) and those with atypical forms of depression (AD). The EQ-5D-3L scores in these subjects compared with those without depression (ND) showed a different impact of AD and MD on QoL.

CONCLUSIONS

The relationship between depression and QoL in people with epilepsy has been demonstrated to be a robust and valid effect, not a result of potential bias of the specific measures used. However, the strength of the association is influenced by the individual instrument. Atypical or subsyndromic forms of depression are as relevant as DSM-based depression in terms of impact on QoL.

Clinical characteristics of patients with epilepsy in a specialist neuropsychiatry service

Neuropsychiatry services provide specialist input into the assessment and management of behavioral symptoms associated with a range of neurological conditions, including epilepsy. Despite the centrality of epilepsy to neuropsychiatry and the recent expansion of neuropsychiatry service provision, little is known about the clinical characteristics of patients with epilepsy who are routinely seen by a specialist neuropsychiatry service. This retrospective study filled this gap by retrospectively evaluating a naturalistic series of 60 consecutive patients with epilepsy referred to and assessed within a neuropsychiatry setting. Fifty-two patients (86.7%) had active epilepsy and were under the ongoing care of the referring neurologist for seizure management. The majority of patients (N=42; 70.0%) had a diagnosis of localization-related epilepsy, with temporal lobe epilepsy as the most common epilepsy type (N=37; 61.7%). Following clinical assessment, 39 patients (65.0%) fulfilled formal diagnostic criteria for at least one psychiatric disorder; nonepileptic attack disorder (N=37; 61.7%), major depression (N=23; 38.3%), and generalized anxiety disorder (N=16; 26.7%) were the most commonly diagnosed comorbidities. The clinical characteristics of patients seen in specialist neuropsychiatry settings are in line with the results from previous studies in neurology clinics in terms of both epilepsy and psychiatric comorbidity. Our findings confirm the need for the development and implementation of structured care pathways for the neuropsychiatric aspects of epilepsy, with focus on comorbid nonepileptic attacks and affective and anxiety symptoms. This is of particular importance in consideration of the impact of behavioral symptoms on patients' health-related quality of life.

Prevalence of depression and anxiety among patients with epilepsy attending the epilepsy clinic at Sheikh Khalifa Medical City, UAE: A cross-sectional study

Depression and anxiety are highly prevalent in patients with epilepsy (PWE), with prevalence rates ranging from 20% to 55%. Unfortunately, the rates, patterns, and risk factors have not been well studied in the Middle East and, to our knowledge, have not been studied at all in the UAE. We screened 186 patients attending an epilepsy clinic using standardized screening tools to determine the rates of both depression and anxiety and compared these rates with that of age- and sex-matched controls. Almost one-third of our patients scored in the depression and anxiety ranges, which was significantly higher compared with the age- and sex-matched controls. Using a multiregression model, none of the studied variables were associated with an increased risk of having either disorder. Depression or anxiety symptoms independently and significantly increased the risk of association with the other disorder. Almost two-thirds of patients with depression and anxiety were not prescribed antidepressant or antianxiety medications.