Risk factors for depression in community-treated epilepsy: systematic review

Resilience and psychosocial factors in adult with epilepsy: A longitudinal study

PURPOSE

Resilience is conceptually characterized as a dynamic process encompassing positive adaptation in the context of significant adversity. Our goal was to assess the resilience in people with epilepsy (PWE) and how it impacts longitudinally on psychosocial factors, with a particular focus on the manifestation of stigmatization-related feelings.

METHODS

We consecutively enrolled 78 adults PWE (42.5 ± 16.2 years old); among them 36 (46.1 %) were seizure-free. All subjects completed at baseline (T0) the Resilience Scale (RS-14) and questionnaires for the assessment of depressive symptoms, anxiety and quality of life: respectively, Beck Depression Inventory-II (BD-II), Generalized Anxiety Disorder-7 (GAD-7) and QOLIE-31 (Q31). All patients were followed up prospectively and re-evaluated after 6-22 months (T1; mean: 14 ± 8 months; median 14 months); at follow up they also completed the Stigma Scale of Epilepsy (SSE) for the assessment of the stigma associated with epilepsy. We correlated resilience values with all psychosocial scores at T0 and T1. Factors associated with resilient and vulnerable outcomes were identified. Finally, a multiple stepwise regression analysis was applied to identify predictors for resilience and stigma perception.

RESULTS

The results showed for the RS-14 score a significant direct correlation with the Q31 (p < 0.001) and an inverse correlation with the depressive and anxiety symptoms at both times (T0 and T1), as evaluated with BDI-II (p < 0.001) and GAD-7 (p < 0.001). Finally, we found a significant inverse correlation between RS-14 at T0 and the levels of stigmatization assessed with SSE at T1 (p =.015). Using a multiple stepwise regression analysis separately for resilience and stigma perception, depressive symptoms turned out as the best predictors for both variables. Finally, considering longitudinal evaluation we did not observe significant changes in depressive and anxious symptoms, despite a significant reduction in the total number of seizures at follow up.

CONCLUSIONS

Our study showed that depressive symptoms, anxiety and quality of life were significantly associated with resilience in PwE. Finally, as a novel finding resilience was proved to affect the perception of stigma related to epilepsy more than seizures.

Experience sampling methodology study of anxiety and depression in adolescents with epilepsy: The role of metacognitive beliefs and perseverative thinking

Emotional distress is common in young people with epilepsy (YPwE). According to the Self-Regulatory Executive Function (S-REF) model, maladaptive metacognitive beliefs and perseverative thinking are fundamental in the development and maintenance of emotional distress. As emotional distress and perseverative thinking can highly fluctuate over short intervals in YPwE, it is important to account for this variability when testing the utility of psychological models. Experience sampling methodology (ESM) was therefore used to explore the momentary relationship between metacognitive beliefs, perseverative thinking, and emotional distress in YPwE. Eighteen participants diagnosed with epilepsy (aged 12-17 years) completed the 10-day ESM period. Participants were prompted to complete the ESM assessment five times daily. The ESM assessment assessed participant's momentary levels of metacognitive beliefs, perseverative thinking (i.e., worry and rumination), and emotional distress (i.e., anxiety and depression). A series of multilevel regression analyses indicated that metacognitive beliefs were significantly positively associated with worry, rumination, anxiety and depression. After controlling for worry and rumination, respectively, metacognitive beliefs did not account for additional variance in anxiety or depression. Findings provide preliminary support for the utility of the S-REF model for emotional distress in YPwE. Metacognitive therapy, which is underpinned by the S-REF model, may be an appropriate intervention for emotional distress in YPwE. Future studies should assess the mediational relationship between metacognitive beliefs, perseverative thinking, and emotional distress using time-lagged models.

Psychosocial factors associated with anxiety and depression in adolescents with epilepsy: A systematic review

Anxiety and depression are common in adolescents with epilepsy. Identifying psychosocial risk factors for anxiety and depression is essential for adolescents with epilepsy to receive appropriate support. This systematic review synthesised findings of studies examining the relationship between psychosocial factors and anxiety and/or depression in adolescents with epilepsy. Outcomes were anxiety, depression, and mixed anxiety & depression. Six electronic databases were searched for studies which: used cross-sectional or prospective designs; quantitatively evaluated the relationship between psychosocial factors and anxiety and/or depression; presented results for adolescents with epilepsy aged 9-18 years; and used validated measures of anxiety and/or depression. Psychosocial factors were categorised as intrapersonal, interpersonal, or parent-specific factors. Sixteen studies (23 articles) were included. All but one were cross-sectional. Regarding intrapersonal factors, alternative mental health difficulties were consistently positively associated with all three outcomes. Negative attitude towards epilepsy, lower seizure self-efficacy, lower self-esteem and stigma were consistently positively associated with depression. Interpersonal factors (i.e., lower family functioning assessed from an adolescent's perspective) and parent-specific factors (i.e., parental stigma, stress, anxiety and psychopathology) were positively associated with at least one outcome. Adolescent epilepsy management should exceed assessment of biological/biomedical factors and incorporate assessment of psychosocial risk factors. Prospective studies examining the interplay between biological/biomedical factors and the psychosocial factors underpinning anxiety and depression in adolescents with epilepsy are needed.

The Relationship of Fatigue and Depression with Trace Element Levels in Epileptic Patients

In this study, it was investigated whether there are trace element abnormalities in epileptic patients, the relationship of trace elements with fatigue and depression, and whether trace elements contribute to the development of fatigue and depression. A total of 87 people, 48 epileptic cases and 39 controls, were included in our study. Trace element levels of lead (Pb), zinc (Zn), copper (Cu), manganese (Mn), and selenium (Se) were measured in a single session on the study day by the same team. Beck Depression Inventory, Fatigue Severity Scale, Mood State Scale, and SF-36 Quality of Life scales were administered to all participants by the same person. The results were compared statistically. Depression rate was found as 35.4% and fatigue rate was 45.8% in epileptics. Se, Cu, and Mn levels were significantly higher in epileptics (p < 0.05), but there was no significant difference in Zn and Pb levels (p > 0.05). In the study, a moderate positive correlation was found between fatigue and depression (r = 0.346, p = 0.016). Fatigue severity scale (FSS) and Beck depression inventory (BDI) scores were found to be significantly higher in epileptics (p < 0.05). Total mood scale (TMS) mean score was compared between patient and control groups, and the difference between the groups was statistically significant (p < 0.005). It was observed that fatigue and depression are more common in epileptics, and there may be abnormalities in trace element plasma levels in epileptics, and it was determined that trace elements did not show a significant difference between those with and without fatigue and depression, and trace elements did not show a significant correlation with fatigue and depression.

Difficulties in emotion and social support in people with epilepsy: relationship with depression levels

Amaç: Bu çalışmada epilepsili bireylerde depresyon düzeyi ile duygu düzenleme güçlükleri ve sosyal destek arasındaki ilişkiyi incelemeyi amaçladık. Gereç ve Yöntem: Fokal epilepsi tanısı ile takip edilmekte olan hastalara Nörolojik Bozukluklarda Depresyon Ölçeği-Epilepsi (NDDI-E), Duygu Düzenleme Güçlükleri Ölçeği (DDGÖ) ve İki Yönlü Sosyal Destek Ölçeği (2-YSDÖ) verilmiştir. Bulgular: Çalışmaya 109 hasta dahil edilmiştir. Hastaların %25’inde depresyon saptanmıştır. Depresyonu olan olguların DDGÖ median değeri 45 (28-55), depresyon saptanmayan grubun ise 24 (18-33,5)’dür. Depresyonu olan grubun DDGÖ skorunun depresyonu olmayan gruba kıyasla anlamlı derecede yüksek olduğu tespit edilmiştir. Tüm çalışma popülasyonunda yapılan 2-YSDÖ (92 (69,5-102,5)) ve DDGÖ (27 (19-41)) skorlarının korelasyon analizinde sosyal destek ve duygu düzenleme güçlükleri arasında negatif bir ilişki mevcuttur. Regresyon analizine göre ise duygu düzenleme güçlükleri depresyonun ana belirleyicisidir ve depresyonu %16,8 oranında açıklamaktadır. Sonuç: Epilepsili bireylerde duygu düzenleme güçlükleri depresyonun ana belirleyicilerinden biridir ve yetersiz sosyal destek duygu düzenleme güçlükleri ile ilişkilidir. Epilepsili bireylerde depresyon sıklığını azaltmak için duygu düzenleme stratejilerini güçlendirecek rehabilitasyon programlarına ihtiyaç vardır.

Felt stigma may potentiate the relationship between perceived stress and depressive symptoms in persons with epilepsy

PURPOSE

This study assessed the strengths of association among perceived stress, felt stigma, and depression in adults with epilepsy, and evaluated whether felt stigma altered the association between perceived stress and depression.

METHODS

This multicenter, cross-sectional study included adults with epilepsy. Depression was assessed using the Beck Depression Inventory (BDI), and perceived stress was evaluated using the 10-item Perceived Stress Scale. Felt stigma was determined using the three-item Stigma Scale for Epilepsy, with individuals categorized as positive for felt stigma if they answered "yes" to at least one of these items. A hierarchical linear regression analysis and an analysis of covariance with interaction terms were performed.

RESULTS

The 316 adults with epilepsy included 171 men and 145 women; of these, 109 (34.5%) reported felt stigma. A hierarchical linear regression analysis showed that perceived stress was the most important correlate of depressive symptoms, followed by felt stigma, being unemployed, recurrence of generalized or focal to bilateral tonic-clonic seizures, and being married. The model explained 54.0% of the variance of BDI scores. Significant interactions between felt stigma and perceived stress on BDI scores was identified in both crude and adjusted models (p < 0.05 each). Specifically, in an adjusted model, BDI scores were more strongly associated with perceived stress in persons with (p < 0.001, partial eta² = 0.225) than without (p < 0.001, partial eta² = 0.205) felt stigma.

CONCLUSIONS

Perceived stress was the most significant correlate of depressive symptoms in adults with epilepsy, followed by felt stigma. The interaction between perceived stress and felt stigma on depressive symptoms was significant. These findings may help in developing cognitive behavioral therapy for stigma and stress management in persons with epilepsy.

Effect of long-term administration of clonazepam, carbamazepine, and valproate on cognitive, psychological, and personality changes in adult epilepsy: a case–control study

Background

Epilepsy can be treated with antiepileptic drugs (AEDs) which may have psychiatric and behavioral side effects. Additionally, the availability of new AEDs has increased, and our understanding of variability to combinations of several AEDs has evolved. Based on the treatment outcomes of carbamazepine, valproate, and clonazepam, this study aims to compare the cognitive function, personality, and psychological issues associated with these drugs and evaluate seizure-related factors related to them. Only 139 participants were included. Clonazepam was used as an add-on antiepileptic drug. Participants were categorized into five groups: group 1, carbamazepine; group 2, valproate; group 3, carbamazepine and clonazepam; group 4, valproate and clonazepam; and group 5, epileptic patients without AED. All participants were assessed using the Wechsler Adult Intelligence Scale (WAIS), Structured Interview for the Five-Factor Personality Model (SIFFM), Hamilton Anxiety and Depression Rating Scale, and Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

Results

In the WAIS, group 1 had the worst mean of verbal intelligence quotient (IQ). Moreover, group 3 was more vulnerable in symptomatic response in all subscales of MMPI-2 except the masculinity–femininity subscale and a high percentage in moderate severity of anxiety and depression in the Hamilton scales.

Conclusions

The use of clonazepam and carbamazepine might increase the incidence of behavioral problems especially increased severity of anxiety and depression and decreased performance IQ compared with either clonazepam or carbamazepine alone. Moreover, patients with carbamazepine treatment might have more personality changes and lowered verbal IQ than others.

Long-term mood, quality of life, and seizure freedom in intracranial EEG epilepsy surgery

OBJECTIVES

To determine the long-term outcomes in patients undergoing intracranial EEG (iEEG) evaluation for epilepsy surgery in terms of seizure freedom, mood, and quality of life at St. Vincent's Hospital, Melbourne.

METHODS

Patients who underwent iEEG between 1999 and 2016 were identified. Patients were retrospectively assessed between 2014 and 2017 by specialist clinic record review and telephone survey with standardized validated questionnaires for: 1) seizure freedom using the Engel classification; 2) Mood using the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E); 3) Quality-of-life outcomes using the QOLIE-10 questionnaire. Summary statistics and univariate analysis were performed to investigate variables for significance.

RESULTS

Seventy one patients underwent iEEG surgery: 49 Subdural, 14 Depths, 8 Combination with 62/68 (91.9%) of those still alive, available at last follow-up by telephone survey or medical record review (median of 8.2 years). The estimated epileptogenic zone was 62% temporal and 38% extra-temporal. At last follow-up, 69.4% (43/62) were Engel Class I and 30.6% (19/62) were Engel Class II-IV. Further, a depressive episode (NDDI-E > 15)was observed in 34% (16/47), while a 'better quality of life' (QOLIE-10 score < 25) was noted in 74% (31/42). Quality of life (p < 0.001) but not mood (p = 0.24) was associated with seizure freedom.

SIGNIFICANCE

Long-term seizure freedom can be observed in patients undergoing complex epilepsy surgery with iEEG evaluation and is associated with good quality of life.

Psychiatric comorbidities in adult patients with epilepsy (A systematic review)

The co-occurrence of epilepsy and psychiatric disorders is long known. The scope of this systematic review was to describe the prevalence of specific interictal psychiatric disorders in patients with epilepsy and to assess possible associations between psychiatric disorders and other sociodemographic or clinical characteristics of epilepsy patients. MEDLINE and ScienceDirect were searched for original articles published between January 2015 and February 2021 describing studies that involved epilepsy patients with psychiatric comorbidities. We identified 13 studies with heterogenous methodology and reporting. Prevalence of any psychiatric disorder observed was up to 51% in idiopathic generalized epilepsy (IGE), up to 43.1% in temporal lobe epilepsy (TLE) and up to 43.3% in a general population of patients with epilepsy. The most frequent psychiatric comorbidities associated with epilepsy included mood/affective disorders (up to 40% for lifetime occurrence and up to 23% for current occurrence), anxiety disorders (up to 30.8% for lifetime occurrence and up to 15.6% for current occurrence), personality disorders [up to 11% in juvenile myoclonic epilepsy (JME)] and psychotic disorders (up to 4% of epilepsy patients). In focal epilepsy, depressive disorders might be associated with specific brain imaging findings and with cognitive impairment. Anxiety disorders are associated with a higher frequency of generalized tonico-clonic seizure (GTCS) and with worse social functioning. Psychotic disorders were found to be associated with longer duration of epilepsy. Childhood maltreatment experiences were found to be a powerful predictor for the occurrence of psychiatric comorbidities in epilepsy patients, while data regarding association of other epilepsy characteristics with the presence of psychiatric disorders is conflicting.

Self-injurious and suicidal behavior in young adults, teens, and children with epilepsy: A population-based study

OBJECTIVE

Whereas studies in adult epilepsy patients have shown higher rates of suicidal ideation and attempt, such studies in children are limited. Using the Rochester Epidemiology Project database, we compared the risk of self-injurious behavior and suicidal ideation in a population-based cohort of childhood epilepsy to controls.

METHODS

We studied 339 cases with epilepsy and 678 age- and sex-matched controls followed to a median age of 24.7 and 23.4 years, and identified 98 subjects with self-injurious behavior or suicidal ideation (43 with epilepsy and 55 controls). All behaviors were categorized using the Columbia Suicide Severity Rating Scale.

RESULTS

Those with epilepsy had a significantly higher rate of any self-injurious behavior and suicidal ideation (hazard ratio [HR] = 1.56, 95% confidence interval [CI] = 1.04-2.35) and tended to have an increased risk of suicidal ideation and attempt (HR = 1.48, 95% CI = 0.93-2.37). The prevalence of preceding mood and substance abuse disorders was similarly high in both cases and controls with self-injurious behavior or suicidal ideation; however, preceding attention-deficit/hyperactivity disorder was more than twice as common in the epilepsy cases. Among cases with epilepsy, we did not identify any specific epilepsy-related variable that was significantly correlated with risk of self-injurious behavior or suicidal ideation.

SIGNIFICANCE

Children, teens, and young adults with a history of childhood epilepsy are at greater risk of self-injurious behavior, highlighting the need for careful screening of mental health concerns as part of routine epilepsy care.

Depression and Anxiety in the Epilepsies: from Bench to Bedside

PURPOSE OF REVIEW

Depression and anxiety substantially contribute to interictal disability in patients with epilepsy (PWE). This review summarizes current studies that shed light on mechanisms of comorbidity.

RECENT FINDINGS

Mounting epidemiological data implicate shared risk factors for anxiety/depression and seizure propensity, but these remain largely elusive and probably vary by epilepsy type. Within PWE, these symptoms appear to be associated with unique genetic, neuropathological, and connectivity profiles. Temporal lobe epilepsy has received enormous emphasis particularly in preclinical studies of comorbidity, where candidate neurobiological mechanisms underlying bidirectionality have been tested without psychopharmacological confounds. Depression and anxiety in epilepsy reflect dysfunction within broadly distributed limbic networks that may be the cause or consequence of epileptogenesis. In refractory epilepsy, seizures and/or certain anticonvulsants may distort central emotional homeostatic mechanisms that perpetually raise seizure risk. Developing future safe and effective combined anticonvulsant-antidepressant treatments will require a detailed understanding of anatomical and molecular nodes that pleiotropically enhance seizure risk and negatively alter emotionality.

Correlates of depression and quality of life among patients with epilepsy in Nigeria

OBJECTIVES

To determine the prevalence of Major Depressive Disorders (MDD) and its relationship to Quality of life.

DESIGN

A cross-sectional observational study.

SETTING

Out-Patient Clinic of the Neuropsychiatric Hospital, Abeokuta, Nigeria.

SUBJECTS

Patients with diagnosis of Epilepsy with Electroencephalogram (EEG) confirmation.

OUTCOME MEASURES

Depression and Quality of life.

RESULTS

The prevalence of current MDD was 11.9 %, and patients having at least 1 seizure per week were 5 times more likely to develop MDD (OR = 5.104, p = 0.014). The mean (SD) QOLIE-31 scores was 77.98 (13.32), with presence of MDD (β = -11.101, p = 0.0001); having at least 1 seizure/week (β = -6.653, p = 0.037) being independent predictors.

CONCLUSION

Depression is a common comorbidity in patients with epilepsy and is associated with a lower quality of life.

Risk factors for depression in patients with epilepsy: A meta-analysis

BACKGROUND

Depression is common and associated with reduced quality of life (QoL) in people with epilepsy (PWE). Although multiple studies have investigated the relevant predictors, the results have been inconsistent. This meta-analysis aimed to investigate the risk factors that might increase the possibility of depression in this population.

METHODS

Medline, The Cochrane Library, Web of Science, and Embase were comprehensively searched for cross-sectional studies on the occurrence of depression in PWE. A random effects model was used to calculate the pooled hazard ratios (HRs) and 95% confidence intervals (95% CIs). Heterogeneity between the study results and the probability of publication bias were also assessed.

RESULTS

Fifty-one cross-sectional studies with sample sizes ranging from 36 to 1763 were included in this meta-analysis. The significant factors associated with an increased risk of depression were older age (odds ratio [OR]: 1.02, 95% CI: 1.00-1.04; p = 0.019), female gender (OR: 1.58, 95% CI: 1.30-1.93; p < 0.001), low education level (OR: 3.38, 95% CI: 2.86-4.00; p < 0.001), not being employed (OR: 1.61, 95% CI: 1.08-2.38; p = 0.019), poor antiepileptic drug (AED) adherence (OR: 2.84, 95% CI: 1.94-4.16; p < 0.001), polytherapy (OR: 2.25, 95% CI: 1.48-3.41; p < 0.001), stigma (OR: 2.22, 95% CI: 1.71-2.88; p < 0.001), and anxiety (OR: 2.21, 95% CI: 1.66-2.94; p < 0.001). A shorter epilepsy duration was significantly associated with a lower risk of depression (OR: 0.99, 95% CI: 0.99-0.99; p < 0.001), whereas marital status (OR: 1.07, 95% CI: 0.90-1.20; p = 0.684), economic level (OR: 1.01, 95% CI: 0.95-1.08; p = 0.684), age at seizure onset (OR: 0.99, 95% CI: 0.75-1.29; p = 0.912), and seizure control (OR: 1.03, 95% CI: 0.65-1.63; p = 0.900) did not increase the risk of depression.

CONCLUSION

This meta-analysis defined several factors related to an increased risk of depression in PWE and can contribute to better prevention and screening strategies for depression in this group. The mechanisms behind this comorbidity remain to be further investigated to determine individually appropriate and targeted interventions.

Psychological distress symptoms and illness perception in patients with epilepsy in Northwest Greece

OBJECTIVE

The purpose of the present study was to compare psychological distress between patients with epilepsy and healthy controls and to evaluate potentially related factors to psychological distress in patients with epilepsy. Furthermore, we assessed how psychological distress and other potential factors mediate illness perception in patients with epilepsy in an urban area of Northwest Greece.

MATERIALS AND METHODS

A case-control study was conducted in adult patients with epilepsy followed up at the University Hospital of Ioannina and in healthy controls. The Symptom Checklist-90 Revised (SCL-90R) for symptoms of psychological distress and the overall psychological distress Global Severity Index (GSI) evaluation, the brief illness perception questionnaire (B-IPQ), and the Adverse Event Profile (AEP) questionnaire for the antiepileptic drugs (AEDs) were used.

RESULTS

Seventy patients with epilepsy and 70 controls were recruited in the study. Somatic, depression, and anxiety symptoms and the GSI were higher in patients than in controls. In patients with epilepsy, the AEP score was significantly associated with psychological distress. Illness perception was associated with the number and the total number of administered AEDs; the AEP score; somatic, obsessive, depressive, and anxiety symptoms; and the GSI. After regression analysis, epilepsy characteristics, AEDs, and psychological distress accounted for 11.7%, 28.7%, and 5.5% of variance in BIP-Q score, respectively.

CONCLUSION

Screening for psychological distress in patients with epilepsy is of high importance in clinical practice as somatic, depression, and anxiety symptoms and overall psychological distress are more severe in patients with epilepsy than in healthy controls. The symptoms of psychological distress are strongly associated with the adverse effects of AEDs. The epilepsy characteristics, the AEDs, and the psychological distress could determine a large part of illness perception in epilepsy, with the adverse effects of AEDs being the strongest predictor.

Depressive Symptoms in Older versus Younger People with Epilepsy: Findings from an Integrated Epilepsy Self-Management Clinical Research Dataset

Aim

There are limited data on psychological outcomes in older people with epilepsy (PWE). This analysis, from a large pooled dataset of clinical studies from the Managing Epilepsy Well (MEW) Network, examined clinical variables including depressive symptom severity, quality of life and epilepsy self-management competency among older (age 55+) vs younger (<age 55) PWE. We were particularly interested in differences between older vs younger individuals with clinically significant depression.

Methods

Analyses used baseline data from 9 MEW Network studies and examined demographic and clinical variables. Older vs younger individuals were compared and then we assessed groups with clinically significant depression vs those without clinically significant depression using the PHQ-9 and QOLIE-10 as a measure of quality of life.

Results

The sample included 935 individuals. Compared to younger adults (n=774), the older group (n=161) had a better quality of life (p= 0.041) and more individuals without clinically significant depression (p=0.038). There was a trend for slightly lower depression severity scores (PHQ-9 total) (p=0.07) in the older group and a trend for fewer seizures (p=0.055) in older adults relative to younger adults.

Conclusion

Compared to younger PWE, older PWE have less clinically significant depression and better quality of life. Future research needs to identify possible mechanisms underlying these differences.

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.

Risk Factors for Depression in Long-Term Care: A Systematic Review

OBJECTIVES

Depression rates are substantially higher among older adults in long-term care when compared with older adults in the community. Furthermore, the needs of older adults in long-term care are increasingly complex, and risk factors that contribute to depression in this population are unclear. This limits not only the identification of those at risk for depression but also the development of therapeutic interventions. This review summarizes the evidence on risk factors for depression.

METHODS

Searches were performed using CINAHL, Cochrane Library, Ovid Medline, PsycINFO and Scopus for research published 1980-2017. Data were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

Eleven studies met the inclusion criteria, representing a total of 11,703 participants, with a mean sample size of 1,064. The most consistently supported risk factor was cognitive impairment, followed by functional impairment and baseline depression score.

CONCLUSIONS

The studies lacked a systematic approach to investigating risk factors for depression, and the research remains largely atheoretical. Few risk factors were consistently studied, with over 20 risk factors examined no more than once each. Psychological and environmental risk factors, which may be modifiable and have the potential to inform therapeutic interventions and preventative strategies, remain under-studied.

CLINICAL IMPLICATIONS

The most consistently supported risk factors-cognitive impairment, functional disability and baseline depression score-have the potential to inform screening protocols and should be monitored longitudinally. When developing psychotherapeutic interventions, close consideration should be given to cognitive and functional impairment as barriers to implementation and uptake.

Self-compassion and depression, anxiety, and resilience in adults with epilepsy

BACKGROUND

Research suggests that people with epilepsy (PWE) are more likely to experience depression and anxiety than the general population. Given the adversity associated with the condition, resilience may also be important. However, to date, resilience has been largely overlooked in the epilepsy literature. Self-compassion has been widely associated with improved psychological wellbeing and, to a lesser extent, resilience. However, the relationship between self-compassion and depression, anxiety, and resilience in PWE has not been examined.

OBJECTIVES

Using a quantitative cross-sectional survey design, the aim of the present study was to examine the extent to which self-compassion predicted depression, anxiety, and resilience when controlling for demographic and illness-related variables.

METHODS

Adults with epilepsy were invited to take part in a survey online or in epilepsy or neurology clinics. Two-hundred and seventy participants completed the survey, and data were analyzed using hierarchical multiple regression models.

RESULTS

In this sample of PWE, self-compassion significantly predicted lower depression and anxiety and higher resilience when other significant sociodemographic and illness-related variables had been taken into account.

CONCLUSIONS

The findings of the present study indicate that self-compassion could be an important factor in determining psychological outcomes for adults with epilepsy, and its role is worthy of further exploration to help improve psychological outcomes for PWE.

Prevalence, Demographic Profile, and Psychological Aspects of Epilepsy in North-Western India: A Community-Based Observational Study

Aims

This study was undertaken to determine the prevalence of active epilepsy, assess the sociodemographic profile, and psychological aspects of epilepsy in the Jaipur district of Rajasthan, India.

Methods

We conducted a community-based, cross-sectional observational study covering both rural (n = 165,660) and urban (n = 179,142) populations of Jaipur district using a house-to-house survey. An adapted, pre-designed World Health Organization screening questionnaire was used to identify the cases. Those confirmed by neurologists as true seizures were included in the study. Cases were classified as per the International League against Epilepsy recommendation. Global Mental Health Assessment Tool electronic questionnaire was used to analyze psychological aspects of cases. The caregivers of the patients participated in the knowledge, attitude, and practice (KAP) survey.

Results

A total of 380 patients (258 men, 122 women) were identified with active epilepsy. The estimated prevalence of active epilepsy was 1.1/1,000 population and 71% of cases belonged to low socioeconomic classes. Primary treatment gap was documented in 18.8% of cases in our study, 38% of cases were non-compliant to treatment with poorer compliance in those on pol-therapy, 76% had some psychiatric disorder, anxiety and depression being the commonest, and positive family history of epilepsy was found in 4.7%. KAP survey revealed that only 15% of the respondents believed that epilepsy is non-curable, 74% denied its infectious nature, 26% believed that epilepsy occurs due to past sins, and 81% said that they would not marry persons with epilepsy.

Conclusion

A relatively low prevalence (1.1/1,000) of active epilepsy and a smaller primary treatment gap (18.8%) was found in our study population. Almost three-fourth of cases had an associated psychological problem, Though caregivers were aware of the nature of disease, majority would not prefer to marry a person suffering from epilepsy.

Patterns of association of chronic medical conditions and major depression

AIMS

Age and sex-related patterns of association between medical conditions and major depressive episodes (MDE) are important for understanding disease burden, anticipating clinical needs and for formulating etiological hypotheses. General population estimates are especially valuable because they are not distorted by help-seeking behaviours. However, even large population surveys often deliver inadequate precision to adequately describe such patterns. In this study, data from a set of national surveys were pooled to increase precision, supporting more precise characterisation of these associations.

METHODS

The data were from a series of Canadian national surveys. These surveys used comparable sampling strategies and assessment methods for MDE. Chronic medical conditions were assessed using items asking about professionally diagnosed medical conditions. Individual-level meta-analysis methods were used to generate unadjusted, stratified and adjusted prevalence odds ratios for 11 chronic medical conditions. Random effects models were used in the meta-analysis. A procedure incorporating rescaled replicate bootstrap weights was used to produce 95% confidence intervals.

RESULTS

Overall, conditions characterised by pain and inflammation tended to show stronger associations with MDE. The meta-analysis uncovered two previously undescribed patterns of association. Effect modification by age was observed in varying degrees for most conditions. This effect was most prominent for high blood pressure and cancer. Stronger associations were found in younger age categories. Migraine was an exception: the strength of association increased with age, especially in men. Second, especially for conditions predominantly affecting older age groups (arthritis, diabetes, back pain, cataracts, effects of stroke and heart disease) confounding by age was evident. For each condition, age adjustment resulted in strengthening of the associations. In addition to migraine, two conditions displayed distinctive patterns of association. Age adjusted odds ratios for thyroid disease reflected a weak association that was only significant in women. In epilepsy, a similar strength of association was found irrespective of age or sex.

CONCLUSIONS

The prevalence of MDE is elevated in association with most chronic conditions, but especially those characterised by inflammation and pain. Effect modification by age may reflect greater challenges or difficulties encountered by young people attempting to cope with these conditions. This pattern, however, does not apply to migraine or epilepsy. Neurobiological changes associated with these conditions may offset coping-related effects, such that the association does not weaken with age. Prominent confounding by age for several conditions suggests that age adjustments are necessary in order to avoid underestimating the strength of these associations.

Psychiatric side effects and antiepileptic drugs: Observations from prospective audits

Psychiatric comorbidities are common in people with epilepsy. A retrospective study of characteristics associated with withdrawal due to psychiatric side effects was undertaken in patients with treated epilepsy participating in prospective audits with new antiepileptic drugs (AEDs). A total of 1058 treated patients with uncontrolled seizures (942 focal-onset seizures, 116 generalized genetic epilepsies [GGEs]) participated in eight prospective, observational audits from 1996 to 2014. These patients were prescribed adjunctive topiramate (n=170), levetiracetam (n=220), pregabalin (n=135), zonisamide (n=203), lacosamide (n=160), eslicarbazepine acetate (n=52), retigabine (n=64), or perampanel (n=54). Doses were titrated according to efficacy and tolerability to optimize zeizure outcomes and reduce side effects. Psychiatric comorbidities were recorded prior to and after the addition of each AED. At baseline, patients with focal-onset seizures (189 of 942; 20.1%) were statistically more likely to have psychiatric diagnoses compared to patients with GGEs (14 of 116, 12.1%; p=0.039). Following adjunctive AED treatment, neuropsychiatric adverse effects led to AED withdrawal in 1.9-16.7% of patients. Patients with a pre-treatment psychiatric history (22 of 209; 10.5%) were statistically more likely to discontinue their new AED due to psychiatric issues compared to patients with no previous psychiatric diagnosis (50 of 849; 5.9%; p=0.017). Patients receiving sodium channel blocking AEDs (4 of 212, 1.9%) were statistically less likely to develop intolerable psychiatric problems, compared to those on AEDs possessing other mechanisms of action (68 of 846, 8.0%; p=0.012). Depression was the commonest problem, leading to discontinuation of AEDs in 2.8% (n=30) patients. Aggression was statistically more common in men (11 of 527, 2.1%) compared to women (1 of 531, 0.2%; p=0.004). Patients with learning disability (12 of 122, 9.8%; p=0.0015) were statistically less likely to have psychiatric issues prior to adjunctive AED treatment compared to other patients (208 of 936, 22.2%), but there were no statistically significant differences once the new AEDs were added (8 of 122 patients with learning disability, 6.6%; 64 of 936 other patients, 6.8%). Awareness of these issues may assist clinicians in avoiding, identifying and treating psychiatric comorbidities in people with epilepsy.

Correlates of perceived stigma for people living with epilepsy: A meta-analysis

OBJECTIVE

Epilepsy, one of the most common, serious chronic neurological diseases, is accompanied by different levels of perceived stigma that affects people in almost all age groups. This stigma can negatively impact the physical and mental health of people living with epilepsy (PLWE). Good knowledge of perceived stigma for PLWE is important. In this study, we conducted a meta-analysis to identify the correlates of perceived stigma for PLWE.

METHODS

Studies on factors associated with perceived stigma for PLWE, including sociodemographic, psychosocial, and disease-related variables, were searched in PubMed, PsychINFO, EMBASE, and Web of Science.

RESULTS

Nineteen variables (k>1) were included in the meta-analysis. For sociodemographic characteristics, findings revealed that the significant weighted mean correlation (R) for "residence" and "poor financial status" were 0.177 and 0.286, respectively. For disease-related characteristics, all variables of significance, including "seizure severity," "seizure frequency," "number of medicines," and "adverse event" (R ranging from 0.190 to 0.362), were positively correlated with perceived stigma. For psychosocial characteristics, "depression" and "anxiety" with R values of 0.414 and 0.369 were significantly associated with perceived stigma. In addition, "social support," "quality of life (QOLIE-31,89)," "knowledge," and "attitude," with R values ranging from -0.444 to -0.200 indicating negative correlation with perceived stigma.

CONCLUSION

The current meta-analysis evaluated the correlates of perceived stigma for PLWE. Results can serve as a basis for policymakers and healthcare professionals for formulating health promotion and prevention strategies.

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.

Epilepsy coexisting with depression

Depression episodes in epilepsy is the most common commorbidity, affecting between 11% and 62% of patients with epilepsy. Although researchers have documented a strong association between epilepsy and psychiatric comorbidities, the nature of this relationship is poorly understood. The manifestation of depression in epilepsy is a complex issue having many interacting neurobiological and psychosocial determinants, including clinical features of epilepsy (seizure frequency, type, foci, or lateralization of foci) and neurochemical or iatrogenic mechanisms. Other risk factors are a family history of psychiatric illness, particularly depression, a lack of control over the seizures and iatrogenic causes (pharmacologic and surgical). In addition, treatment with antiepileptic drugs (AEDs) as well as social coping and adaptation skills have also been recognised as risk factors of depression associated with epilepsy. Epilepsy may foster the development of depression through being exposed to chronic stress. The uncertainty and unpredictability of seizures may instigate sadness, loneliness, despair, low self-esteem, and self-reproach in patients with epilepsy and lead to social isolation, stigmatization, or disability. Often, depression is viewed as a reaction to epilepsy's stigma and the associated poor quality of life. Moreover, patients with epilepsy display a 4-5 higher rate of depression and suicide compared with healthy population.

Protocol for the ENCODE trial: evaluating a novel online depression intervention for persons with epilepsy

BACKGROUND

Depression is common among persons with epilepsy (PwE), affecting roughly one in three individuals, and its presence is associated with personal suffering, impaired quality of life, and worse prognosis. Despite the availability of effective treatments, depression is often overlooked and treated inadequately in PwE, in part because of assumed concerns over drug interactions or proconvulsant effects of antidepressants. Internet-administered psychological interventions might complement antidepressant medication or psychotherapy, and preliminary evidence suggests that they can be effective. However, no trial has yet examined whether an Internet intervention designed to meet the needs of PwE can achieve sustained reductions in depression and related symptoms, such as anxiety, when offered as adjunct to treatment as usual.

METHODS/DESIGN

This randomized controlled trial will include 200 participants with epilepsy and a current depressive disorder, along with currently at least moderately elevated depression (Patient Health Questionnaire (PHQ-9) sum score of at least 10). Patients will be recruited via epilepsy treatment centers and other sources, including Internet forums, newspaper articles, flyers, posters, and media articles or advertisements, in German-speaking countries. Main inclusion criteria are: self-reported diagnosis of epilepsy and a depressive disorder, as assessed with a phone-administered structured diagnostic interview, none or stable antidepressant medication, no current psychotherapy, no other major psychiatric disorder, no acute suicidality. Participants will be randomly assigned to either (1) a care-as-usual/waitlist (CAU/WL) control group, in which they receive CAU and are given access to the Internet intervention after 3 months (that is, a CAU/WL control group), or (2) a treatment group that may also use CAU and in addition immediately receives six-month access to the novel, Internet-administered intervention. The primary outcome measure is the PHQ-9, collected at three months post-baseline; secondary measures include self-reported anxiety, work and social adjustment, epilepsy symptoms (including seizure frequency and severity), medication adherence, potential negative treatment effects and health-related quality of life. Measurements are collected online at pre-treatment (T0), three months (T1), six months (T2), and nine months (T3).

DISCUSSION

Results of this trial are expected to extend the body of knowledge with regard to effective and efficient treatment options for PwE who experience elevated depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02791724 . Registered 01 June 2016.

Major depressive episode, cognition, and epilepsy

PURPOSE

In patients with epilepsy (PWE), relationships between depression, epilepsy characteristics, and cognitive aspects are complex. This study aimed to assess the occurrence of possible major depressive episode in PWE and to verify whether it is associated with the clinical aspects of the disease and cognition.

METHODS

Two hundred consecutive PWE with a mean age and standard deviation of 47.6 (±15.1) years were included in the study. We determined whether their Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) scores were associated with their clinical, cognitive, and QOLIE-31 aspects using a significance level of 5% (p<0.05).

RESULTS

Twenty-six patients (13%) had an NDDI-E score >15, suggestive of major depressive episode. Logistic regression showed that NDDI-E >15 was associated with seizure frequency (p=0.022) and worse performance in the category fluency test (p=0.003). An NDDI-E >15 was also correlated with lower quality of life (p<0.001).

CONCLUSION

The present findings suggest that possible major depressive episode is associated not only with epilepsy characteristics but also with cognitive aspects, such as category fluency, and quality of life.

Diagnosing and treating depression in epilepsy

At least one third of patients with active epilepsy suffer from significant impairment of their emotional well-being. A targeted examination for possible depression (irrespective of any social, financial or personal burdens) can identify patients who may benefit from medical attention and therapeutic support. Reliable screening instruments such as the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) are suitable for the timely identification of patients needing help. Neurologists should be capable of managing mild to moderate comorbid depression but referral to mental health specialists is mandatory in severe and difficult-to-treat depression, or if the patient is acutely suicidal. In terms of the therapeutic approach, it is essential first to optimize seizure control and minimize unwanted antiepileptic drug-related side effects. Psychotherapy for depression in epilepsy (including online self-treatment programs) is underutilized although it has proven effective in ten well-controlled trials. In contrast, the effectiveness of antidepressant drugs for depression in epilepsy is unknown. However, if modern antidepressants are used (e.g. SSRI, SNRI, NaSSA), concerns about an aggravation of seizures and or problematic interactions with antiepileptic drugs seem unwarranted. Epilepsy-related stress ("burden of epilepsy") explains depression in many patients but acute and temporary seizure-related states of depression or suicidality have also been reported. Limbic encephalitits may cause isolated mood alteration without any recognizable psychoetiological background indicating a possible role of neuroinflammation. This review will argue that, overall, a bio-psycho-social model best captures the currently available evidence relating to the etiology and treatment of depression as a comorbidity of epilepsy.

What factors contribute to the risk of depression in epilepsy?--Tasmanian Epilepsy Register Mood Study (TERMS)

OBJECTIVE

To model the factors associated with depression in a community sample of people with epilepsy. The factors investigated were derived from proposed risk factors for depression from patients with epilepsy, other chronic illness, and the general population.

METHODS

Multivariate analysis using general linear regression models of factors associated with depression in the Tasmanian Epilepsy Register Mood Study (TERMS), a cross-sectional community sample of 440 patients with epilepsy.

RESULTS

A model with acceptable fit was created that explained 66% of the variance of depression. Associated factors included in this model were neuroticism, physical functioning, social support, past history of depression, and stressful life events.

SIGNIFICANCE

In this cross-sectional study designed specifically to investigate depression in epilepsy, we showed that general risk factors for depression in other illness and in the general population are also important in patients with epilepsy, with little support for disease-related risk factors.

Effect of Chaihu-Shugan-San on the mRNA expression of the 5-HT1A receptor and cellular proliferation in the hippocampus of epileptic rats with depression

Chaihu-Shugan-San (CHSGS) is a herbal preparation that has been shown to effectively relieve neurologic impairment and reduce depression. However, the efficacy of CHSGS in the treatment of patients with epilepsy with depression is unknown. Therefore, in the present study, adult rats were exposed to chronic mild stress following the establishment of chronic pilocarpine-induced epilepsy. Subsequently, a sucrose consumption test and open-field test (OFT) were performed to assess depression-like behavior. Rats were randomly divided into four groups: Control, model, fluoxetine (1.8 g/kg) and CHSGS (2.7 g/kg) groups. The control and model groups received normal saline. The mRNA expression levels of the 5-hydroxytryptamine 1A (5-HT1A) receptor and the number of 5-bromo-2′-deoxyuridine (BrdU)-labeled cells in the hippocampal dentate gyrus were detected using reverse transcription-quantitative polymerase chain reaction and immunohistochemical analysis, respectively. Treatment administration was conducted by once daily intragastric perfusion for 28 days. The mRNA expression levels of the 5-HT1A receptor, the number of BrdU-labeled cells in the hippocampal dentate gyrus, the consumption of sucrose, and frequency of vertical and horizontal movement scores in the OFT were enhanced in the fluoxetine and CHSGS groups compared with the model group (P<0.05). However, no statistically significant difference was detected between the fluoxetine and CHSGS groups. These data suggest that CHSGS is able to increase the expression of 5-HT1A receptor mRNA and cellular proliferation in the hippocampal dentate gyrus in epileptic rats with depression, and thus effectively improve certain symptoms of depression.