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ORIGINAL ARTICLE
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Prevalence and correlates of psychiatric comorbidity in patients with epilepsy: A cross-sectional hospital-based study


1 Department of Psychiatry, Dr. D Y Patil Medical College, Dr. D Y Patil Vidyapeeth, Pune, India
2 Department of Psychiatry, SNBT Institute of Medical Sciences and Research Centre, Nashik, Maharashtra, India

Date of Submission27-Nov-2020
Date of Decision30-Dec-2021
Date of Acceptance08-Jan-2022

Correspondence Address:
Suprakash Chaudhury,
Department of Psychiatry, Dr. D Y Patil Medical College, Dr. D Y Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_654_20

  Abstract 


Background: People with epilepsy are more likely than the general population to have comorbid psychiatric disorders. There are several studies addressing the issue using various tools, but very few studies have been done on Indian population. Country-specific studies are necessary for proper and more accurate evaluation of psychiatric disorder in patients with epilepsy. Aim: To study the prevalence and correlates of psychiatric comorbidity in patients with epilepsy. Materials and Methods: This study was carried out in the Neurology Outpatient Department of a tertiary care hospital and research centre attached to a medical college, from September 2018 to September 2020. By purposive sampling, 140 patients diagnosed with epilepsy by neurologist and attending neurology outpatient department were included in the study with their consent. Equal number of age- and sex-matched subjects without physical or psychiatric morbidity were selected as controls. Patients and participants were assessed on sociodemographic questionnaire, MINI international neuropsychiatric interview, quality of life in epilepsy, Depression Anxiety Stress scale, and Big five inventory. Results: Significantly more patients with epilepsy (n = 64;45.71%) as compared to the control group (n = 45;32.14%) were diagnosed with psychiatric disorders (Chi-square = 5.423; P = 0.019). Depression was seen in 33.57% of people suffering from epilepsy. Anxiety was seen in 25.714% of cases compared to 14.28% among controls.Stress is present in 9.28% of patients with epilepsy. The quality of life is poor in patients with epilepsy in comparison with participants from the control group. Epilepsy was associated with significantly lower scores on extraversionand significantly higher neuroticism scores. Conclusion: The prevalence of psychiatric disorder is significantly more in patients with epilepsy in comparison with the general population.Epilepsy had a negative impact on quality of life of the subjects.

Keywords: Epilepsy, psychiatric comorbidity, quality of life



How to cite this URL:
Gandhi S, Menon P, Jagtap BL, Chaudhury S, Saldanha D. Prevalence and correlates of psychiatric comorbidity in patients with epilepsy: A cross-sectional hospital-based study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=342495




  Introduction Top


Recurrent nonprovoked seizures are suffered by 50 million people in the world. The frequency of seizure is 20–70 cases/100,000/year, point prevalence is 5–10 cases/1000, and lifetime prevalence is 2%–5% in developed countries. In India, with a population of around 120 crores, there might be around 60 lakhs to 1 crore people suffering from epilepsy, which consists of around one-fifth of the world cases.[1] Patients with seizure disorders suffer morefrom comorbid psychiatric disorder in comparison with the general population. Recorded rates of comorbid psychiatric conditions in chronic epilepsy patients range between 19% and 62%. Psychiatric comorbidity in epilepsy patients createsan extra burdenon patients and their relatives.[2] The assessment of co-morbidities in people with epilepsy is one of the most significant issues which is not related to the pharmacological mechanism of seizures. The risk for cognitive, behavioral, and psychosocial disorders is increased in these patients.[3] The occurrence of psychiatric co-morbidities and poor control of seizures may directly affect the quality of life of patients with epilepsy. Suicide risk is also increased in patients with epilepsy. In comparison with the general population risk of suicide is more in epilepsy patients with psychiatric comorbidities; this risk is even higher in patients who have the presence of both depression and anxiety.[3]

Psychiatric disorders in patients with epilepsy are mainly because of neurobiological, psychosocial, and pharmacological factors. The main neurobiological factors are the type of seizure, the incidence of seizure, duration of seizure, age of onset and lateralization of seizure, hereditary factors, sex, and presence of structurallesion also contribute to the risk factor. Additional issueslike volume loss in the hippocampus, glucose hypometabolism in the temporal and frontal lobe, and neurotransmitter and hormonal changes are also responsible. Psychosocial factors are learned helplessness, restriction in normal day-to-day living activities, reduced confidence, scholastic and occupational problems, stigmatization, and social rejection. From the pharmacological aspects, side effects of antiepileptic medications which act as central nervous system depressor, removal of a mood stabilizer medicine, polypharmacy, starting afresh antiepileptic drug, and dosage regulation havebeen quoted.[3] There is a growing indication of the seizure disorder and psychological disorders that they cause changes in the communication between serotonergic and noradrenergic neurons. They cause changes in glutamatergic systemswhich areassociatedwith abnormalneuronal circuits and hyperexcitability. Seizure activity and emotional dysfunctions could beevoked by hyperexcitability.[4]

Psychiatric disorders are reported to affect between 32% and 41% of seizure disorder patients.[5],[6],[7] Common psychiatric conditions found in patients with a seizure disorder aredepression, anxiety, and psychoses. Comorbid psychiatric disorders worsenthe prognosis of epilepsy patients compared to epilepsy patients without psychiatric comorbidities.[7],[8] Distinct consideration must be kept on depression because it is associated with increased chances of suicide in patientswith seizure disorder.[9] Numerous patients diagnosed with epilepsy admit that seizure occurs due to stress or are worsened by stress, but the association between stress andepilepsy is hard to assess. Objectivemeasures of stress and other aspects such as tiredness andsleep deficiency must be measured.[10] Due to the paucity of Indian studies in this area, the present study was planned to assess the prevalence and correlates of psychiatric comorbidity in patients with epilepsy.


  Materials and Methods Top


The cross-sectional analytical studywas conducted in a tertiary care centerin a semi-urban area in the state of Maharashtra. Institutional Ethics Committee, clearance was obtained before the start of the study (vide DPU/R&R(M)/19(13) 2019 dt 08/01/2019). The study was conducted from September 2018 to September 2020.

Sample size calculation



N = Required sample size

m = Margin of error at 5%

t = Confidence level at 95%

p = 20%

Sample size

One hundred and forty.

Sample

By purposive samplingpatients attending neurology out-patient departmentwho had been diagnosed with epilepsy, between the age of 18 and 64 years were taken as cases and age-sex matched individual as control group.

Inclusion criteria

  • Patients diagnosed with epilepsy by neurophysician, between the age of 18 and 64 yearswere taken as cases
  • Age- and sex-matched individual with no chronic medical or psychiatric disorder as the control group
  • Subjects willing to give written informed consent.


Exclusion criteria

  • Known history of head injury, mental retardation
  • Patients who are unable to give informed consent due to acute psychotic, behavioral or cognitive impairment.


Tools

Sociodemographic proforma

A specially designed proformawas used to document demographic and clinical details.

Mini international neuropsychiatric interview

Mini international neuropsychiatric interview (MINI) is designed as a brief structured interview for the major psychiatric disorders in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and ICD-10. Validation and reliabilitystudies have been done comparing the MINI to the SCID-P for DSM-III-R and the CIDI. The MINI has comparable reliability and validity but may be administered in a much shorter time than the above instruments. Cronbach's alphas of Depression-0.88, Anxiety-0.79, Expansive mood-0.77, Obsessive–compulsive disorder (OCD)-0.55, Psychosis-0.77, Unspecified disorder-0.55, autism-0.95.[11]

Depression anxiety stress scale

The Depression Anxiety Stress Scale (DASS) is a 42-item self-report instrument designed to measure the states of depression, anxiety, and tension/stress. The patient is interviewed with a list of 42 questions on a 4-point rating scale.Internal consistency of the DASS subscales is high, with Cronbach's alphas of 0.94, 0.88, and 0.93 for depression, anxiety, and stress subscales, respectively.[12]

Big five inventory

This 44-item inventory measures an individual on the Big Five Factors (dimensions) of personality.Internal consistency was satisfactory for the neuroticism, extraversion, and openness to experience, agreeableness, and conscientiousness subscales, respectively (Cronbach's alpha = 0.83,0.82,0.79,0.82,0.90 respectively) for males and (Cronbach's alpha = 0.74,0.83,0.85,0.81,0.92 respectively) for females.[13]

Quality of life in epilepsy (QOLIE-31)

The quality of life in epilepsy (QOLIE-31) is a survey of health-related quality of life for adults (18 years or older) withepilepsy. There are 31 questions about your health and daily activities.Cronbach's alpha coefficient was 0.92.[14]

Methods

Patients diagnosed with epilepsy by a neurologist were taken in the study group. Equal number of age- and sex-matched controls with no known psychiatric and neurological disorder after clinical interview were included in the control group. Initially, the socio-demographic and clinical data sheet was filled up for all participants. Thereafter, the MINI, DASS -42, QOLIE-31, and the Big Five Inventorywereapplied. The scales were scored as per their manuals.

Statistical analysis

The data wereanalyzed by SPSS (IBM, Chicago, USA) Software. Statistical analysis was carried out with the help of both descriptive and inferential statistics.

Descriptive statistics

Data summarization was carried out with the help of percentages and summary statistics was with mean, range, and standard deviation.

Inferential statistics

Frequency data compared using Chi-square test and Fisher'sexact test. Ordinal data with Mann–Whitney u test. A P < 0.05 was considered to be statistically significant.


  Results Top


A total of 156 patients diagnosed with epilepsy were selected for study out which 16 patients refused to give consent. A total of 160 age- and sex-matched participants were selected as the control group out of which 20 refused to give consent. The epilepsy patients and control group were well matched on age and sex [Table 1]. On the MINI significantly more patients with epilepsy (n = 64;45.71%) as compared to the control group (n = 45;32.14%) were diagnosed with psychiatric disorders (Chi-square = 5.423; P = 0.019).Major depressive disorder was the most prevalent psychiatric co-morbidity in the epilepsy patients followed by generalized anxiety disorder, social anxiety and alcohol dependence[Table 2]. Distribution of epilepsy patients and control subjects on DASS-42 is shownin [Table 3]. Scores of epilepsy patients and control group on the DASS42, Big five inventory, and QOLIE aregiven in [Table 4]. Demographic and clinical correlates of epilepsy patients with and without psychiatric comorbidity are shown in [Table 5]. Comparison of scores on QOLIE-31, DASS-42scale, and BIG FIVE inventory in epilepsy patients with and without psychiatric co-morbidity is given in [Table 6].
Table 1: Demographic characteristics of epilepsy patients and matched control subjects

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Table 2: Results of psychiatric evaluation using mini international neuropsychiatric interview

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Table 3: Distribution of epilepsy patients and control subjects on Depression Anxiety Stress Scale-42 depression subscale

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Table 4: Scores on Depression Anxiety Stress Scale-42 in epilepsy patients and control group

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Table 5: Demographic and clinical correlates of epilepsy patients with and without psychiatric comorbidity

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Table 6: Comparison of scores on quality of life in epilepsy-31, Depression Anxiety Stress Scale-42scale and big five inventory in epilepsy patients with and without psychiatric comorbidity

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  Discussion Top


In our study, the mean age for patients with epilepsy was 32.86 and 44.3% of patients were in the age group of 21–30 years. An earlier study on patients with epilepsy also reported that 38.3% were in the age group of 20–30 years.[15] The finding of greater number of male subjects (55%) in our study sample may be due to males receiving more, better and professional health care than females as observed in a previous Indian study.[16] The finding of significantly lower percentage of married persons in the epilepsy group may possibly be due to the fact that many think that it is better to keep a distance from a person with a seizure disorder due to chronic nature of the illness and also socioeconomic reasons.[17] This social problem with epilepsy patients may possibly be ascribed to the social stigma associated with a seizure disorder.The subsequent coping behavior by the affected person results in internalized stigma. This perceived stigma by the patient is harsh. This destructiveness is equal to actual discrimination. This social stigma destroys a person's dignity, and it marginalizes affected individuals. Epileptic patients commonly do not tell their partners regarding their disorder before marriage because of their distress regarding their negative consequences and impacts on married life.[17]

In the current study, the majority of epilepsy patients had studied up to the secondary level. This finding can be explained by the fact that patients with epilepsy have additional problems with their cognitive functions and behavioral disturbances than people who are not suffering from a seizure disorder. Patients with epilepsy have low self-esteem, educational, and learning difficulties due to cognitive impairments. Epilepsy is found to be negatively affect attendance in school and academic performance in some studies but not in others. In seizure disorder academic under-achievement occurs mainly because of comparatively reduced intelligence, psychosocialproblems, poor school attendance due to recurrent illness, the effect of anti-epileptic medication, and the effect of seizure variables like seizure type, age of onset, electroencephalogram results, and seizure control. Though, there is a disagreement about the comparativesignificance of the different factors.[18],[19],[20]The frequency of memory problems inpatients with refractory epilepsy is higher. The prevalence has been estimatedas high as 20%to 50%, and more than 50% of the patients sent for neuropsychological assessment described memory problems in their day-to-day life.[21]

A significantly lesser number of person in the case group were employed as compared to the control group. The occurrence of seizure is extremely noticeable and may occur at their place of work, leading to greater barriers and lower social acceptability.[22] As a result, patients with epilepsy have higher rates of joblessness and under-employment,[23] despite the fact that70% of patients with epilepsy control their seizures with suitable antiepileptic medication.[24]

A significantly higher prevalence of psychiatric disorderswas observed in patients with epilepsy (43.57%) compared to the control group (32.14%). Our findings match with someprevious studies.[25],[26],[27] Our findings are slightly higher than the 35.8% reported in a study from Ethiopia[28] and 32.50% psychiatric disorder in epilepsy patients from Bangalore,[29] but lower than the findings of 54% in Brazil,[30] 78% in the USA.[31] A review of psychiatric disorders in epilepsy reported prevalence rates between 19% and71%.[32] The variability of the results obtained has been ascribed to differences in the methodology applied.[29]

In the present study among individual psychiatric disorders, the highest prevalence was for depression followed by anxiety disorders, OCD, and alcohol use disorders. Few earlier studies found that depression and anxiety were among the major psychiatric disturbances in people suffering fromepilepsy.[33],[34],[35]

Among anxiety disorders, we found social anxiety most prevalent followed by panic disorder and agoraphobia as a person with epilepsy has more anxiety in public spaces. Social anxiety would be deleteriously affected the outcome of epilepsy. It is preventing a person from disclosing about their illness in public. Most of the patients report more anxiety, ruminating thoughts about having a seizure in a situation where others were unaware of their illness compared with situations where others were aware about their illness.

Patients who have social anxiety are more worried about the probability of humiliating or embarrassing themselves in social circumstances and, consequently, being negatively evaluated by others. To prevent themselves from being negatively evaluated by other people, patients with social anxiety carefully screen what they are doing, and what kind of safety precautions they should take to prevent or to alleviate their anxiety.[36] In the case of patients with epilepsy, a precautionary measurement is nondisclosure about their diagnosis in public and to avoid such a situation which are embarrassingas proven by not recognizing worries associated with seizures or not to think about their condition.[36]

In contrast to our findings, screening of 118 consecutive People with epilepsy (PWE) aged 18–65 years from a tertiary epilepsy centerin Poland using Structured Clinical Interview for DSM-IV-TR Axis I Disorders found 16.7% prevalence of Anxiety disorders.[37] A German study evaluated 97 consecutive outpatients who had refractory focal epilepsy using the German version of the anxiety section of the structured clinical Interview for DSMIV Axis I disorders and found 19 patients were suffering from an anxiety disorder.[38] The difference in results may have been because of the different scale used in this study, and exclusion of borderline and antisocial personality disorder in one study[37] and inclusion of only person with refractory focal epilepsy in the other study.[38]

Alcohol consumption was found in only 2.14% while 12.85% consumed tobacco among the epilepsy group compared to 7.14% and 19.28% respectively in the control group. The difference is not statistically significant. Less number of substance usage found in case group compared to the control group was probably due to the clinician's recommendation to avoid alcohol. It may also be due to the patients' denial or under-reporting their alcohol intake. Our findings match with an earlier study.[39] Antiepileptic medications used in the management of epilepsy could also reduce cravings for alcohol.[40]

On the DASS 42, depression was seen in 33.57% of epilepsy patients. A meta-analysis of four studies reported the prevalence of depression in patients with epilepsy ranging from 4% to 32%.[41] The difference in our results is mainly because the scales used by the scales used in the studieswere CES-D and K-6 scales. These scales measure suffering more largely, with sub-elements associated with depression were marginally greater than those using validated depression-only scales.A Nigerian study of 152 patients with epilepsy found that the incidence of depressive symptoms were 42% and 45% using the Hamilton rating scale for depression (HRSD) and Beck depression inventory (BDI).[42] The difference with our results was due to differences in the scales, the inclusion of person with epilepsy who were on treatment for 6 months only, and the study was carried out on the Nigerian population. An Ethiopianstudy of 422 patients with epilepsy and reported 43% prevalence of depression. The difference in results may be explained by the use of a different scale (patient health questionnaire 9) for the assessment of depression and differences in the population under study.[43] Using DASS Anxiety was seen in 25.714% of cases compared to 14.28% among controls. Anxiety was significantly more prevalent in epilepsy patients than in the control group. A study carried out in an outpatient clinic for epilepsy patients in Pakistan on 146 patients using a GAD-7 questionnaire reported that 49% were screened as having GAD.[44] The difference could be due to the fact that in this study 98% of the patients had focal onset seizure, while in our study most patients have generalized onset of seizure. In the present study, stress among patients with epilepsy was significantly more than stress in the control group. The findings of our study are in agreement with earlier studies.[10],[45],[46]

There are very few studies using Big five inventory in epilepsy patients. Extraversion is characterized by sociability, talkativeness, assertiveness, and excitability. The mean score for extraversion in subjects with epilepsy was significantly less compared to the control group.This may explain the tendency of epilepsy patients to isolate themselves, which is compounded by the unpredictability of seizures and social stigma.However, this finding is not in agreement with earlier studies.[47],[48] Neuroticism is related to anxiety, worry, fear, anger, and frustration. The mean value for the case group is significantly more than the control group which means anxiety, worries, and anger increases in person with epilepsy. May be due to the fact that life with chronic uncertain illness, the occurrence of which is not under voluntary control creates anxiety.Our findings match with previous studies.[47],[48],[49]

Openness is not significantly different as compared to normal controls in the current study. This finding is in agreement with one study[47] but another study reported low openness scores in epilepsy patients.[48] Epilepsy had no impact on agreeableness and conscientiousness which is in agreement with previous studies.[47],[48]

The finding of significantly lower quality of life is poor in patients with epilepsy in comparison with participants from the control group is in agreement with the findings of previous studies.[50],[51]

Comparison of epilepsy patients with and without psychiatric comorbidity

In the current study, there was no significant differences between epilepsy patients with and without psychiatric comorbidity with regard to age, sex, education, marital status, and occupation.Comparing patients on a single drug and those who are on more than one drug, we found that significantly more patients on multiple drugs are in epilepsy patients with psychiatric comorbidity, which is in agreement with an earlier study.[52] In consonance with earlier studies, significantly more patients with focal seizure were found in epilepsy patients with psychiatric comorbidity.[53],[54],[55] We concluded that patient with focal seizure has more chances of developing of psychiatric comorbidity than other types of seizures.

On comparing the domains of qolie-31 of epilepsy, patients with psychiatric comorbidity and without psychiatric comorbidity, poor quality of life was found in patients having psychiatric comorbidity. This is in agreement with an earlier study.[56] Depression, anxiety, and stress were significantly higher in epilepsy patients with psychiatric comorbidity.On the Big Five Inventory, result is significant for extraversion and neuroticism. From this, we conclude that epilepsy patients with psychiatric comorbidity try to isolate themselves, less outgoing compare to patients without psychiatric comorbidity. A high score of neuroticism is related to show that epilepsy patients with psychiatric comorbidity have moreanxiety, worry, fear, anger, and frustrationcompared to epilepsy patients without psychiatric comorbidity.

Limitations

Since it is a hospital-based study, it may not be generalized to the community. Being a cross-sectional analysis, the cause and effect relation between associated factors could not be established. An observational longitudinal study could have given more information.


  Conclusion Top


Epilepsy patients have a higher prevalence of comorbid psychiatric disorder and lower quality of life comparedwith the general population. The most commonpsychiatric comorbid disorder in epilepsy patientswere major depressive disorder, generalized anxiety disorder, social anxiety, and panic disorder. It is important to identify the comorbid psychiatric disorders in patients with epilepsy as the treatment of comorbid psychiatric disorders is likely to improve the quality of life. Epilepsy patients with psychiatric comorbidity have higherlevels of depression, anxiety, stress, and neuroticism and lowerquality of life and extraversion in comparison to epilepsy patients without psychiatric comorbidity.

Financialsupportandsponsorship

Nil.

Conflictsofinterest

There are no conflicts of interest.



 
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