The effect of seizure severity on quality of life in epilepsy

Understanding the Patient Perspective of Seizure Severity in Epilepsy: Development of a Conceptual Model

PURPOSE

For patients with uncontrolled epilepsy, the severity and postictal sequelae of seizures might be more impactful than their frequency. Seizure severity is often assessed using patient-reported outcome (PRO) instruments; however, evidence of content validity for existing instruments is lacking. Our aim was to understand the real-life experiences of patients with uncontrolled epilepsy.

METHODS

A preliminary conceptual model was developed. The model was refined through (1) a targeted literature review of qualitative research on seizure severity; (2) interviews with four clinical epilepsy experts to evaluate identified concepts; and (3) qualitative interviews with patients with uncontrolled epilepsy, gathering descriptions of symptoms and impacts of epilepsy, focusing on how patients experience and describe "seizure severity." Findings were summarized in a final conceptual model of seizure severity in epilepsy.

RESULTS

Twenty-five patients (12 who experienced primary generalized tonic-clonic seizures and 13 who experienced partial-onset seizures) expressed 42 different symptoms and 26 different impacts related to seizures. The final conceptual model contained a wide range of concepts related to seizure frequency, symptoms, and duration.

CONCLUSION

Our model identified several new concepts that characterize the patient experience of seizure severity. A seizure severity PRO instrument should cover a wide range of seizure symptoms alongside frequency and duration of seizures. This qualitative work reinforces the notion that measuring seizure frequency is insufficient and that seizure severity is important in defining the patient's experience of epilepsy. This model could be used to assess the content validity of existing PRO instruments, or could support the development of a new one.

Dose effects of lacosamide as add-on therapy for partial-onset seizure in adult

The objective of the study was to evaluate the dose effects of lacosamide on the efficacy and safety as adjunctive therapy for partial-onset seizure in adults. We searched online databases such as Pubmed, Embase, Cochrane Online Library, and Clinicaltrial.gov for randomized control trials. A meta-analysis was performed on RevMan 5.3 software. Four randomized control trials with 1855 patients out of 310 citations and 30 registered trials were identified. 400 mg/d was more effective than 200 mg/d [RR 1.23 (95 % CI 1.05-1.45), P = 0.01], but the 600 mg/d didn't show more benefit than 400 mg/d [RR 1.01 (95 % CI 0.81-1.27), P = 0.90]. Increasing the dosage led to higher incidence of quitting the medication because of adverse events [400 vs. 200 mg/d RR 2.17 (95 % CI 1.15-4.11), P = 0.02; 600 vs. 400 mg/d RR 1.55 (95 % CI 1.12-2.15), P = 0.009]. Incidence of serious adverse events did not occur with the increase of dose [400 vs. 200 mg/d RR 1.26 (95 % CI 0.50-3.20), P = 0.62], [600 vs. 400 mg/d RR 0.52 (95 % CI 0.21-1.30), P = 0.16]. A dose of 400 mg/d resulted in a higher chance of dizziness [RR 1.50 (95 % CI 1.02-2.20), P = 0.04], vomiting [RR 1.73 (95 % CI 1.03-2.90), P = 0.04], and diplopia [RR 1.98 (95 % CI 1.19-3.30), P = 0.008] than that of 200 mg/d. 400 mg/d is the optimal dose for efficacy. The dose of 200 mg/d has the best safety for less occurrence of adverse events and less quitting. Current evidence suggests that a dose of 600 mg/d is unnecessary, except for particular reasons.

Risk Factors on Health-Related Quality of Life in Children With Epilepsy

The goal of this study was to evaluate how epilepsy affected the health-related quality of life (HRQOL) in children with epilepsy, as well as the risk factors for poor HRQOL. Parents of epileptic children (n = 223) and parents of healthy children (n = 216) were enrolled. The Child Epilepsy Questionnaire-Parental form was given to all parents. Children with epilepsy had significantly lower HRQOL scores for overall QOL and all subscales. Seizure types were not associated with HRQOL, but the age of the child with epilepsy, disease courses and seizure frequency did influence the quality of life. Epilepsy has a severe impact on children's HRQOL, and age, increased seizure frequency and longer duration of epilepsy are associated with poor HRQOL.

Do drivers with epilepsy have higher rates of motor vehicle accidents than those without epilepsy?

OBJECTIVE

We sought to understand the magnitude of the risk that drivers with epilepsy (DWE) contribute to motor vehicle accidents (MVAs) compared to other drivers.

METHODS

We performed an evidence-based, systematic review using the American Academy of Neurology (AAN) guideline methodology.

RESULTS

Contributory evidence consisted of six Class II studies and one Class III study. Two articles reported a trend toward a decreased rate of overall MVA rates for DWE when compared with the general population with a relative risk (RR) of 0.86 (95% CI: 0.65-1.14) (Class III) and a RR of 1.00 (95% CI: 0.95-1.06) (Class II); both studies used patient report to ascertain MVA rates. Three Class II studies reported either a trend toward or an increased risk of MVA rates for DWE when compared with the general population with a RR of 1.62 (95% confidence interval (CI): 0.95-2.76), as ascertained by insurance, emergency department, and physician reporting databases, a RR of 1.73 (95% CI 1.58-1.90), as ascertained by police reports, and a RR of 7.01 (95% CI 2.18-26.13), as ascertained by casualty department visits. One Class II study showed that, compared to fatal crashes with DWE, fatal crashes were 26 times more likely to occur because of other medical conditions and 156 times more likely to occur because of alcohol abuse. Motor vehicle accident crashes due to seizures in DWE occurred in one out of every 2800 MVAs, as reported in another Class II study.

CONCLUSIONS

The evidence for the difference in MVA rates in DWE compared to the general population is inconsistent, and no conclusion can be made. Important methodological differences across the studies contribute to the imprecision. Future research should be performed using objective measures rather than self-reporting of MVAs by DWE and "miles driven" as the denominator to calculate MVA rates.

Factors associated with hopelessness in epileptic patients

AIM: To investigate factors related to hopelessness in a sample of epileptic patients, including measures of depression and quality of life (QOL).

METHODS: Sixty-nine participants were administered the following psychometric instruments: Beck Depression Inventory-II, Beck Hopelessness Scale (BHS), and QOL in Epilepsy (QOLIE)-89. Patients were dichotomized into two categories: those affected by epilepsy with generalized tonic-clonic seizures vs those having epilepsy with partial seizures.

RESULTS: The groups differed on the QOLIE Role Limitation/Emotional dimension. Patients with generalized seizures reported more limitations in common social/role activities related to emotional problems than patients with other types of epilepsy (89.57 ± 25.49 vs 72.86 ± 36.38; t₆₃ = -2.16; P < 0.05). All of the respondents reported moderate to severe depression, and 21.7% of patients with generalized seizures and 28.6% of patients with other diagnoses had BHS total scores ≥ 9 indicating a higher suicidal risk. The study did not control for years of the illness.

CONCLUSION: Patients with generalized seizures reported more limitations in common social/role activities related to emotional problems compared to patients with other types of seizures. Patients at increased suicide risk as evaluated by the BHS were older than those who had a lower suicidal risk. Future studies are required to further investigate the impact of hopelessness on the outcome of epileptic patients.

Neurologists' knowledge of and attitudes toward epilepsy surgery: a national survey

OBJECTIVES

In the current study, we aim to assess potential neurologist-related barriers to epilepsy surgery among Canadian neurologists.

METHODS

A 29-item, pilot-tested questionnaire was mailed to all neurologists registered to practice in Canada. Survey items included the following: (1) type of medical practice, (2) perceptions of surgical risks and benefits, (3) knowledge of existing practice guidelines, and (4) barriers to surgery for patients with epilepsy. Neurologists who did not complete the questionnaire after the initial mailing were contacted a second time by e-mail, fax, or telephone. After this reminder, the survey was mailed a second time to any remaining nonresponders.

RESULTS

In total, 425 of 796 neurologists returned the questionnaire (response rate 53.5%). Respondents included 327 neurologists who followed patients with epilepsy in their practice. More than half (56.6%) of neurologists required patients to be drug-resistant and to have at least one seizure per year before considering surgery, and nearly half (48.6%) failed to correctly define drug-resistant epilepsy. More than 75% of neurologists identified inadequate health care resources as the greatest barrier to surgery for patients with epilepsy.

CONCLUSIONS

A substantial proportion of Canadian neurologists are unaware of recommended standards of practice for epilepsy surgery. Access also appears to be a significant barrier to epilepsy surgery and surgical evaluation. As a result, we are concerned that patients with epilepsy are receiving inadequate care. A greater emphasis must be placed on knowledge dissemination and ensuring that the infrastructure and personnel are in place to allow patients to have timely access to this evidence-based treatment.

Ketogenic dietary therapies for adults with epilepsy: feasibility and classification of response

Ketogenic dietary therapies are an effective treatment for children with drug-resistant epilepsy. There is currently no high-quality evidence regarding ketogenic dietary therapies in adults, and further research has been recommended. This audit aimed to provide further evidence for the feasibility of dietary treatment for adults and to consider factors that may aid response classification in this population. We evaluated the effectiveness and tolerability of ketogenic dietary therapies in 23 adults with epilepsy attending specialist clinics. Medical notes were used to obtain seizure frequency information and other effects associated with dietary treatment. Individuals who achieved ≥50% seizure reduction at all follow-up points were classified as responders. Response rates, in terms of seizure frequency, were similar to those commonly reported in pediatric cohorts: 9/23 (39%) adults were classified as responders. These responders remained on the diet for at least one year (follow-up: 1-10 years). Other benefits reported by patients, but not quantified, included a reduction in seizure severity and increased alertness and concentration. Such factors often favor continuation of ketogenic dietary therapies despite a <50% seizure reduction. One individual experienced psychosis while following dietary treatment; most commonly reported adverse events were gastrointestinal. Adverse events did not lead to discontinuation of treatment in any cases. Our findings suggest that adults with epilepsy are able to follow ketogenic dietary therapies long-term, and such treatment can lead to seizure reduction. Other aspects besides seizure frequency may be relevant when classifying response in adults, and appropriate ways to quantify these factors should be considered for use in future studies.

Safety and feasibility of nucleus accumbens stimulation in five patients with epilepsy

In five adult patients with intractable partial epilepsy, safety and feasibility of chronic bilateral electrical stimulation of the nucleus accumbens (NAC) were assessed, also providing initial indications of therapeutic efficacy. Concurrent medication remained unchanged. In this phase 1 trial, clinical outcome parameters of interest were Quality of Life in Epilepsy questionnaire (QOLIE-31-P), Beck Depression Inventory, Mini International Neuropsychiatric Interview, neuropsychological testing, and Liverpool Seizure Severity Scale. Those data were obtained after 6 months of NAC stimulation and compared to the equivalent assessments made directly before implantation of electrodes. Additionally, monthly frequencies of simple partial seizures, complex partial seizures (CPS), and generalised tonic–clonic seizures (GTCS) were assessed during 3 months before electrode implantation and at the end of 6-month NAC stimulation. Proportion of responders, i.e. ≥50 % reduction in frequency of disabling seizures (sum of CPS and GTCS), was calculated. Main findings were unchanged psychiatric and neuropsychological assessment and a significant decrease in seizure severity (p = 0.043). QOLIE-31-P total score trended towards improvement (p = 0.068). Two out of five participants were responders. The median reduction in frequency of disabling seizures was 37.5 %. In summary, we provide initial evidence for safety and feasibility of chronic electrical stimulation of the NAC in patients with intractable partial epilepsy, as indicated by largely unchanged neurocognitive function and psychiatric comorbidity. Even though our data are underpowered to reliably assess efficacy, the significant decrease in seizure severity provides an initial indication of antiictal efficacy of NAC stimulation. This calls for larger and at best randomised trials to further elucidate efficacy of NAC stimulation in patients with pharmacologically intractable epilepsy.

Seizure frequency and severity: How really important are they for the quality of life of patients with refractory epilepsy

Introduction:

The data in the scientific literature about the significance of seizure severity and frequency for the quality of life (QOL) of patients with refractory epilepsy (RE) are contradictory.

Objective:

Our objective was to assess the impact of the seizure severity and frequency on the QOL of Bulgarian patients with RE.

Materials and Methods:

A total of 70 patients with RE were studied by examining the medical documentation and seizure diaries. All study participants completed quality of life epilepsy inventory (QOLIE-89). Seizure severity of only 59 patients who had a seizure in the last month was assessed by the Liverpool seizure severity scale.

Results:

A limited negative impact of the seizure severity and frequency on some aspects of the physical health, epilepsy, all aspects of the social health and epilepsy and the overall QOL has been demonstrated. A weak to moderate reverse correlation between the specified factors and the respective QOLIE-89 subscales has been found.

Conclusion:

The clinical factors seizure severity and seizure frequency have a limited negative impact mostly on the social aspects of QOL. The study results support the multidisciplinary approach to persons with epilepsy.

Study of Inter-relationship of Depression, Seizure Frequency and Quality of Life of People with Epilepsy in India

Epilepsy is a chronic neurological disorder that can have profound physical, social and psychological consequences. We aimed to assess the clinical predictors of quality of life of people with epilepsy. We recruited 31 patients suffering from epilepsy in this cross-sectional study. Their clinical profile was recorded. Quality Of Life in Epilepsy (QOLIE-31) was used to assess quality of life of our patients. Depression was screened by Neurological Disorders Depression Inventory in Epilepsy (NDDI-E). Among all the clinical variables, only seizure frequency significantly correlated with seizure worry (P=0.002), emotional well-being (P=0.026) and social functions (P=0.013) subscales of QOLIE-31. NDDIE score showed a significant negative correlation with all the subscales of QOLIE-31 except medication effects (P=0.993). A significant positive correlation was also noted between seizure frequency and NDDI-E score (r=0.417, P=0.020). Seizure frequency and depression are the most important predictors of quality of life in epilepsy patients. The management of patients with epilepsy should not only be aimed at just preventing seizures but the treating clinicians should also be cognizant about depression which itself can significantly affect the quality of life of patients.

Effects of seizure severity and seizure freedom on the health-related quality of life of an African population of people with epilepsy

PURPOSE

This study aimed at determining the effects of seizure severity and seizure freedom on health-related quality of life (HRQOL) of people with epilepsy (PWE) in the presence of perceived stigma in a sub-Saharan African culture.

METHODS

Health-related quality of life was assessed using QOLIE-31 in 93 consecutive adults (56 males and 37 females) with epilepsy. They were stratified into seizure-free, low-moderate seizure severity, and high seizure severity groups based on the seizure type and the number of seizures in the previous 6months. Other illness variables and sociodemographic variables were also obtained. A 3-item perceived stigma scale was administered. A modified QOLIE-31 (excluding the epilepsy-specific items) was given to 102 age- and sex-matched healthy controls.

RESULTS

There was moderate negative correlation between seizure severity and mean total HRQOL score as well as scores on the Seizure Worry (p=.000), Overall Quality of Life (p=.000), and Social Function (p=.001) subscales of QOLIE-31. Overall, the healthy control subjects had a higher mean HRQOL score compared with the PWE put together (71.0+11.1 vs 64.2±13.6, p=.001). However, there was no difference in the mean HRQOL score between the seizure-free individuals and the healthy controls (p=.270). Seizure severity was associated with HRQOL independent of perceived stigma on a multiple regression analysis.

CONCLUSION

This study provides evidence that seizure severity relates to health-related quality of life in an inverse, graded manner and independent of perceived stigma. Seizure-free people with epilepsy can have quality of life comparable with healthy individuals.

Seizure severity and health-related quality of life of adult Nigerian patients with epilepsy

OBJECTIVES

There is paucity of information about the association of seizure severity and quality of life in people with epilepsy (PWE) in sub-Saharan Africa. We evaluated the relationship of seizure severity to health-related quality of life of patients with epilepsy being followed up in an outpatient neurology clinic in southwestern Nigeria.

MATERIALS AND METHODS

Eighty-eight consecutive patients with epilepsy who met the recruitment criteria completed the study questionnaire in company of an eyewitness. The study questionnaire comprised of the National Hospital Seizure Severity Scale (NHS3), the Quality of Life Inventory in Epilepsy (QOLIE-31), and the Beck's Depression Inventory-II (BDI-II).

RESULTS

We found a minute association between seizure severity and QOLIE-31 total score (r = -0.262, P = 0.014). Increased seizure severity predicted a worse QOLIE-31 seizure worry (R(2) = 0.311, β = -0.289; P = 0.003). Of the seven seizure severity items, generalization of seizures and presence of falls were items that predicted a worse QOLIE-31 seizure worry score and time to recover predicted a worse QOLIE-31 total score.

CONCLUSIONS

Reducing seizure severity may be an alternate endpoint in epilepsy care in Nigeria (particularly difficult to control seizures) because of its practical clinical relevance in view of the fact that state-of-the-art epilepsy care is still farfetched.

Psychometric properties of Chinese language Liverpool Seizure Severity Scale 2.0 (LSSS 2.0) and status and determinants of seizure severity for patients with epilepsy in China

OBJECTIVES

This study aimed to translate and validate the Liverpool Seizure Severity Scale (LSSS) in Chinese-speaking patients with epilepsy and explore the determinants of seizure severity in China.

METHODS

Accepted procedures were followed to translate the LSSS. Each participant was interviewed to complete the LSSS, Seizure Severity Index, Quality of Well-being Scale Self-Administered (QWB-SA), EuroQol (EQ-5D), and Mini Mental State Examination (MMSE). Construct validity and internal consistency were assessed. The determinants of seizure severity were explored.

RESULTS

The construct validity of the LSSS was demonstrated by good convergent and discriminant validities. Cronbach's alpha and the intraclass correlation coefficient were 0.886, respectively. In the multivariate analysis, seizure types (p=0.001), seizure frequency (p=0.001), and numbers of antiepileptic drugs (p=0.042) predicted the scores on the LSSS. Types of antiepileptic drugs also contributed to the variation in the LSSS scores.

CONCLUSIONS

Chinese LSSS is a valid, reliable, and sensitive seizure severity scale. Seizure frequency, seizure types, and quantities and types of AEDs predict seizure severity.

Sensitivity testing of the Seizure Severity Questionnaire (SSQ)

The sensitivity of the Seizure Severity Questionnaire (SSQ) was evaluated using pooled data from open-label extensions of two clinical trials in patients with partial-onset seizures. The SSQ includes questions relating to frequency and helpfulness of warning signs as well as frequency, severity, and bothersomeness of ictal and postictal effects. Differences between mean change from baseline for each SSQ item for responders and nonresponders were described and compared between patients solely with complex partial seizures (CPSs: responders, n=166; nonresponders, n=127) and those solely with secondarily generalized partial seizures (SGPSs: responders, n=26; nonresponders, n=24) at baseline. Seizure Severity Questionnaire total score and individual SSQ items related to ictal movement, consciousness, bothersomeness of postictal effects, and frequency of postictal emotional effects showed differentiation between seizure type responders. These data provide further validation of the SSQ by demonstrating its sensitivity in describing treatment effects.

Long-term impact of cognitive deficits and epilepsy on quality of life in patients with low-grade meningiomas

BACKGROUND

WHO Grade I meningiomas are common, usually benign, primary brain tumors. Little is known about the health-related quality of life (HRQOL) of patients with meningiomas.

OBJECTIVE

To investigate the long-term HRQOL in patients with meningiomas and its association with cognitive deficits and epilepsy.

METHODS

HRQOL was assessed by the Short-Form Health Survey questionnaire (SF-36) in 89 patients with WHO Grade I meningiomas at least 1 year following neurosurgery with or without radiotherapy. Cognitive functioning was measured by a neuropsychological test battery, and epileptic seizure frequency and antiepileptic drug (AED) use were determined for each patient. HRQOL of patients was compared to that of 89 healthy controls individually matched for age, sex, and educational level.

RESULTS

As a group, patients with meningiomas did not differ from healthy controls on 7 out of 8 SF-36 scales; the only difference was that patients reported more role limitations caused by physical problems (P < .05). Patients with meningiomas had significant impairment in 4 of 6 cognitive domains, most pronounced in the domain of executive functioning. Both impaired cognitive functioning and AED use were associated with a compromised HRQOL. Of the 23 patients using AEDs, HRQOL was significantly impaired on 5 out of 8 SF-36 scales. In patients using AED, neither cognitive functioning nor HRQOL differed between those with and those without seizure control.

CONCLUSION

The HRQOL of most patients with WHO Grade I meningiomas is comparable to that of the general population. However, HRQOL is worse in patients with major cognitive deficits and those using AEDs, irrespective of seizure control.

Health-related quality of life among people with epilepsy with mild seizure-related head injuries

Seizure-related head injury (SRHI) is an under-recognized condition frequently experienced by people with epilepsy (PWE). The purpose of this study is to investigate the potential impact of SRHI on health-related quality of life (HRQOL) among PWE receiving care in a tertiary epilepsy center. Consecutive adult PWE receiving care at the Baylor Comprehensive Epilepsy Center (BCEC) were recruited for the study. After their informed consent was obtained, patients were administered the QOLIE-31 to measure HRQOL and the NDDI-E to screen for depression. Simple linear regression was used to identify clinical variables associated with HRQOL and that included SRHI obtained systematically at each clinic visit. Data were also compared between the SRHI and non-SRHI groups. Participants included 172 subjects. Recurrent mild SRHI occurred in 50 (29%) subjects. Factors with a negative effect on HRQOL included depression (slope=-19.99 [95% CI -25.16, -14.81]; p<.0001), recurrent SRHI (-17.02 [-22.35, -11.69]; p<.0001), past SRHI (-13.46 [-18.43, -8.48]; p<.0001), and seizure frequency (-0.17 [-0.26, -0.07]; p=0.001) on univariate analysis. With stepwise multiple regression, depression and recurrent SRHI significantly impacted HRQOL with slopes (95% CI; p-value) of (-17.53 [-22.34, -12.73]; p<.0001) and (-14.03 [-18.78, -9.28]; p<.0001), respectively. Patient-derived HRQOL is negatively associated with depression and recurrent SRHI, independently. There has been a justifiable increased awareness of the potential effects of head injuries among healthy individuals. Our data suggest that head injuries can certainly be detrimental among PWE, and greater efforts should be made to recognize and formulate prevention strategies for SRHI.

Epilepsy and quality of life: socio-demographic and clinical aspects, and psychiatric co-morbidity

Objective To study socio-demographic and clinical aspects, as well as psychiatric co-morbidity that influence the quality of life of adult epileptic patients. Methods One hundred and thirty-two individuals diagnosed with epilepsy were evaluated from neurological/clinical and psychiatric points of view and by the Quality of Life in Epilepsy Inventory (QOLIE-31). Predictive factors for the QOLIE-31 scores were studied. Results The regression analyses indicated the existence of psychiatric co-morbidity (total score, seizure worry, emotional well-being, energy/fatigue, social function and cognitive function) and a greater seizure frequency (total score, cognitive function and energy/fatigue) as predictive factors for lower scores in the total QOLIE-31 score and in various dimensions. Abnormalities in the neurological exam and poly-therapy with anti-epileptic drugs were negative factors limited to one of the dimensions cognitive function and social function, respectively. Conclusion The presence of psychiatric co-morbidity and a greater seizure frequency were the main factors influencing the quality of life in epileptic patients as evaluated by QOLIE-31.

Cognitive-behavioral therapy for depression in patients with temporal lobe epilepsy: a pilot study

Depression has a high prevalence among patients with temporal lobe epilepsy (TLE). A pilot study was carried out to evaluate group cognitive-behavioral therapy (CBT) as a treatment for depression in patients with TLE. Twenty-three outpatients with TLE and major depressive disorder, according to DSM-IV criteria, were enrolled and divided into two groups to receive 16 weekly sessions of CBT. The primary outcome measures were depression severity (assessed with the Beck Depression Inventory) and quality of life (measured with the Quality of Life in Epilepsy-31). Sixteen patients (70%) completed at least 80% of the sessions. From week 8, CBT had a significant positive effect on severity of depression that lasted until the end of treatment. A significant improvement in quality of life was also observed. CBT seems to be a useful intervention for treating depression and improving quality of life in patients with TLE.

Quality of life in 1931 adult patients with epilepsy: seizures do not tell the whole story

OBJECTIVE

The aim of the work described here was to characterize quality of life (QOL) and its determinants in a large cohort of adult patients with epilepsy.

METHODS

Validated measures reflecting disease severity and psychosocial functioning were electronically collected on all outpatients seen during 2009. Multivariate regression adjusting for repeated measures identified determinants of QOL, as defined by the Quality of Life in Epilepsy Questionnaire-10 (QOLIE-10).

RESULTS

Seven thousand seven hundred eighty-four visits from patients with epilepsy were identified. The questionnaire completion rate was 77%, yielding 5960 records corresponding to 1931 individual patients for analysis. Following multivariate modeling, the two most clinically significant QOL predictors were seizure severity (mean QOLIE-10 score=28.8 if LSSS>40 vs 19.2 otherwise) and depression (mean QOLIE-10 score=31.7 if PHQ-9≥10 vs 19.3 otherwise).

CONCLUSIONS

Optimizing quality of life in patients with epilepsy requires an approach that extends beyond controlling seizures. Collection of validated health status measures improving patient management is possible within the setting of routine clinical care.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of health-related quality of life and costs in adults with epilepsy: a systematic review

PURPOSE

Given the high burden of epilepsy on both health-related quality of life (HRQoL) and costs, identification of factors that are predictive of either reduced HRQoL or increased expenditure is central to the better future targeting and optimization of existing and emerging interventions and management strategies for epilepsy.

METHODS

Searches of Medline, Embase, and Cochrane Library (up to July 2010) to identify studies examining the association between demographic, psychosocial, and condition-related factors and HRQoL, resource utilization or costs in adults with epilepsy. For each study, predictor factor associations were summarized on the basis of statistical significance and direction; the results were then combined across studies.

KEY FINDINGS

Ninety-three HRQoL and 16 resource utilization/cost studies were included. Increases in seizure frequency, seizure severity, level of depression, and level of anxiety and presence of comorbidity were strongly associated with reduced HRQoL. The majority of studies were cross-sectional in design and had an overall methodologic quality that was judged to be "moderate" for HRQoL studies and "poor" for health care resource or costs studies. In the 53 multivariate studies, age, gender, marital status, type of seizure, age at diagnosis, and duration of epilepsy did not appear to be associated with HRQoL, whereas the predictive influence of educational and employment status, number of antiepileptic drugs (AEDs) and AED side effects was unclear. The association between predictive factors and HRQoL appeared to be consistent across individuals whether refractory or seizures controlled or managed by AEDs. There were insufficient multivariate studies (five) to reliably comment on the predictors of resource utilization or cost in epilepsy.

SIGNIFICANCE

In addition to seizure control, effective epilepsy management requires the early detection of those most at risk of psychological dysfunction and comorbidity, and the targeting of appropriate interventions. There is need for more rigorous studies with appropriate multivariate statistical methods that prospectively investigate the predictors of HRQoL, resource utilization, and costs in epilepsy.

Social-cultural aspects of epilepsy in Kilimanjaro Region, Tanzania: knowledge and experience among patients and carers

OBJECTIVE

Understanding the social-cultural aspects of epilepsy in sub-Saharan Africa will help to improve the situation of people with epilepsy (PWE) in this region.

METHODS

This qualitative study comprised interviews with 41 PWE and their carers. Participants were identified from a large community-based epidemiological study of epilepsy conducted in 2009.

RESULTS

Epilepsy was commonly ascribed to witchcraft and curses. Nearly all PWE demonstrated pluralistic care-seeking behavior, including the use of prayers and traditional healers alongside modern care. PWE reported discrimination as a result of their condition. The majority of PWE had suffered burns during seizures.

CONCLUSIONS

Poor knowledge and strong cultural and religious beliefs characterize the experience of PWE in this population. Epilepsy-related stigma contributes to overall disease burden, and PWE face exclusion across major life domains. There is a need to educate communities and inculcate perceptions and attitudes that promote early detection of epilepsy and early care-seeking behavior.

Quality of life in young people with treatment-responsive epilepsy: A controlled study

OBJECTIVE

Quality of life (QoL) has been shown to be lower in individuals with epilepsy than the general public. However, few studies have investigated the QoL of individuals with well-controlled epilepsy. This study investigated the effects of epilepsy on QoL in persons with treatment-responsive seizures, beyond factors directly related to the presence of seizures.

METHODS

Fifty young patients with controlled epilepsy and 102 healthy controls completed a generic, multidimensional, self-report QoL instrument, along with standardized scales assessing anxiety, depression, and other emotional or behavioral difficulties.

RESULTS

Young people with epilepsy reported increased anxiety (P=0.037) and more emotional and behavioral difficulties (P<0.001). Though there were was no difference between the groups in Total QoL score, treatment-responsive epilepsy was associated with lower QoL within the Self domain (P=0.016).

CONCLUSIONS

Epilepsy may exert a negative influence on QoL in relation to thoughts and feelings about the self in the context of complete seizure remission. Future research should investigate the therapeutic value of interventions targeting detrimental changes to self-perception in young people living with controlled epilepsy.

Changes in seizure severity and quality of life in patients with refractory partial epilepsy

This 6-month observational, prospective, multicenter study assessed the influence of changes in seizure severity on quality of life in patients with refractory partial epilepsy. Patients (N = 262) diagnosed with partial epilepsy and receiving two antiepileptic drugs as determined by usual clinical practice were enrolled in this study. The primary endpoint was the mean seizure severity score obtained from the Seizure Severity Questionnaire. Reductions in seizure severity were detected from baseline to months 3 and 6 (P<0.0001). Improvements compared with baseline were found for several secondary measures: Hamilton Anxiety and Depression scales (P<0.0001), most Medical Outcomes Study-Sleep subscales (P<0.05), and seven subscales of the Quality of Life in Epilepsy Inventory-31 (QOLIE-31; P<0.0005). Seizure severity correlated directly with anxiety (P<0.0001) and inversely with QOLIE-31 measures (P<0.0001). In conclusion, reducing seizure severity with appropriate medication may lead to improvement in the overall quality of life of patients with refractory partial epilepsy.

Mood and substance use disorders among adults seeking speech treatment for stuttering

OBJECTIVES

Stuttering has been associated with a range of anxiety disorders, including social phobia. In the general community, anxiety disorders are frequently associated with increased rates of mood and substance use disorders. Therefore, in the present study, the authors sought to determine the rate of mood and substance use disorders among adults who stutter.

METHOD

The study employed a matched case-control design. Participants included 92 adults seeking treatment for stuttering and 920 age- and gender-matched controls. Mental health assessments were conducted via a computerized psychiatric diagnostic interview. Conditional logistic regression models were used to estimate odds ratios for the prevalence of mood and substance use disorders in both groups.

RESULTS

When compared with matched controls, adults seeking treatment for stuttering had twofold increased odds of meeting criteria for a 12-month diagnosis of any mood disorder but were not found to report significantly higher lifetime prevalence rates for any substance use disorder.

CONCLUSIONS

Although adults who stutter in the present study were characterized by significantly higher rates of mood disorders than matched controls, they do not appear to self-medicate with substances such as alcohol. Results are discussed in terms of treatment implications and possible reasons why adults who stutter may avoid alcohol.

Assessment of health-related quality of life and influencing factors using QOLIE-31 in Japanese patients with epilepsy

The aim of epilepsy treatment is not only to eliminate seizures, but also to improve health-related quality of life (HRQOL). We conducted a postal self-administered survey of HRQOL for Japanese patients using the Quality of Life in Epilepsy inventory (QOLIE-31), Version 1.0, and analyzed factors influencing their quality of life (QOL). Data from 599 analyzable patients were evaluated and a number of factors influencing QOL were identified, including severity and frequency of seizures, seizure control, type of epilepsy, contributing events such as injuries and falls during seizures, number of antiepileptic drugs, employment status, and surgical outcome. These findings suggest that comprehensive management of the patient should be emphasized. Consideration of all the results led to classification of these factors as one of two types: "all or nothing" and "linear." With respect to "all or nothing" factors (e.g. "daytime remarkable seizures"), patients may not be able to improve their QOL unless these factors can be completely controlled. Comparison of each score on the QOLIE-31 subscales with published data revealed that the scores for the subscale Medication Effects were markedly low.

The five factor model of personality applied to adults who stutter

Previous research has not explored the Five Factor Model of personality among adults who stutter. Therefore, the present study investigated the five personality domains of Neuroticism, Extraversion, Openness, Agreeableness and Conscientiousness, as measured by the NEO Five Factor Inventory (NEO-FFI), in a sample of 93 adults seeking speech treatment for stuttering, and compared these scores with normative data from an Australian and a United States sample. Results revealed that NEO-FFI scores for the stuttering group were within the 'average' range for all five personality domains. However, adults who stutter were characterized by significantly higher Neuroticism, and significantly lower Agreeableness and Conscientiousness, than normative samples. No significant differences were found between groups on the dimensions of Extraversion and Openness. These results are discussed with reference to the relationship between personality factors among adults who stutter, their directionality, and implications for predicting treatment outcome.

LEARNING OUTCOMES

The reader will be able to: (1) describe the Five Factor Model of personality, including the NEO-FFI personality domains of Extraversion, Neuroticism, Openness, Agreeableness, and Conscientiousness, and (2) discuss differences in NEO-FFI domain scores between adults who stutter and normative samples, and (3) understand the clinical implications of personality profiles in terms of treatment process and outcome for adults who stutter.

Seizure severity is associated with quality of life independent of seizure frequency

OBJECTIVE

The goal of the work described here was to determine whether seizure severity is associated with quality of life and if this association exists independent of seizure frequency.

METHODS

We administered a survey questionnaire to patients followed at the Comprehensive Epilepsy Program, University of Florida Health Sciences Center/Jacksonville.

RESULTS

The study population comprised 142 subjects. On univariate analysis, increased seizure severity (as measured with the revised Liverpool Seizure Severity Scale, LSSS) and seizure frequency were significantly associated with poorer Quality of Life in Epilepsy-10 (QOLIE-10) scores. Most items on the LSSS were significantly associated with QOLIE-10 scores, as well as the various scales of the QOLIE-10. Likewise, all QOLIE-10 scales were significantly associated with overall LSSS scores. The correlation between seizure severity and frequency was insignificant. On multiple linear regression, both seizure severity and frequency were independently associated with QOLIE-10 scores.

CONCLUSION

Seizure severity is associated with quality of life and this association exists independent of seizure frequency.

Suicidality in people taking antiepileptic drugs: What is the evidence?

Suicide is an important cause of premature death. In the general population, most people who commit suicide have a psychiatric problem at the time. People with epilepsy are thought to be at increased risk from suicide and suicidality (suicidal ideation or behaviour). Standardized mortality ratios estimated for suicide in people with epilepsy are usually between 3 and 5. Risk factors for suicide in people with epilepsy have been suggested, including early age of onset of seizures, temporal lobe epilepsy, severe seizures and recent control of seizures. Psychiatric co-morbidity also seems to be an important factor in people with epilepsy who commit suicide. In recent years, suicidality has been recognized as a complication of several groups of drugs and, most recently, antiepileptic drugs (AEDs) have been implicated. The US FDA performed a meta-analysis of 199 placebo-controlled studies of 11 AEDs used for seizure control, psychiatric or 'other' indications. There were four completed suicides in those taking AEDs and none in those taking placebo. The odds ratio for suicidal behaviour or ideation was 1.8 (95% CI 1.24, 2.66), suggesting that people taking AEDs are more at risk than those taking placebo. The odds ratio was significantly raised for people taking AEDs for epilepsy, but not for the other indications. AEDs may affect mood by means of several mechanisms. In people with epilepsy, however, the concept of forced normalization (or alternative psychosis) may also play a part. In this situation, control of seizures (by AEDs or epilepsy surgery) may alternate with psychotic features or, less commonly, depression, although this is not fully understood. The risk of suicidal ideation and behaviour as adverse effects of AED treatment, although increased, seems low. As a result of the FDA's alert clinicians are supposed to inform patients and their families of this increased risk but it is important to place it in a proper perspective. Some people with epilepsy are more likely to develop psychiatric adverse effects with any AEDs, and these people should be followed closely whenever a new AED is introduced. Nonetheless, in people with epilepsy the risk of suicidality associated with AEDs needs to be balanced against the risk of not treating the seizures. In fact, the risk of stopping AEDs or refusing to start AEDs for the control of a seizure disorder may be significantly worse and may result in serious harm, including death of the patient.

The contribution of seizures to psychosocial ill-health

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

Antiepileptic drugs and psychopathology of epilepsy: an update

Anti-epileptic drugs (AEDs) continue to be the mainstay of epilepsy treatment, but the benefits of seizure control need to be weighed carefully against possible adverse effects, which can include behavioral problems and psychiatric disorders. In this paper, the associations between AEDs and psychosis, depression and behavioral changes are reviewed. The concept of forced normalization and its clinical counterpart, alternative psychosis, are also discussed. Depression seems to be linked with AEDs potentiating GABAergic neurotransmission in patients with limbic system abnormalities such as hippocampal sclerosis. Psychoses have been described as associated with several of the new AEDs, and they are often seen in a setting in which previously refractory patients suddenly become seizure-free. In general terms, the use of AEDs in monotherapy, adopting slow titration schedules and low doses when possible, can significantly reduce the occurrence of behavioral adverse effects. A previous history of psychiatric disorder or a familial predisposition are important risk factors and should be always considered when choosing the appropriate AED.

Perception and recall of faces and facial expressions following temporal lobectomy

The perception of and memory for faces, with or without emotional content, were studied in 43 patients with temporal lobe epilepsy who had undergone unilateral resection of the hippocampus and the amygdala and in 43 healthy participants for comparison. Each participant performed four tasks from the Florida Affect Battery (Facial Discrimination, Affect Discrimination, Affect Naming, Affect Selection) and two memory tasks (in one case of a face and in the other of a facial expression). Findings indicated that, although patients with unilateral temporal lobectomy (right or left) showed no difficulty in discriminating faces, they were not as good at remembering faces. Also, patients who had had a left temporal lobectomy showed impairment in discriminating facial expressions, in the memory of a facial expression and/or in naming facial expressions.

Patient-perceived risk associated with epilepsy and its medication treatment

Regardless of the expert advice of health care practitioners, it is ultimately the patient's decision how to best manage his or her condition. This decision can be influenced by the perceived risk of both the disease and its treatment. The objective of this study was to develop a survey to evaluate perceived risk associated with epilepsy and its medication treatment. Risk was evaluated in five domains: performance, financial, social, psychological, and physical. A 40-item patient-perceived risk questionnaire was developed and administered to patients at one university-affiliated epilepsy clinic. Pearson correlation and regression analysis was used to identify significant components of overall perceived risk. A total of 64 patients completed the survey. Performance and physical risk significantly explained 34% of the variance in overall perceived risk associated with epilepsy. The overall perceived risk associated with the treatment of epilepsy was explained by performance, physical, psychological, and social risks (r(2)=0.386). Thus, the treatment of epilepsy poses more challenges for patients to maintain their lifestyle than the disease itself.

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

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