The psychosocial correlates of depressive disorders and suicide risk in people with epilepsy

Providing integrated mental health care as a neurologist

Mental health comorbidities are highly prevalent and problematic in epilepsy, making it important for neurologists to be equipped to manage their patients' mental health concerns. This article explores the paradigm shift toward integrated mental health care approaches, aiming to educate early-career neurologists on their role within epilepsy care. We focus on depression and anxiety, how they present in epilepsy, and the role of integrated mental health care in managing these comorbidities. Key areas include the neurologist's role in identifying mental health issues through patient discussions and screening tools, and the basics of neurologist-led management. This covers the selection and adjustment of antiseizure medications and the use of psychopharmacology. Additionally, we emphasize the importance of providing psychoeducation and promoting healthy lifestyle choices that support mental well-being. Finally, we discuss the neurologist's role in facilitating referrals to mental health specialists, including information about the role of psychological interventions and psychiatry. This article aims to provide foundational knowledge to encourage early-career neurologists to actively engage in integrated mental health care approaches with their patients. This care can be flexible in how it incorporates different modalities and is tailored to local resources. It does not have to be extensive but should be meaningful enough to identify mental health concerns and facilitate patient access to appropriate resources and care.

Development of an instrument for measuring the work functioning of persons with epilepsy in clinical settings

OBJECTIVE

To describe the development process of the Work Functioning Assessment for Epilepsy (WOFAE), an instrument recently developed in Brazil for measuring the work functioning of persons with epilepsy (PwE) in clinical settings, and to evaluate to what extent this instrument is in line with existing generic and epilepsy-specific tools used to measure general and work functioning.

METHODS

The development process included four phases: the content development, based on a literature review and using the International Classification of Functioning, Disability and Health (ICF) as a reference framework; a preliminary field test, conducted with 20 PwE; an expert consultation, applying the Delphi Method; and the mapping and content comparison of the WOFAE to other five functioning assessments, using the ICF linking rules.

RESULTS

The WOFAE containing 46 items structured into eight domains was developed in an evidence-based and participatory process. It is broader in terms of body functions and environmental factors than the other functioning assessments.

CONCLUSION

It is a useful tool to guide multidisciplinary interventions, measure clinical progress and assess disability for the granting of social benefits and retirement pensions of PwE. The future phases consist of revision and psychometric analyses of the instrument to ensure its validity and reliability.

Association of depression and epilepsy in Rwanda: A prospective longitudinal study

INTRODUCTION

Depression is the most common psychiatric comorbidity for persons living with epilepsy. In Rwanda, the prevalence of epilepsy and depression are high, with 4,9% and 13.0% respectively. This prospective interventional study aimed to determine the prevalence and incidence of depression and the outcome of persons living with epilepsy (PwE) with depression attending the outpatient neurology department of a tertiary center.

METHODS

Persons living with epilepsy enrolled between February and June 2018 in a screening cohort with a 12-month follow-up. At every 3-month study visit, PwE were screened for depression using the Patient Health Questionnaire (PHQ-9) questionnaire. Any positively screened subject was administered the Hamilton Depression Rating Scale (HDRS) to confirm the diagnosis and severity of depression. Subjects with moderate to severe depression (MSD), were started on treatment and were followed for another year. We describe the prevalence and incidence of depression, baseline characteristics, epilepsy and depression outcomes, and changes in PGI-C.

RESULTS

Of 572 PwE enrolled, 46 were diagnosed with MSD in a twelve-month period, resulting in an incidence of MSD of 32.7/1000 patient-years. The prevalence of any depression and MSD was 14.2% and 4.7%, respectively. Longer epilepsy duration and seizure status at baseline were associated with MSD. Significant improvements in PGI-C and seizure frequency were observed after treatment optimization.

CONCLUSION

The use of PHQ-9 and HDRS proved successful in identifying depression in PwE. Combined treatment of epilepsy and depression resulted in improved outcomes, warranting the implementation of depression screening every six months in daily neurology practice.

Point prevalence of depression in persons with active epilepsy and impact of methodological moderators: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to determine the pooled prevalence of depression in persons with epilepsy and assess the methodological moderators affecting the prevalence estimates.

METHODS

Five electronic databases PubMed, The Cochrane Library, EMBASE, WHO Global Index Medicus, and Clinicaltrial.gov were searched for studies reporting prevalence of depression in PWE ≥ 18 years of age in any setting.

RESULTS

Out of 13,873 studies, after deduplication and screening, 56 studies with 10,527 PWE met the eligibility criteria. The overall pooled prevalence of depression in PWE was 32% (95%confidence interval [CI] 28-35%) and significant heterogeneity (Chi-square = 1171.53, p = 0.00; τ² = 0.02; I² = 94.36%). Prevalence has doubled in the recent years (16% in 2000-2005 vs. 35% in 2016-2020), was higher in Asia than in Europe (coefficient 0.899, 95%CI: 0.809-0.999; p = 0.049). Among assessment methods, prevalence was highest in HAM-D scale (54%, 95%CI: 27-82%) and lowest in MINI (22%, 95%CI: 19-26%). Sensitivity analysis also corroborated findings when MINI was excluded (35%, 95%CI: 31-38%).

CONCLUSIONS

A significant proportion of PWE have depression. Though there is substantial heterogeneity due to various methodological moderators, it is unlikely to affect the routine screening of PWE for depression. Use of a screening tool should be based on ease of administration, and cutoff selection should ensure identification of minimal depression as well.

Assessment of the Frequency of Depressive Symptoms in Epileptic Children (Single Center Study)

Background

Epilepsy, the most common neurological disorder in children, may present with many psychiatric comorbidities, the most common of which is depression.

Aim of the Work

We evaluated the frequency of depressive symptoms in epileptic children, with regard to the possible association between depression and their demographic data or seizure-related variables.

Patients and Methods

This cohort study was conducted on 80 children (6-13 years old) diagnosed as idiopathic epilepsy and were regularly recruiting the pediatric neurology clinic at Minya University Children Hospital. The Structured Birleson Depression Scale Questionnaire was used for assessment of presence of depressive symptoms, and Quality Of Life in Epilepsy (QOLIE-31) score was used to assess quality of life in those patients.

Results

Depressive symptoms were found in 37.5% of enrolled patients. There were statistically significant differences between the patients with depressive symptoms and the other group regarding age (p=0.001), residence (p=0.006) and past history of mood disorders (p=0.03). Sleep disturbance was the highest predictor of depression in cases with depressive symptoms, detected in 90% of cases, followed by appetite disturbance in 86.6% of cases, while delusions and hallucinations were the lowest, detected in only 10% of cases. Both duration of epilepsy and frequency of seizures were significantly higher in cases with depressive symptoms than the other group (p=0.001) for both. QOLIE score was significantly lower in cases with depressive symptoms than the other group (p= 0.01 for all).

Conclusion

Depressive symptoms are common in epileptic children, and it is often challenging and underestimated. It should be screened during the management of such children. Early diagnosis and more comprehensive package of care for depression in epileptic children will enable them to have a better quality of life.

Are Common Sense Model constructs and self-efficacy simultaneously correlated with self-management behaviors and health outcomes: A systematic review

This systematic review answered two questions among adults with chronic conditions: When included in the same statistical model, are Common Sense Model constructs and self-efficacy both associated with (1) self-management behaviors and (2) health outcomes? We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and included 29 articles. When included in the same statistical model, Common Sense Model constructs and self-efficacy were both correlated with outcomes. Self-efficacy was more consistently associated with self-management behaviors, and Common Sense Model constructs were more consistently associated with health outcomes. Findings support the continued inclusion and integration of both frameworks to understand and/or improve chronic illness self-management and outcomes.

[Suicidality in epilepsy: epidemiology and clinical risk factors]

The results of studies on the prevalence of suicidal behavior in patients with epilepsy are discussed in the article. The reasons for the high incidence of suicides among patients with epilepsy are given, with special attention paid to social, demographic, clinical and pathopsychological risk factors. Existing gaps in our knowledge about suicidal behavior in patients with epilepsy are analyzed.

[Suicidological research in epilepsy: problems of methodology]

The review highlights contemporary views on the problem of suicide in patients with epilepsy. The most relevant theories are presented that describe the emergence of suicidal thoughts and the transition to suicidal attempts. Along with a description of risk factors, protective factors, as well as the possible impact of comorbidity, a description of methodological deficiencies in papers on suicide in patients with epilepsy is given. Recommendations for studies related to suicidal behaviour in patients with epilepsy are discussed.

Coping and suicide risk in high risk psychiatric patients

Background: A dysfunctional use of coping strategies has repeatedly been linked to suicidal behaviour in non-psychiatric populations. However, data regarding association between coping strategies and suicidal behaviour in psychiatric populations are limited.Aims: The aim of the study was to investigate the possible relationship between self-reported suicide risk, suicidal ideation and coping strategies in three psychiatric cohorts.Method: Three cohorts of psychiatric patients were involved in the study; recent suicide attempters (n = 55), suicide attempters at follow-up 12 years after a suicide attempt (n = 38) and patients with ongoing depression without attempted suicide (n = 72). Patients filled in the self-rating version of The Suicide Assessment Scale (SUAS-S) from which items no. 17-20 addressing current suicidal ideation were extracted. To investigate coping strategies, the Coping Orientation of Problem Experience Inventory (COPE) was used.Results: In all cohorts, regression analyses showed that only avoidant coping was significantly correlated with the scores of SUAS-S adjusted for covariates. The items no. 17-20 correlated significantly to avoidant coping but not with other coping strategies in all cohorts.Conclusion: The results of this study indicate that among coping strategies only avoidant coping may be associated with suicide risk in psychiatric patients independently of history of attempted suicide.

Predicting wellbeing among people with epilepsy using illness cognitions

OBJECTIVE

This study sought to examine the synergistic contribution of illness-related perceptions (stigma, severity, and threat) and illness behavior to wellbeing among people with epilepsy. Poorer wellbeing was expected among those who perceived greater stigma, illness severity, and threat and had more extreme illness behavior.

METHODS

Individuals with a diagnosis of epilepsy (N=210), recruited through local and online support groups, completed a questionnaire comprising demographic and epilepsy-specific information, and validated measures of illness perceptions and behavior, epilepsy-related quality of life, and general psychological health.

RESULTS

Bivariate associations among illness cognition, illness behavior, and wellbeing were all as expected. Structural equation modeling highlighted the strong, direct effect of illness threat on quality of life, with other contributions from perceived stigma and an abnormal illness behavior syndrome (i.e., maladaptive illness responses). Significant variance was accounted for in both quality of life (64%) and psychological health (34%).

CONCLUSION

Preliminary evidence of the contributions of illness threat and maladaptive illness responses to wellbeing highlights the need for longitudinal research to examine the dynamic nature of such findings. Clinicians are encouraged to consider the potential value of screening for both illness threat and abnormal illness behavior to facilitate interventions.

PRISM, a Novel Visual Metaphor Measuring Personally Salient Appraisals, Attitudes and Decision-Making: Qualitative Evidence Synthesis

Background

PRISM (the Pictorial Representation of Illness and Self Measure) is a novel, simple visual instrument. Its utility was initially discovered serendipitously, but has been validated as a quantitative measure of suffering. Recently, new applications for different purposes, even in non-health settings, have encouraged further exploration of how PRISM works, and how it might be applied. This review will summarise the results to date from applications of PRISM and propose a generic conceptualisation of how PRISM works which is consistent with all these applications.

Methods

A systematic review, in the form of a qualitative evidence synthesis, was carried out of all available published data on PRISM.

Results

Fifty-two publications were identified, with a total of 8254 participants. Facilitated by simple instructions, PRISM has been used with patient groups in a variety of settings and cultures. As a measure of suffering, PRISM has, with few exceptions, behaved as expected according to Eric Cassell’s seminal conceptualisation of suffering. PRISM has also been used to assess beliefs about or attitudes to stressful working conditions, interpersonal relations, alcohol consumption, and suicide, amongst others.

Discussion

This review supports PRISM behaving as a visual metaphor of the relationship of objects (eg ‘my illness’) to a subject (eg ‘myself’) in a defined context (eg ‘my life at the moment’). As a visual metaphor, it is quick to complete and yields personally salient information. PRISM is likely to have wide applications in assessing beliefs, attitudes, and decision-making, because of its properties, and because it yields both quantitative and qualitative data. In medicine, it can serve as a generic patient-reported outcome measure. It can serve as a tool for representational guidance, can be applied to developing strategies visually, and is likely to have applications in coaching, psychological assessment and therapeutic interventions.

Illness perceptions and coping in physical health conditions: A meta-analysis

OBJECTIVE

There is a considerable body of research linking elements of Leventhal's Common Sense Model (CSM) to emotional well-being/distress outcomes among people with physical illness. The present study aims to consolidate this literature and examine the evidence for the role of coping strategies within this literature.

METHODS

A systematic review was conducted where the outcomes of interest were: depression, anxiety and quality of life. A total of 1050 articles were identified and 31 articles were considered eligible to be included in the review.

RESULTS

Across a range of illnesses, perceptions of consequences of the illness and emotional representations were consistently the illness perceptions with the strongest relationship with the outcomes. Coping variables tend to be stronger predictors of outcomes than the illness perception variables. The evidence for the mediating effect of coping was inconsistent.

CONCLUSIONS

Illness perceptions and coping have an important role to play in the explanation of distress outcomes across a range of physical health conditions. However, some clarity about the theoretical position of coping in relation to illness perceptions, and further longitudinal work is needed if we are to apply this information to the design of interventions for the improvement of psychological health among people with physical health conditions.

Anxiety in epilepsy: a neglected disorder

OBJECTIVE

Anxiety disorders and symptoms are highly prevalent and problematic comorbidities in people with epilepsy (PWE), yet they remain poorly understood and often go undetected. This research aimed to further our understanding about anxiety in PWE.

METHODS

Study 1 assessed the effectiveness of the commonly utilised yet unvalidated measure (Hospital Anxiety Depression Scale-Anxiety subscale; HADS-A) to identify DSM-IV anxiety disorders in 147 adult epilepsy outpatients.

RESULTS

This study found that although the HADS-A had reasonable specificity (75%), its poor sensitivity (61%) and inadequate area under the curve (.68) deemed it unreliable as a screener for anxiety disorders in this population.

METHODS

Study 2 aimed to further our understanding of the relationship between anxiety disorders, as defined by clinical interview, and psychosocial correlates in PWE. One hundred and twenty-two participants from Study 1 completed a battery of psychosocial measures.

RESULTS

Multivariate analysis revealed that the presence of an anxiety disorder was associated with unemployment, which was found to be the only independent predictor. That is, despite the fact that psychosocial factors together contributed to the variance in anxiety disorders none were revealed to be significant independent predictors.

CONCLUSION

These findings add to the literature indicating that the HADS may indicate distress, but does not adequately identify people with anxiety disorders and highlights the urgent need for the development of a reliable anxiety screening measure for PWE. Further, the results suggest that anxiety disorders in PWE are likely to be multiply determined with respect to psychosocial factors and require further investigation.