Psychosocial issues in people with epilepsy in Togo and Benin (West Africa) I. Anxiety and depression measured using Goldberg's scale

Health-related quality of life and medication adherence of people living with epilepsy in Pakistan: A cross-sectional study

INTRODUCTION

The primary purpose of this study was to determine adherence and health-related quality of life (HRQoL) in PWE. Secondary aims were to assess association between adherence and HRQoL and determine predictors of HRQoL in PWE in Pakistan.

METHODS

A descriptive cross-sectional study was conducted among PWE receiving treatment from two tertiary care hospitals of Pakistan. The HRQoL and adherence were assessed with Urdu versions of Quality of Life in Epilepsy-31 (QOLIE-31), and Medication Adherence Rating Scale (MARS). Relationship between HRQoL and adherence was assessed by Pearson's product-moment correlation coefficient. Forced entry multiple linear models were used to determine relationship of independent variables with HRQoL.

RESULTS

219 PWE with a mean (±standard deviation) age, 34.18 (± 13.710) years, participated in this study. The overall weighted mean HRQoL score was (51.60 ± 17.10), and mean score for adherence was 6.17 (± 2.31). There was significant association between adherence and HRQoL in PWE (Pearson's correlation = 0.820-0.930; p ≤ .0001). Multiple linear regression found adherence (B = 16.8; p ≤ .0001), male gender (B = 10.0; p = .001), employment status (employed: B = 7.50; p = .030), level of education (Tertiary: B = 0.910; p = .010), duration of epilepsy (>10 years: B = -0.700; p ≤ .0001), and age (≥46 years: B = -0.680; p ≤ .0001), and ASM therapy (polypharmacy: B = 0.430; p = .010) as independent predictors of HRQoL in PWE from Pakistan.

CONCLUSIONS

The findings suggest PWE from our center have suboptimal adherence which affects HRQoL. Independent factors such as male gender, employment status and duration of epilepsy are predictors of HRQoL.

Teacher depressive symptoms and children's school readiness in Ghana

This study investigated associations between kindergarten teachers' (N = 208) depressive symptoms and students' (Ghanaian nationals, N = 1490, Mage  = 5.8) school-readiness skills (early literacy, early numeracy, social-emotional skills, and executive function) across 208 schools in Ghana over one school year. Teachers' depressive symptoms in the fall negatively predicted students' overall school-readiness skills in the spring, controlling for school-readiness skills in the fall. These results were primarily driven by social-emotional skills (r = .1-.3). There was evidence of heterogeneity by students' fall skill levels; teacher depressive symptoms predicted more negative spring overall school readiness for children who had higher fall school-readiness skills. Findings underscore the importance of teachers' mental health in early childhood education globally, with implications for policy and practice.

Depression in Sub-Saharan Africa

Mood disorders can be considered among the most common and debilitating mental disorders. Major depression, as an example of mood disorders, is known to severely reduce the quality of life as well as psychosocial functioning of those affected. Its impact on the burden of disease worldwide has been enormous, with the World Health Organisation projecting depression to be the leading cause of mental illness by 2030. Despite several studies on the subject, little has been done to contextualise the condition in Africa, coupled with the fact that there is still much to be understood on the subject. This review attempts to shed more light on the prevalence of depression in Sub-Saharan Africa (SSA), its pathophysiology, risk factors, diagnosis and the experimental models available to study depression within the sub-region. It also evaluates the contribution of the sub-region to the global research output of depression as well as bottlenecks associated with full exploitation of the sub region's resources to manage the disorder.

Depression, anxiety and associated factors among people with epilepsy and attending outpatient treatment at primary public hospitals in northwest Ethiopia: A multicenter cross-sectional study

Objective

To assess the magnitude and factors associated with depression and anxiety among people with epilepsy and attending out-patient treatment at central Gondar zone primary public hospitals, northwest, Ethiopia.

Method

An institutional based cross-sectional study was conducted from May—June, 2020 at central Gondar zone primary public hospitals. A total of 589 participants were chosen by systematic sampling technique. Data was collected by utilizing Amharic version interviewer-administered structured and semi-structured questioners. Depression and anxiety were assessed by using hospital anxiety and depression scale. Bivariate and multivariate logistic regression analysis was done to recognize variables related to both depression and anxiety. Association was described by using “adjusted odds ratio” (AOR) along with 95% full Confidence interval (CI). Finally, P-values < 0.05 in adjusted analysis were taken as a cut off for significant association.

Result

Out of 556 participants included in the study, 30.9%, 33.1% had depression and anxiety respectively. Being divorced/widowed (AOR = 2.43, 95% CI, 1.18–4.99), using two and above number of antiepileptic medications (AOR = 1.77,95% CI,1.02–3.09), very frequent seizure frequency (AOR = 2.68, 95% CI,1.30–5.51), current substance use (AOR = 1.82, 95% CI, 1.03–3.22), perceived stigma (AOR = 5.67,95% CI,3.14–8.18), and hazardous alcohol use (AOR = 2.84, 95% CI,1.32–6.09) were statistically associated with depression. While, being a single (AOR = 1.65, 95% CI, 1.04–2.63), using two and above number of antiepileptic medications (AOR = 2.27, 95% CI, 1.42–3.62), duration of illness ≥16 years (AOR = 2.82, 95% CI, 1.26–6.31), and perceived stigma (AOR = 2.49, 95% CI, 1.63–3.82) were statistically associated with anxiety at a p-value < 0.05.

Conclusion

This study showed that the magnitude of depression and anxiety were relatively high among people with epilepsy. Using two and above number of antiepileptic medications and perceived stigma were statistically associated with both depression and anxiety. Screening, early identification and providing appropriate intervention of depression and anxiety among people with epilepsy should be great concern for the health care providers.

Depressive and anxiety symptoms in early childhood education teachers: Relations to professional well-being and absenteeism

This study investigated how early childhood education teachers' (N = 444) depressive and anxiety symptoms predicted their professional well-being outcomes and absenteeism over the course of one school year in Ghana. Higher anxiety and depressive symptoms predicted lower job motivation and job satisfaction and higher levels of emotional exhaustion at the end of the school year. Increased depressive symptoms were further associated with more days absent over the course of the school year. Findings point to the importance of considering teachers' mental health for early educational quality. Implications for policy and practice are discussed.

Prevalence, severity, and associations of depression in people with epilepsy in Guinea: A single-center study

BACKGROUND AND OBJECTIVE

Depression has long been recognized as a comorbidity of epilepsy in high-income countries, ranging from 17 to 49% of people with epilepsy (PWE). Of the limited studies from sub-Saharan Africa (SSA), where most people have uncontrolled seizures, an even higher prevalence of depression is reported among PWE at times exceeding 80%. We sought to assess the prevalence and severity of depression and its associated factors among PWE in Guinea, a sub-Saharan West African country where most PWE have poorly controlled seizures.

METHODS

People with epilepsy from the community, age 16 years old and above, were consecutively recruited into a convenience cohort at the Ignace Deen Hospital in the capital city, Conakry, in summer 2018 as part of a larger study characterizing PWE in Guinea. Each participant was evaluated by a team of Guinean physicians and a U.S.-based neurologist to confirm the diagnosis of epilepsy. Inperson interviews were performed to measure demographic, clinical, socioeconomic, and related variables. Depression was measured via the Patient Health Questionniare-9 in the language of the participant's preference with a cutoff of 5 or more points being categorized as depressed. Regression analyses were performed to measure the associations between explanatory variables with the outcome of depression.

RESULT

Of 140 PWE (age range: 16-66 years old; 64 female; 64% taking an antiseizure medication including 28% carbamazepine, 16% phenobarbital, and 14% valproic acid; duration of epilepsy: 11 years; 71% with one or more seizures in the past month; 17% never treated with an antiseizure medication; 90% with loss of consciousness during seizures; 10% without formal education; 31% with university level education; 62% using tap water; 48% with a serious seizure-related injury), the point prevalence of depression was 66% (95% confidence interval [CI]: 58%-74%): 43% of PWE had mild depression, 19% moderate, 4% moderate to severe, and 0.1% severe. In a multivariate analysis, the occurrence of a seizure in the past month (odds ratio: 3.03, 95% CI: 2.63-3.48, p = 0.01) was associated with depression, while gender, self-perceived stigma score, serious injuries, and the number of antiseizure medications taken were not statistically significantly associated (p > 0.05). Twenty-five percent of all participants endorsed thoughts of self-harm or suicidality.

CONCLUSION

Two-thirds of PWE in Guinea had depression in this single-institution convenience cohort. The presence of a seizure in the last month was the factor most associated with depression and is modifiable in many PWE. The high prevalance of depression suggests that screening and addressing depressive symptoms should be incorporated into routine epilepsy care in Guinea.

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

INTRODUCTION

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

METHODS

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

CONCLUSION

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

Validity, reliability and cut-offs of the Patient Health Questionnaire-9 as a screening tool for depression among patients living with epilepsy in Rwanda

BACKGROUND

Patients with epilepsy (PwE) have an increased risk of active and lifetime depression. Two in 10 patients experience depression. Lack of trained psychiatric staff in low- and middle-income countries (LMIC) creates a need for screening tools that enable detection of depression in PwE. We describe the translation, validity and reliability assessment of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for depression among PwE in Rwanda.

METHOD

PHQ-9 was translated to Kinyarwanda using translation-back translation and validated by a discussion group. For validation, PwE of ≥15 years of age were administered the PHQ-9 and Hamilton Depression Rating Scale (HDRS) by trained psychiatry staff at Visit 1. A random sample of 20% repeated PHQ-9 and HDRS after 14 days to assess temporal stability and intra-rater reliability. Internal structure, reliability and external validity were assessed using confirmatory factor analysis, reliability coefficients and HDRS-correlation, respectively. Maximal Youden's index was considered for cut-offs.

RESULTS

Four hundred and thirty-four PwE, mean age 30.5 years (SD ±13.3), were included of whom 33.6%, 37.9%, 13.4%, and 15.1% had no, mild, moderate and severe depression, respectively. PHQ-9 performed well on a one-factor model (unidimensional model), with factor loadings of 0.63-0.86. Reliability coefficients above 0.80 indicated strong internal consistency. Good temporal stability was observed (0.79 [95% CI: 0.68-0.87]). A strong correlation (R = 0.66, p = 0.01) between PHQ-9 and HDRS summed scores demonstrated robust external validity. The optimal cut-off for the PHQ-9 was similar (≥5) for mild and moderate depression and ≥7 for severe depression.

CONCLUSION

PHQ-9 validation in Kinyarwanda creates the capacity to screen PwE in Rwanda at scores of ≥5 for mild or moderate and ≥7 for severe depression. The availability of validated tools for screening and diagnosis for depression is a forward step for holistic care in a resource-limited environment.

Comorbidities of epilepsy in low and middle-income countries: systematic review and meta-analysis

Epilepsy is a major public health concern in low and middle-income countries (LMICs) and comorbidities aggravate the burden associated with the disease. The epidemiology of these comorbidities has not been well described, although, identifying the main comorbidities of epilepsy, and their relative importance, is crucial for improving the quality of care. Comorbidities were defined as disorders coexisting with or preceding epilepsy, or else compounded or directly attributed to epilepsy or to its treatment. A meta-analysis of the proportion of main comorbidities by subcontinent as well as overall was also conducted. Out of the 2,300 papers identified, 109 from 39 countries were included in this systematic review. Four groups of comorbidities were identified: parasitic and infectious diseases (44% of comorbid conditions), somatic comorbidities (37%), psychosocial (11%), as well as psychiatric comorbidities (8%). Heterogeneity was statistically significant for most variables then random effect models were used. The most frequently studied comorbidities were: neurocysticercosis (comorbid proportion: 23%, 95% CI: 18-29), head trauma (comorbid proportion: 9%, 95% CI: 5-15) malnutrition (comorbid proportion: 16%, 95% CI: 28-40), stroke (comorbid proportion: 1.3%, 95% CI: 0.2-7.0), and discrimination for education (comorbid proportion: 34%, 95% CI: 28-40). Many comorbidities of epilepsy were identified in LMICs, most of them being infectious.

Predictors of anxiety and depressive symptoms among teachers in Ghana: Evidence from a randomized controlled trial

RATIONALE

While teachers are heralded as key drivers of student learning outcomes, little attention has been paid to teachers' mental health, especially in less-developed countries such as Ghana. Professional background, workplace environment, and personal life stressors may threaten teachers' mental health and subsequent effectiveness in the classroom.

OBJECTIVES

The objectives of this study were to investigate 1) whether and how professional background, workplace environment, and personal life stressors predicted teachers' anxiety and depressive symptoms, and 2) whether participation in a professional development intervention predicted change in teachers' symptoms over the course of one school year in Ghana.

METHOD

We used multilevel models to examine predictors of depressive and anxiety symptoms among 444 kindergarten teachers (98% female; age range: 18-69) who participated in the Quality Preschool for Ghana (QP4G) Study. QP4G was a school-randomized control trial (n = 108 public schools; n = 132 private schools) evaluating a one-year teacher professional development intervention program implemented with and without parental-awareness meetings. Teacher depressive and anxiety symptoms were assessed at baseline before the intervention and at the end of the school year.

RESULTS

Poor workplace environment was associated with increased anxiety and depressive symptoms. Social support also predicted symptoms, with lack of support from students' parents and being new to the local community associated with more anxiety symptoms. Within teachers' personal lives, household food insecurity predicted more depressive symptoms. Finally, anxiety and depressive symptoms increased for all teachers over the school year. However, randomization to either intervention was linked to a significantly smaller increase in symptoms over the school year.

CONCLUSIONS

Results suggest that teachers' personal and professional lives are consequential for their mental health, and that professional development interventions that provide training and in-class coaching and parent engagement may benefit teachers' mental health.

Women with epilepsy in sub-Saharan Africa: A review of the reproductive health challenges and perspectives for management

BACKGROUND

Epilepsy is one of the commonest neurological conditions affecting women of reproductive age. Epilepsy management during pregnancy is a clinical conundrum, requiring a balance between seizure control and risk minimization for the women with epilepsy (WWE) as well as for their fetuses. The objective of this comprehensive review is to explore the reproductive health challenges of WWE in sub-Saharan Africa (SSA) and ways to address them.

METHOD

Relevant documentation published until June 2019 were retrieved via literature searches performed in PubMed and Google Scholar, as well as a manual search to identify grey literature.

RESULTS

WWE in SSA are generally more stigmatized and sexually exploited than women without epilepsy. Contraception use among WWE was reported only in Senegal (51%) and Kenya (14.7%). Only two prospective studies (one in Senegal and one in Nigeria) investigated pregnancy outcomes for a total of 97 WWE. The prevalence of convulsive epilepsy in pregnancy was estimated at 3.33 per 1000. Among pregnant WWE treated with first line anti-epileptic drugs, 16.2% had miscarriages, 41.9% premature births, and 4.1% had babies with malformations. Carbamazepine, which is frequently prescribed to pregnant WWE in SSA, still entails a 2.1-fold increased risk of congenital malformation. No reports were found concerning pre-conceptual counseling and post-natal outcomes in WWE in SSA.

CONCLUSION

Our review underscores the need for contextualized evidence-based clinical guidelines and a collaborative approach to treat WWE in SSA. High risks of congenital malformations and drug interactions with first line AED warrant the provision of safer second line alternatives.

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

Background

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

Methods

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

Results

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

Conclusion

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

Knowledge, attitudes, and practices of health sciences students regarding epilepsy at the end of their curriculum in Benin

OBJECTIVE

The main objective of this study was to evaluate the knowledge, attitudes, and practices (KAP) of health sciences students regarding epilepsy at the end of their curriculum in Benin.

METHODS

We conducted a cross-sectional survey among medical, pharmacy, nursing, and midwife students in their last year of health sciences training in the University of Abomey-Calavi in Benin. Students completed a self-administered questionnaire, containing items addressing demographics, epilepsy treatment, diagnosis, clinical practice, and social tolerance regarding a person with epilepsy (PWE).

RESULTS

The response rate to our survey was 87.7% (n = 164). The sample consisted of 64 medical students, 22 pharmacy students, 43 nursing students, and 35 midwife students. They were divided into 95 female subjects and 69 males; sex ratio was 0.7. The mean age of participants was 23.6 ± 1.8 years. The mean scores for epilepsy knowledge, practices, and attitudes were respectively 7.6 ± 1.7 out of a maximum score of 11, 3.9 ± 1.8 out of 8, and 9.6 ± 0.8 out of 10. The KAP overall score was 21.1 ± 3.4 out of a maximum score of 29.0. The variables associated with the overall KAP score were training school, gender, having heard about epilepsy before health sciences studies (p = 0.017), and having a relative with epilepsy (p = 0.001). Male students and medical school students had significantly better overall KAP score than female students or the other training schools respectively (p < 0.001).

SIGNIFICANCE

These findings support the need to improve the health sciences students' knowledge of epilepsy, in particular, during their training.

Psychosocial challenges affecting the quality of life in adults with epilepsy and their carers in Africa: A review of published evidence between 1994 and 2014

BACKGROUND

Little attention has been paid to the psychosocial challenges of adult patients with epilepsy and their carers in Africa in published studies conducted between 1994 and 2014 - yet these psychosocial challenges have been reported to have a major impact on the quality of life (QOL) of people living with the illness and those who care for them.

AIM

This review aimed to examine the literature on published studies conducted in Africa between 1994 and 2014 that examined psychosocial challenges of adult people with epilepsy and their carers. The aim was to examine the kind of psychosocial challenges from published evidence and to identify gaps in current knowledge.

METHODS

MEDLINE, PubMed, ERIC, Web of Science, Scopus, Cochrane Library, Africa Wide, PsycINFO, EMBASE, PASCAL, SABINET and Google Scholar databases and hand searches of Epilepsy & Behavior, Epilepsia, South African Medical Journal, African Journal of Disability, African Journal of Primary Health Care and Family Medicine were reviewed.

RESULTS

Very few studies in Africa have examined psychosocial challenges affecting the adult patients with epilepsy and their carers. This review reported the existence of evidence of such challenges and the insights into the psychosocial and economic factors that underpin them. There is evidence that where these have been addressed, there were valuable insights on the types of psychosocial, socio-cultural and socio-economic challenges. Collaborative empowering interventions are needed to enable the attainment of good QOL for those affected.

CONCLUSION

Research on psychosocial challenges of adult patients with epilepsy and their carers from different sectors of healthcare to inform the design of appropriate models is needed.

Prevalence and correlates of major depressive disorder (MDD) among adolescent patients with epilepsy attending a Nigerian neuropsychiatric hospital

BACKGROUND

A high prevalence of mood disorders exists in patients with epilepsy. In most cases, this is not detected and, consequently, not treated. This study aimed to determine the prevalence and correlates of major depressive disorder (MDD) among adolescents with epilepsy attending a child and adolescent clinic in Nigeria.

METHODS

We recruited 156 participants consecutively for the study. Adherence was assessed using the 8-item Morisky Medication Adherence Questionnaire, while the K-SADS was used to assess the presence of major depressive disorder. Seizure control was evaluated by the frequency of seizures within a year.

RESULTS

Major depressive disorder (DSM-IV criteria) was diagnosed in 28.2% of the participants. The age of participants (p=0.013), seizure control (p=0.03), medication adherence (p=0.045), frequency of seizures in the preceding 4weeks (p<0.001), and duration of illness (p<0.001) were all significantly associated with the presence of MDD. Participants with seizures occurring more than once weekly in the preceding 4weeks were 16 times more likely to have a MDD compared with those with no seizures in the preceding 4weeks (p<0.001, 95% C.I. [4.13, 65.43]), while participants with a duration of illness more than 10years were more than four times likely to have MDD compared with those with an illness duration of 5-10years (p<0.01, 95% C.I. [0.07, 0.70]).

CONCLUSION

The prevalence of MDD among patients with epilepsy was high. Poor seizure control, poor medication adherence, and long duration of illness were associated with the presence of MDD among such patients. Intervention should focus on ensuring good seizure control and optimal adherence in order to mitigate the impact of MDD in patients with epilepsy.

[Psychiatric disorders and associated factors in patients with epilepsy in Fez, Morocco]

BACKGROUND

The prevalence of psychiatric disorders in epileptic patients remains unclear.

OBJECTIVE

This study was conducted in order to determine the prevalence and nature of the psychiatric disorders and the associated factors in patients with idiopathic epilepsy.

METHODS

A cross-sectional study was conducted over a period of eighteen months in the psychiatric unit of the University Hospital Hassan II of Fez (Morocco). A questionnaire was completed by the included patients, which specified: the socio-demographic data, personal and family history, and the clinical features of epilepsy and its management. Psychiatric disorders were identified by the Mini International Neuropsychiatric Interview test (MINI). The severity of the depression and anxiety symptoms was investigated using the Beck Depression Inventory (BDI) and the Hamilton Rating Scale.

RESULTS

Eighty-nine patients met the inclusion criteria. The average age of patients was 29.7±10.8years. Mood disorders were the leading psychiatric comorbidity: 32.6% among which 25.8% of major depressive episodes, 15.7% of dysthymia and 2.2% of hypomanic episodes. Anxiety disorders came second: 28.1% (among which 19.1% panic disorder, 13.5% agoraphobia, 12.4% generalized anxiety disorder, 10.1% social phobia and 4.5% post-traumatic stress disorder). Female gender, unemployment and poor compliance to antiepileptic drugs are all risk factors for the occurrence of psychiatric disorders in this population.

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

OBJECTIVE

Depression is one of the most common psychiatric comorbidities in epilepsy; however, the factors contributing to this association remain unclear. There is a growing consensus that methodological limitations, particularly selection bias, affect many of the original studies. A systematic review focussed on community-based studies offers an alternative approach for the identification of the risk factors for depression.

METHODS

Searches were performed in MEDLINE (Ovid), 2000 to 31 December 2013, EMBASE, and Google Scholar to identify studies examining risk factors for depression in epilepsy. Community-based studies of adults with epilepsy that reported at least one risk factor for depression were included.

RESULTS

The search identified 17 studies that met selection criteria, representing a combined total of 12,212 people with epilepsy with a mean sample size of 718. The most consistent risk factors for depression were sociodemographic factors, despite the fact that most studies focus on epilepsy-related factors.

SIGNIFICANCE

Most studies lacked a systematic conceptual approach to investigating depression, and few risk factors were consistently well studied. Future community-based studies require a detailed systematic approach to improve the ability to detect risk factors for depression in epilepsy. Psychological factors were rarely studied in community-based samples with epilepsy, although the consistent association with depression in the few studies that did suggests this warrants further examination.

The impact of self-efficacy, alexithymia and multiple traumas on posttraumatic stress disorder and psychiatric co-morbidity following epileptic seizures: a moderated mediation analysis

This study investigated the incidence of posttraumatic stress disorder (PTSD) and psychiatric co-morbidity following epileptic seizure, whether alexithymia mediated the relationship between self-efficacy and psychiatric outcomes, and whether the mediational effect was moderated by the severity of PTSD from other traumas. Seventy-one (M=31, F=40) people with a diagnosis of epilepsy recruited from support groups in the United Kingdom completed the Posttraumatic Stress Diagnostic Scale, the Hospital Anxiety and Depression Scale, the Toronto Alexithymia Scale-20 and the Generalized Self-Efficacy Scale. They were compared with 71 people (M=29, F=42) without epilepsy. For people with epilepsy, 51% and 22% met the diagnostic criteria for post-epileptic seizure PTSD and for PTSD following one other traumatic life event respectively. For the control group, 24% met the diagnostic criteria for PTSD following other traumatic life events. The epilepsy group reported significantly more anxiety and depression than the control. Partial least squares (PLS) analysis showed that self-efficacy was significantly correlated with alexithymia, post-epileptic seizure PTSD and psychiatric co-morbidity. Alexithymia was also significantly correlated with post-epileptic seizure PTSD and psychiatric co-morbidity. Mediation analyses confirmed that alexithymia mediated the path between self-efficacy and post-epileptic seizure PTSD and psychiatric co-morbidity. Moderated mediation also confirmed that self-efficacy and PTSD from one other trauma moderated the effect of alexithymia on outcomes. To conclude, people can develop posttraumatic stress disorder symptoms and psychiatric co-morbidity following epileptic seizure. These psychiatric outcomes are closely linked with their belief in personal competence to deal with stressful situations and regulate their own functioning, to process rather than defend against distressing emotions, and with the degree of PTSD from other traumas.

Alexithymia and posttraumatic stress disorder following epileptic seizure

This study investigated (1) the incidence of posttraumatic stress disorder following epileptic seizure (post-epileptic seizure PTSD) and psychiatric co-morbidity and (2) the extent to which alexithymia traits related to the severity of the preceding outcomes. Seventy-one people with epilepsy participated in the study and completed the Posttraumatic Stress Diagnostic Scale, Hospital Anxiety and Depression Scale (HADS), and Toronto Alexithymia Scale. The control group comprised 71 people without epilepsy who completed the HADS. Fifty-one percent met the diagnostic criteria for full-PTSD; 30 % for partial-PTSD and 19 % for no-PTSD. The epilepsy group reported significantly more anxiety and depression than the control with demographic variables controlled for. Difficulty identifying feelings predicted post-epileptic seizure PTSD, anxiety and depression. It was positively correlated with post-epileptic seizure PTSD and depression, while it was negatively correlated with anxiety. People can develop PTSD and psychiatric co-morbid symptoms following epileptic seizures. The severity of these symptoms was related to difficulty in identifying internal feelings and emotions.

An estimate of the prevalence of epilepsy in Sub-Saharan Africa: A systematic analysis

Background

Epilepsy is a leading serious neurological condition worldwide and has particularly significant physical, economic and social consequences in Sub–Saharan Africa. This paper aims to contribute to the understanding of epilepsy prevalence in this region and how this varies by age and sex so as to inform understanding of the disease characteristics as well as the development of infrastructure, services and policies.

Methods

A parallel systematic analysis of Medline, Embase and Global Health returned 32 studies that satisfied pre–defined quality criteria. Relevant data was extracted, tabulated and analyzed. We modelled the available information and used the UN population figures for Africa to determine the age–specific and overall burden of epilepsy.

Results

Active epilepsy was estimated to affect 4.4 million people in Sub–Saharan Africa, whilst lifetime epilepsy was estimated to affect 5.4 million. The prevalence of active epilepsy peaks in the 20–29 age group at 11.5/1000 and again in the 40–49 age group at 8.2/1000. The lowest prevalence value of 3.1/1000 is seen in the 60+ age group. This binomial pattern is also seen in both men and women, with the second peak more pronounced in women at 14.6/1000.

Conclusion

The high prevalence of epilepsy, especially in young adults, has important consequences for both the workforce and community structures. An estimation of disease burden would be a beneficial outcome of further research, as would research into appropriate methods of improving health care for and tackling discrimination against people with epilepsy.

Epilepsy, poverty and early under-nutrition in rural Ethiopia

PURPOSE

The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition.

METHODS

Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes.

RESULTS

Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037).

CONCLUSION

Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy.

Depression and anxiety in a community sample with epilepsy in Brazil

OBJECTIVE

To estimate the frequency of depression/anxiety and to establish the social, epilepsy and psychiatric characteristics in individuals with epilepsy.

METHOD

A cross-sectional study was employed to evaluate 153 subjects with epilepsy who were identified in a previous community-based survey. First, a structured interview was conducted, followed by a psychiatric evaluation. Subjects with depression were compared to those without, and subjects with anxiety were compared to those without.

RESULTS

The prevalence of anxiety and depression was 39.4 and 24.4%, respectively. Both were associated with low schooling (OR 3.8, 95% CI 1.6 to 9.0 and OR 2.8, 95% CI 1.2 to 6.5 for depression and anxiety, respectively), lifetime suicidal thoughts (OR 4.4, 95% CI 1.9 to 10.3 and OR 3.6, 95% CI 1.7 to 7.7) and lifetime suicide attempts (OR 9.3, 95% CI 2.6 to 32.8 and OR 6.9, 95% CI 1.8 to 26.4).

CONCLUSION

The high rates of depression and anxiety reinforced the need for recognition and treatment of mental disorders in epilepsy.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

Packages of care for epilepsy in low- and middle-income countries

In the second in a series of six articles on packages of care for mental health disorders in low- and middle-income countries, Caroline Mbuba and Charles Newton discuss treatment for epilepsy.

Assessing local instrument reliability and validity: a field-based example from northern Uganda

This paper presents an approach for evaluating the reliability and validity of mental health measures in non-Western field settings. We describe this approach using the example of our development of the Acholi psychosocial assessment instrument (APAI), which is designed to assess depression-like (two tam, par and kumu), anxiety-like (ma lwor) and conduct problems (kwo maraco) among war-affected adolescents in northern Uganda. To examine the criterion validity of this measure in the absence of a traditional gold standard, we derived local syndrome terms from qualitative data and used self reports of these syndromes by indigenous people as a reference point for determining caseness. Reliability was examined using standard test-retest and inter-rater methods. Each of the subscale scores for the depression-like syndromes exhibited strong internal reliability ranging from alpha = 0.84-0.87. Internal reliability was good for anxiety (0.70), conduct problems (0.83), and the pro-social attitudes and behaviors (0.70) subscales. Combined inter-rater reliability and test-retest reliability were good for most subscales except for the conduct problem scale and prosocial scales. The pattern of significant mean differences in the corresponding APAI problem scale score between self-reported cases vs. noncases on local syndrome terms was confirmed in the data for all of the three depression-like syndromes, but not for the anxiety-like syndrome ma lwor or the conduct problem kwo maraco.

Repeated seizures lead to altered skilled behaviour and are associated with more highly efficacious excitatory synapses

People with epilepsy have a high incidence of interictal behavioural problems that appear to be related to the location of their seizure focus. This study investigated a novel test of the hypotheses that repeated seizures result in behavioural deficits and altered performance during the interictal state, and that those behaviours are related to the presence of more highly efficacious excitatory synapses. We tested these hypotheses by first repeatedly eliciting seizures with electric current through indwelling electrodes in the corpus callosum at the level of the caudal forelimb area of sensorimotor neocortex in the rat. We then assessed learned skilled behaviours that primarily utilize the forelimbs on tasks that are sensitive to the functional integrity of that structure. We observed both behavioural deficits and altered kinematic performance in rats that experienced repeated neocortical seizures relative to an electrode-implanted control group. From a separate set of rats, tissue was prepared for quantification of thickness and excitatory synaptic subtypes from neocortical layer V. We observed significantly increased numbers of perforated synapses that make their connections directly onto the dendritic shaft at 3 weeks following the last seizure. Altered reaching behaviours are likely due to neural reorganization in the neocortex including more efficacious synapses.

Is it possible to carry out high-quality epidemiological research in psychiatry with limited resources?

PURPOSE OF REVIEW

This review covers the epidemiological research from developing countries to identify the scope of research in the various aspects of epidemiology and the strengths of research. The period covered is June 2004 to June 2005. The literature survey used searches of Medline, key psychiatric journals and personal correspondence with leading psychiatric researchers from developing countries.

RECENT FINDINGS

There is a new interest in epidemiological studies in developing countries. These studies have been driven by three factors, namely international collaboration; specific situations like disasters, terrorism and severe acute respiratory syndrome; and international attention to specific topics like maternal depression. There is limited long-term research on specific conditions. There are a number of leads suggesting local social-cultural factors contribute to the distribution of psychiatric problems. Child psychiatry continues to be low in priority. There is also lack of research in areas such as personality disorders and organic psychiatric disorders.

SUMMARY

It is possible to carry out high quality epidemiological research in developing countries. Such research has provided new insights into the distribution, causation, course and outcome of mental disorders. There is need for greater attention to the development of epidemiological assessment tools to suit local conditions. Specific centers/institutions developing long-term research interests on specific subjects would be valuable for future efforts. There is also need to widen the conditions to be studied.