Reevaluating the prevalence and diagnostic subtypes of depressive disorders in epilepsy

Factors related to the severity of obsessive-compulsive symptoms and their impact on suicide risk in epileptic patients

OBJECTIVE

To explore relevant factors for the severity of obsessive-compulsive symptoms (OCSs) in adult epileptic patients and investigate whether the severity of OCSs is a mediator in the relationship between depressive/anxiety symptoms and suicide risk in epileptic patients.

METHODS

This was a cross-sectional study from a hospital in Northeast China. Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Neurological Disorders Depression Inventory for Epilepsy (NDDIE), Generalized Anxiety Disorder (GAD-7), and Nurses' Global Assessment of Suicide Risk (NGASR) were used to assess the severity of OCSs, depressive symptoms, anxiety symptoms, and suicide risk in epileptic patients, respectively. The independent factors of the severity of OCSs and their mediating effects in the relationship between depressive/anxiety symptoms and suicide risk were evaluated by regression analyses and mediator models, respectively.

RESULTS

NDDIE scores (β = 0.404, p < 0.001), GAD-7 scores (β = 0.247, p = 0.009), and polytherapy (β = 0.119, p = 0.032) were the independent factors of Y-BOCS scores. The Y-BOCS scores partially mediated the relationship between GAD-7 scores and NGASR scores (standardized coefficients of indirect effect = 0.109, Bootstrap 95% CI = 0.024 to 0.214). Still, they did not mediate the relationship between NDDIE scores and NGASR scores (standardized coefficients of indirect effect = 0.062, Bootstrap 95% CI = -0.024 to 0.169).

CONCLUSIONS

Depressive symptoms, anxiety symptoms, and polytherapy are independently associated with the severity of OCSs in epileptic patients. Depressive and anxiety symptoms mediate the effect of the severity of OCSs on suicide risk in epileptic patients completely.

Dysphoria and Irritability-Diagnostic Pitfalls in the Assessment of Interictal Dysphoric Disorder in Epilepsy

This article aims to review the concept of epilepsy-specific psychiatric disturbance, Interictal Dysphoric Disorder (IDD), focusing on issues related to its core symptoms and methodological pitfalls. In the psychiatric literature, an epilepsy-specific pleomorphic mood disorder has been long recognized and described as IDD, a condition characterized by eight symptoms, which are grouped into four labile depressive symptoms, two labile affective symptoms, and two specific symptoms. The existence of IDD is still a matter of debate because of several methodological issues. The main features of IDD, such as dysphoria and irritability, lack precise and clear definition. This review article explores the different definitions and approaches towards both terms described in the psychiatric literature and the rationale for modifying the diagnostic process of IDD.

Multiple Comorbidity Profile of Psychiatric Disorders in Epilepsy

The co-occurrence of psychiatric disorders in people with epilepsy (PWE) is not well documented or studied. Anxiety and depressive disorders are the most frequent comorbid disorders in PWE. In this paper, we characterized the rates of multiple psychiatric disorder comorbidity by reanalyzing data from a study sample of PWE. A total of 96 outpatient PWE completed the self-report symptom scale, and were diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) Axis I disorders (SCID-I). For analyses, patients were assigned to a comprehensive diagnostic group of anxiety and depressive disorders. In order to determine comorbidity across psychiatric diagnoses for the DSM-IV categories, Pearson's chi-squared test (χ²) was used. In the study sample, eight patients (8.3% of the study sample, n = 96) had comorbid major depressive disorder and anxiety disorder. When looking at comorbidity of each diagnosis separately, it was determined that 50% of individuals with an anxiety disorder had comorbid Major Depressive Disorder (MDD) and 38% patients with MDD had comorbid anxiety disorder. This finding encourages a more systematic reporting of psychiatric prevalence data in epilepsy, especially taking into account the high ratio of multiple comorbid anxiety and depressive disorders in PWE.

Effects of perceived stigma, unemployment and depression on suicidal risk in people with epilepsy

PURPOSE

Stigma toward people with epilepsy (PWE) is common around the globe. Perceived stigma produced by mental or physical disorders may represent a significant risk factor for suicide.This study examines whether and how perceived stigma, unemployment and depression interact to influence suicidal risk in PWE.

METHODS

A consecutive cohort of people with epilepsy (PWE) was recruited from the First Affiliated Hospital of Chongqing Medical University. Each patient completed the Stigma Scale for Epilepsy (SSE), the Neurological Disorders Depression Inventory for Epilepsy scale (NDDI-E) and the suicidality module of Mini-International Neuropsychiatric Interview(MINI) v.5.0.0. Spearman's correlation and moderated mediation analysis were used to examine the associations among perceived stigma, depression, unemployment and suicidal risk.

RESULTS

Perceived stigma was positively associated with depression severity and suicidal risk. Depression severity mediated the association between perceived stigma and suicidal risk. The indirect effect of perceived stigma on suicidal risk through depression severity was positively moderated by unemployment.

CONCLUSIONS

The effect of perceived stigma on suicidal risk can be explained by the mediation of depression severity, At the same time, getting out from the shadow of perceived stigma may help reducing suicidal risk in PWE. In addition, improving employment status of PWE may attenuate the indirect effect of perceived stigma on suicidal risk through depression severity.

The prevalence of depressive and anxiety symptoms in Polish epilepsy patients - The context of pharmaco-resistance

PURPOSE

Patients with epilepsy (PWE) are at a higher risk of experiencing depressive and anxiety symptoms than the general population; these symptoms are more prevalent in patients with drug-resistant epilepsy (DRE) compared to those with non-drug-resistant epilepsy (NDRE). The aim of the present study was to compare the level of reported depressive and anxiety symptoms in patients with DRE and patients with NDRE and to examine the relationships between demographic and epilepsy-related variables and severity of depression and anxiety symptoms.

MATERIAL AND METHODS

A total of 193 adult PWE, divided into a DRE group (n = 87), and an NDRE group (n = 106), completed the Beck Depression Inventory (BDI) and the Stat-Trait Anxiety Inventory (STAI-Sand STAI-T). Data analysis included sociodemographic and disease-related variables such as the type of epilepsy syndrome, age at onset of disease, and duration of the disease.

RESULTS

The DRE group presented a higher score of BDI than the NDRE group (p = 0.04). Age correlated with the score of STAI-S in the NDRE group (r = 0.22). Sex was the only significant predictor of the score of STAI-T in the NDRE group. Men from the DRE group presented higher scores in BDI, STAI-S, and STA-T compared with the NDRE group.

CONCLUSIONS

Patients with DRE reported more severe depressive symptoms than patients with NDRE. In NDRE patients, the level of anxiety, considered as a state, was correlated with age. Sex was a significant predictor of the level of anxiety in DRE patients. Pharmaco-resistance was significantly associated with severity of depression and anxiety in male patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interictal dysphoric disorder of epilepsy: A continuing diagnostic challenge

OBJECTIVE

The interictal dysphoric disorder (IDD) is a proposed epilepsy-specific mood disorder characterized by a cluster of symptoms such as depressed mood, irritability, euphoria, and anxiety. Since its introduction, the concept of IDD has been a matter of debate. This study aimed to evaluate the frequency of the IDD and the association between psychiatric disorders and IDD. We also analyzed potential associations between IDD symptoms and epilepsy-related variables.

METHODS

A consecutive group of 118 outpatients with epilepsy were screened. Ninety-six patients met inclusion criteria and examined by a trained psychiatrist using Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders fourth edition Text Revision (DSM-IV-TR) (SCID-I). In order to diagnose IDD, all participants completed the self-rating questionnaire consisting of a set of questions aimed to assess the eight key symptoms of IDD. On completion of the questionnaire, the psychiatrist reviewed all the data for completeness and accuracy with the patient.

RESULTS

In our group with epilepsy, we observed IDD in 49.0% (47 of 96) of people with epilepsy (PWE) with substantial overlap (85%) of IDD with depressive and anxiety disorders. The frequency of depressive mood, anergia, and irritability was significantly higher in patients with IDD diagnosis. Older age at epilepsy onset was associated with IDD.

STUDY LIMITATIONS

The cross-sectional study design, a consecutive sample of patients presenting to a tertiary referral center, a small sample size of the population, and applied methodology could have affected the results.

CONCLUSIONS

The present study indicates that IDD occurs in high frequency in PWE with a substantial overlap of IDD with depressive and anxiety disorders. The study highlights the importance of the observer-based systematic approach for diagnosing IDD and the usage of operationalized diagnostic criteria for psychiatric comorbidities in PWE. Future research should be directed at validating whether IDD is nosologically independent of other psychiatric conditions.

Depression and quality of life in patients with epilepsy in Northwest Greece

PURPOSE

The purpose of the present study was to compare depression and QoL between patients with epilepsy and healthy controls, evaluating potentially related factors to depression and QoL in patients with epilepsy in Northwest Greece.

METHODS

A case study was conducted in adult patients with epilepsy followed up at the University Hospital of Ioannina and in healthy controls. The Patient Health Questionnaire (PHQ-9) for depression's severity evaluation, the WHOQOL-BREF questionnaire for the QoL estimation and the Adverse Event Profile (AEP) questionnaire for the Antiepileptic Drugs (AEDs) adverse effects assessment were used.

RESULTS

Seventy patients with epilepsy and 70 controls were recruited. The PHQ-9 score was higher in patients compared to controls and slightly higher than reported in patients with epilepsy. PHQ-9 was significantly associated with the AEP score. Our patients had a poorer QoL compared to controls. The level of education, the AEP and the PHQ-9 scores were associated to QoL, the last two being the most powerful predictors of QoL.

CONCLUSION

Patients with epilepsy in Northwest Greece had higher rates of depression than reported in patients with epilepsy and poorer QoL compared to controls. The adverse effects of AEDs were related to depression in our study, while the adverse effects of AEDs and depression were more powerful predictors of QoL compared to demographics and other characteristics of epilepsy.

Major depressive disorder in epilepsy clinics: A meta-analysis

BACKGROUND AND PURPOSE

Although depression is a frequent psychiatric comorbidity in people with epilepsy (PWE), its prevalence has been underestimated. Comorbid depression has negative impacts on treatment outcomes and quality of life (QOL). It also causes various problems in PWE, such as fatigue, irritability, and suicidality. This meta-analysis was performed to estimate the frequency of major depression disorder (MDD) in clinics managing PWE.

METHODS

We searched MEDLINE, EMBASE, Cochrane Library, Web of Science, and SCOPUS to identify studies. Hospital-based studies and original research presenting information regarding prevalence of MDD, determined using a gold standard diagnostic tool in adult PWE, were considered for inclusion. The prevalence of depression was examined by meta-analysis. In addition, subgroup analysis was performed based on the continent where the selected studies were conducted, the strictness of selection criteria, and gender. Strict selection criteria were defined as any mention of the use of exclusion criteria.

RESULTS

A total of 6607 studies were identified by searching the five databases outlined above. After screening and rescreening, 35 studies were included in the meta-analysis. The total number of PWE was 5434. In the test for heterogeneity of the studies, I² was 68.014, and the Cochran Q value was 106.296 (p < 0.01). As a pooled estimate, the point prevalence of MDD in PWE was 21.9% with a 95% confidence interval (CI) of 20.8-23.0 in a fixed effects model. In subgroup analyses, continent partly explained the heterogeneity among the selected studies, but the strictness of selection criteria did not. The prevalence of MDD was higher in females than in males (26.4% vs. 16.7%, respectively) with an odds ratio (OR) of 1.805 (95% CI: 1.443-2.258; p < 0.01).

CONCLUSIONS

The point prevalence of MDD is estimated at 21.9% among PWE in epilepsy clinics and is higher in females than in males. Based on this relatively high prevalence in PWE, measures are required to identify and resolve MDD. In addition, the female predominance of MDD among PWE indicates a need to pay greater attention to females. Such efforts may reduce the impact of depression in PWE and improve their QOL.

Prevalence of anxiety disorders in epilepsy

OBJECTIVE

Anxiety disorders (ADs) are common in patients with epilepsy (PWE). The aim of this study was to estimate the prevalence of specific ADs in outpatients with epilepsy.

METHODS

A group of 118 consecutive outpatients with epilepsy were screened, and 96 patients meeting inclusion criteria were examined by a trained psychiatrist using Structured Clinical Interview (SICD-I) for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (Text Revision) (DSM-IV-TR).

RESULTS

A diagnosis of any current AD was established in 16 (16.7%) out of 96 participants. Furthermore, panic disorder (PD) was the most frequent AD; it was observed in 13.5% of PWE and constituted 81.2% of the identified ADs in the study group. Older age and later age of seizure onset were associated with increased odds of AD diagnosis.

STUDY LIMITATIONS

The cross-sectional study design, a consecutive sample of patients presenting to a tertiary referral center, and small sample size of the population could have affected the results.

CONCLUSIONS

Panic disorder and other forms of AD are common among PWE. Age and age of seizure onset are important factors associated with AD among PWE.

Validation of the Polish version of the Beck Depression Inventory in patients with epilepsy

BACKGROUND

Despite the fact that depressive disorders are the most common comorbidities among patients with epilepsy (PWE), such disorders often go unrecognized and untreated. In addition, the availability of validated screening instruments to detect depression in PWE is limited. The aim of the present study was thus to validate the Polish version of the Beck Depression Inventory (BDI) in adult PWE.

METHODS

A group of 118 outpatient PWE were invited to participate in the study. Ninety-six patients meeting the inclusion criteria completed the Polish Version of Beck Depression Inventory-I (BDI-I) and were examined by a trained psychiatrist using the Structured Clinical Interview (SICD-I) for Diagnostic and statistical manual of mental disorders - fourth edition (Text revision) (DSM-IV-TR). Receiver operating characteristic (ROC) curves were used to determine the optimal threshold scores for BDI.

RESULTS

Receiver operating characteristic analysis showed the area under the curve to be approximately 84%. For major depressive disorder (MDD) diagnosis, the BDI demonstrated the best psychometric properties for a cut-off score to be 18, with a sensitivity of 90.5%, specificity of 70.7%, positive predictive value (PPV) of 46.3%, and negative predictive value (NPV) of 96.4%. For the 'any depressive disorder' group, the BDI optimum cut-off score was 11, with a sensitivity of 82.5%, specificity of 73.2%, PPV of 68.8%, and NPV of 85.4%.

CONCLUSIONS

The BDI score is a valid psychometric indicator for depressive disorders in PWE maintaining adequate sensitivity and specificity, high NPV, and acceptable PPV with an optimum cut-off score of 18 for MDD diagnosis.

Diagnosing and treating depression in epilepsy

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

Validation of the Polish Version of the Hamilton Rating Scale for Depression in patients with epilepsy

OBJECTIVE

Depressive disorders are the most common comorbidities among patients with epilepsy (PWE). The availability of standardized clinical instruments for PWE is limited with scarce validation studies available so far. The aim of the study was to validate the Polish Version of the Hamilton Rating Scale for Depression (HRSD) in adult PWE.

METHODS

A group of 96 outpatient PWE were examined by a trained psychiatrist using the Structured Clinical Interview (SCID-I) for DSM-IV-TR and the 17-item Polish Version of HRSD (HRSD-17). Receiver operating characteristic (ROC) curves were used to determine the optimal threshold scores.

RESULTS

The ROC analyses showed areas under the curve approximately 0.9. For diagnoses of MDD, HRSD-17 demonstrated the best psychometric properties for a cutoff score of 11 with sensitivity of 100%, specificity of 89.3%, positive predictive value of 72.4%, and negative predictive value of 100%.

CONCLUSIONS

The 17-item Polish Version of HRSD proved to be reliable and valid in the epilepsy setting with a cutoff score of 11 points.

Validation of the Hospital Anxiety and Depression Scale in patients with epilepsy

OBJECTIVE

Despite the fact that depressive disorders are the most common comorbidities among patients with epilepsy (PWEs), they often go unrecognized and untreated. The availability of validated screening instruments to detect depression in PWEs is limited. The aim of the present study was to validate the Hospital Anxiety and Depression Scale (HADS) in adult PWEs.

METHODS

A consecutive group of 118 outpatient PWEs was invited to participate in the study. Ninety-six patients met inclusion criteria, completed HADS, and were examined by a trained psychiatrist using Structured Clinical Interview (SCID-I) for DSM-IV-TR. Receiver operating characteristic (ROC) curves were used to determine the optimal threshold scores for the HADS depression subscale (HADS-D).

RESULTS

Receiver operating characteristic analyses showed areas under the curve at approximately 84%. For diagnoses of MDD, the HADS-D demonstrated the best psychometric properties for a cutoff score ≥7 with sensitivity of 90.5%, specificity of 70.7%, positive predictive value of 46.3%, and negative predictive value of 96.4%. In the case of the group with 'any depressive disorder', the HADS-D optimum cutoff score was ≥6 with sensitivity of 82.5%, specificity of 73.2%, positive predictive value of 68.8%, and negative predictive value of 85.4%.

CONCLUSIONS

The HADS-D proved to be a valid and reliable psychometric instrument in terms of screening for depressive disorders in PWEs. In the epilepsy setting, HADS-D maintains adequate sensitivity, acceptable specificity, and high NPV but low PPV for diagnosing MDD with an optimum cutoff score ≥7.