Felt stigma in seizure-free persons with epilepsy: Associated factors and its impact on health-related quality of life

How do anxiety, depression, and stigma affect quality of life in people with epilepsy?

BACKGROUND

Anxiety, depression, and stigma can significantly affect the quality of life of people with epilepsy. This study was carried out to determine the relationship between these factors.

METHOD

The study was conducted with 325 people with epilepsy admitted to the neurology outpatient clinic of a training and research hospital in Istanbul, Türkiye. Data were collected using a General Information Form, the Depression in Neurological Disorders Scale-Epilepsy (NDDI-E), Generalized Anxiety Disorder-7 Scale (GAD-7), Epilepsy Self-Stigma Scale (ESSS), and Quality of Life in Epilepsy Scale (QOLIE-31). Data were analyzed using the Student's t-test, one-way ANOVA, Pearson correlation, and multiple linear regression test.

RESULTS

Of the included patients, 60.9 % were female, 61.5 % were married, and 84.3 % had generalized seizures. The mean anxiety score was 16.80 ± 6.13, and 13.5 % of patients had mild anxiety, 27.7 % had moderate anxiety, and 58.8 % had severe anxiety. The mean depression score was 14.07 ± 3.58, and 39.7 % of the patients were at risk for depression. The mean total score for stigma was 14.29 ± 5.67, and the mean total score of the quality of life scale was 47.54 ± 11.36. Quality of life decreased with increasing levels of depression (r = -0.418; p < 0.001), anxiety (r = -0.292; p < 0.001), and stigma (r = -0.224; p < 0.001). Depression, anxiety, stigma, and seizure frequency explained 25 % of the total variance in quality of life.

CONCLUSION

There was a negative correlation between anxiety, depression, stigma, and quality of life. These factors, as well as seizure frequency, were statistically significant predictors of quality of life in people with epilepsy.

Evolution of epilepsy comorbidities in seizure free patients: Is no seizure a synonym of no epilepsy?

Epilepsy is a prevalent neurological disorder, with most patients achieving seizure freedom through antiseizure medications (ASM). However, being seizure-free does not necessarily equate to being free from epilepsy-related comorbidities. This review explores the persistence of psychiatric, cognitive, and social challenges in seizure-free patients and their impact on quality of life (QoL). Seizure-free patients generally report a better QoL than those with active epilepsy, with scores approaching those of the general population. However, detailed analyses reveal impairments in specific subdomains, such as emotional well-being, energy levels, and employment concerns. The most significant determinants of QoL in seizure-free patients include ASM side effects, psychiatric symptoms, and social functioning. Notably, polytherapy is associated with a poorer QoL. After epilepsy surgery, improvements in QoL are well documented, especially in the first two years postoperatively. However, for some patients, achieving seizure freedom does not necessarily result in significant QoL improvements, often due to persistent psychiatric or cognitive impairments. Psychiatric comorbidities, particularly depression and anxiety, remain a significant determinant of QoL in seizure-free patients, sometimes exerting a greater influence than seizure control itself. Depression is significantly more prevalent in patients treated with ASMs, especially those on polytherapy. After surgery, 15-45% of patients achieve remission from psychiatric disorders, particularly those who become seizure-free. Cognitive deficits could persist in seizure-free patients, particularly in those on ASMs. Studies have reported impairments in verbal fluency, memory, and processing speed, especially in patients with magnetic resonance imaging lesions or early epilepsy onset. ASM withdrawal has been associated with improved verbal fluency, psychomotor speed, and attention in some patients, but not necessarily in overall QoL. After epilepsy surgery, cognitive outcomes vary, with verbal memory decline being the most concerning effect, particularly after left-sided resections. However, some patients experience cognitive improvements, particularly in executive functioning and IQ in children. Importantly, QoL improvements post-surgery are generally independent of cognitive changes, as long as seizure control is achieved. Seizure freedom positively impacts employment, with studies reporting that seizure-free patients are significantly more likely to obtain or retain full-time employment. However, barriers remain, including stigma and employer perceptions of epilepsy. Driving ability is crucial to patient independence, with up to 80% of seizure-free patients regaining their license. While most seizure-free patients achieve financial and residential independence, social adaptation can be challenging. Some patients and families struggle with the "burden of normality," which describes difficulties adjusting to life without epilepsy. This can lead to strained family dynamics and, in some cases, divorce. Achieving seizure freedom is a critical goal, but it is not synonymous with complete recovery from epilepsy-related burdens. A comprehensive approach, including psychiatric, cognitive, and social assessments, is essential to optimize the well-being of seizure-free patients.

Effects of stigma on the quality of life in patients with epilepsy

BACKGROUND

This study was aimed to evaluate the stigma and quality of life (QoL) in adult patients with epilepsy (PWEs) and explore the relationship between stigma and QoL.

METHODS

Two hundred and ninety-eight PWEs admitted to the Epilepsy Center of the First Affiliated Hospital of Chongqing Medical University during September 2020 and March 2021 were enrolled in this study. All participants completed self-reported questionnaires including the Stigma Scale for Epilepsy and the Quality of Life in Epilepsy Inventory-31 (QOLIE-31).

RESULTS

A total of 146 (49%) PWEs reported an experience of stigma. The total score of QOLIE-31 and the individual scores of seven subscales (worry about new seizures, emotion, well-being, energy and fatigue, cognitive impairment, medication effect, and social function) were significantly decreased in these patients (P < 0.001). Multivariate stepwise linear regression analysis showed that the annual household income per capita, the number of antiseizure medications and stigma had statistically significant effects on QoL (P < 0.05). Among them, stigma had the most significant negative effect.

CONCLUSIONS

Nearly half of PWEs have experienced stigma. Stigma, lower household income per capita, and polypharmacy treatment are associated with poorer QoL. Stigma has the most obvious negative impact.

An investigation of stigma and self-management in individuals diagnosed with epilepsy

AIM

The complex nature of epilepsy disease confronts individuals with difficulties such as stigma. Stigma has a negative impact, particularly on individuals' coping with the disease. It is important for individuals diagnosed with epilepsy to adopt many self-management behaviors so that they can control these situations. This study aims to measure the stigma and self-management levels of individuals diagnosed with epilepsy and determine the relationship between stigma and self-management.

METHODS

This descriptive and associational study was conducted in the Neurology Outpatient Clinic of a Training and Research Hospital and 295 patients were included in the sample based on various inclusion criteria such as having a diagnosis of epilepsy for at least six months and not having any psychiatric disorder that would prevent reading and comprehension. Data were collected through the Descriptive Information Form, the Stigma Scale of Epilepsy, and the Epilepsy Self-Management Scale. Data analysis was performed using IBM SPSS Statistics Standard Concurrent User V 26 statistical package program.

FINDINGS

The Stigma Scale of Epilepsy total mean score was found 60.62 ± 15.40 in individuals diagnosed with epilepsy. The mean scores for the sub-scales were found 7.08 ± 2.20 for the false beliefs sub-scale, 18.86 ± 4.97 for the discrimination sub-scale, 21.64 ± 7.07 for the social isolation sub-scale, 8.46 ± 3.18 for the inadequacy sub-scale, and 5.45 ± 1.41 for the stigma resistance sub-scale. The ESMS total mean score of individuals diagnosed with epilepsy was found to be 140.54 ± 15.33. The mean scores for the ESMS sub-scales were 44.76 ± 4.29 for the medicine management sub-scale, 20.29 ± 5.98 for the information management sub-scale, 30.49 ± 4.80 for the safety management sub-scale, 23.95 ± 4.34 for the seizure management sub-scale, and 21.02 ± 4.65 for lifestyle management sub-scale. A significant and negative relationship was found between the Epilepsy Self-Management Scale (ESMS) and the Stigma Scale of Epilepsy.

CONCLUSION

This study found that individuals experienced a moderate level of stigma and had high levels of self-management. Stigma was found to decrease with the increase in the self-management level. In this regard, it is recommended to conduct intervention studies to increase self-management levels and reduce stigma for individuals diagnosed with epilepsy.

Psychological and social aspects of people with epilepsy expressed through drawing: Pilot study

INTRODUCTION

Frequently, the psychological and social aspects of PWE go unnoticed in medical consultations. Even in spite of having seizure control, some people can experience a poor quality of life. The objective of the study was to determine if drawing facilitates the expression of the psychological and social difficulties of PWE.

METHODS

Hermeneutic, qualitative, situated knowledge study located in the city of Medellín, Colombia. The participants were asked to make one or several drawings under the question "what it is like to live with epilepsy". The drawings were analyzed with criteria of Gestalt psychology, semiotics, image-word relationship and context.

RESULTS

Sixteen drawings of ten participants were obtained. The drawings revealed the construction of an identity of otherness and negative emotionality due to epilepsy. The social concepts of restriction, prohibition, dependency, and exclusion appear in the drawings. The authors expose the ways to face adversity.

CONCLUSION

Drawing can expose and facilitate the expression of the psychological and social difficulties of PWE, which often go unnoticed in the medical office. Free drawing is an easy-to-use global tool that has been underused in the medical field.

A study of factors influencing self-stigma in people with epilepsy: A nationwide online questionnaire survey in Japan

OBJECTIVE

Epilepsy carries a significant stigma. While there is some evidence that self-stigma accompanies a lack of knowledge about epilepsy, there are no studies in Japan. This study aimed to determine factors contributing to self-stigma in Japan.

METHODS

We conducted an online questionnaire survey. Three hundred and ten patients completed the questionnaire (mean age of 47.8 ± 11.9) in contrast to the total registered users on the questionnaire site as 28 315 from Jul 29 to Aug 2, 2021. We asked about demographic variables, satisfaction with treatment, limitations in life, support status, seizure frequency, the Epilepsy Self-Stigma Scale (ESSS), the Rosenberg Self-Esteem Scale (RSES), and the Epilepsy Knowledge Scale (EKS). We conducted the statistical analysis on self-stigma, self-esteem, knowledge of epilepsy, and seizure frequency associations by Spearman's rank correlation.

RESULTS

The mean value of the EKS was 40.19 ± 18.75, the ESSS was 17.69 ± 6.25, and the RSES was 26.02 ± 6.13. We identified a significant moderate negative correlation between self-esteem and self-stigma (P < .001, ρ = -.423), a significant weak positive correlation between self-esteem and knowledge (P = .005, ρ = .177), and a significant weak negative correlation between seizure frequency and self-stigma (P < .001, ρ = -.162). Of the 186 respondents who were working or studying, 91 (49%) participants had experienced any discrimination due to epilepsy. The use of psychosocial support, that is, participating in epilepsy self-help groups and educational programs, was 5.8%.

SIGNIFICANCE

There was no correlation between the strength of self-stigma and the knowledge, while there was a positive correlation between self-esteem and knowledge (P = .005, ρ = .177). There was a negative and weak correlation between seizure frequency and self-stigma (p < .001, ρ = -.162). These results suggest that sufficient knowledge may improve the self-esteem and thus reduce the self-stigma. In addition, short-term treatment for seizure control is insufficient to reduce self-stigma. The dissemination for people to enable sufficient epilepsy knowledge and positive perceptions of epilepsy by increasing self-efficacy throughout a lifetime may reduce self-stigma.

Felt Stigma and Its Underlying Contributors in Epilepsy Patients

Objective

To explore the correlated clinical and psychological factors of stigmatization and investigate the relationship between stigma and white matter abnormalities in epilepsy patients.

Methods

Stigmatization was obtained by a three-item stigma scale in 256 epilepsy patients with genetic or unknown etiology. Personality and quality of life (QOL) were assessed by Eysenck Personality Questionnaire (EPQ) and QOL-31 questionnaire respectively. One hundred and fourteen of them were performed Hamilton Depression Scale-17 (HAMD) and scanned with diffusion tensor imaging in 3T MRI. Fractional anisotropy (FA) values of frontotemporal contact fibers were calculated.

Results

There were about 39.8% patients felt stigma, with the highest score (Score 3) in 8.2% (21/256). Stigma scores were significantly negatively correlated with education (P < 0.01), age of onset (P < 0.05), extraversion score of EPQ (P < 0.01), total and all the subscale QOL scores (P < 0.001), and positively correlated with duration (P < 0.01), HAMD score (P < 0.001), neuroticism score of EPQ (P < 0.001). We found negative correlation between stigma scores and FA values of right superior longitudinal fasciculus and left cingulum (P < 0.05). Logistic regression results showed that FA value of left cingulum (P = 0.011; OR = 0.000), social function (P = 0.000; OR = 0.935) of QOL, and neuroticism score of EPQ (P = 0.033; OR = 1.123) independently correlated to felt stigma.

Conclusion

Felt stigma in epilepsy patients was found to be correlated with neuroticism, depression, and deficient social function of QOL, which might be predisposed by the impairment of the left cingulum. Our results provide preliminary evidence for the underlying neural circuits in stigmatization.

Validity and reliability of the Chinese version of the epilepsy stigma scale

OBJECTIVE

This study was conducted to test the validity and reliability of the Chinese version of the epilepsy stigma scale (ESS), which aims to better understand the stigma of patients with epilepsy (PWEs), lays the foundation for future investigation and explores appropriate strategies to mitigate PWEs' stigma in Chinese culture.

METHODS

The scale was translated following standard procedures. For psychometric validation, the Chinese version of the ESS was administered to 214 PWEs above the age of 16 who were diagnosed with epilepsy by two trained epileptologists and were taking anti-seizure drugs for at least a month. All of the patients were recruited from Xiangya Hospital of Central South University of China from August 2021 to September 2021.

RESULTS

The Cronbach's alpha coefficient was 0.893 for the entire scale, 0.903 for felt stigma, and 0.688 for enacted stigma. Exploratory and confirmatory factor analyses were conducted and showed that the scale was grouped under two dimensions, and the results of confirmatory factor analysis support the structure.

CONCLUSION

The Chinese version of the ESS is a valid and reliable tool to assess epilepsy-related stigma in Chinese culture.

Prejudices against people with epilepsy as perceived by affected people and their families

PROBLEM

Prejudices can impair social participation of people with epilepsy.

METHODS

From 2019 to 2020, we invited people with epilepsy and their relatives across Germany to fill in a questionnaire.

RESULTS

Two hundred and thirty people with epilepsy (PWE, median age: 40 years; min./max.: 19/83; 66% female) and 103 relatives (REL, median age: 42 years; min./max. 23/70; 83% female) took part in the survey. 44% PWE and 40% REL said prejudices against PWE had not declined in recent years. Of PWE, 64% reported they had experienced prejudices themselves. In an open question with multiple answers possible, 71% of the PWE described concrete prejudices against PWE, 62% of the REL did so. The reported prejudices concerned symptoms of epilepsy (37% PWE; 23% REL), academic or occupational performance (47% PWE; 38% REL), social or family life (27% PWE, 29% REL), and other topics (7% PWE, 4% REL). Of PWE, 88% said all or almost all relatives knew about their condition, 74% stated this applied to all or almost all friends, and 48% told all or almost all colleagues about their epilepsy. Of PWE, 94% would want to know if a relative had epilepsy, 87% would like to know about a friend's epilepsy, 70% about a colleague's epilepsy. Fear of stigmatization was a reason for not always communicating the condition according to 20% PWE and 63% REL. None of PWE and 16% of REL named shame as a reason.

CONCLUSION

People with epilepsy still experience prejudices and fear of stigmatization hinders an open communication about the condition.

Depression severity mediates the impact of perceived stigma on quality of life in patients with epilepsy

OBJECTIVE

To determine whether and the extent to which depression severity mediates the impact of perceived stigma on quality of life in patients with epilepsy (PWE).

METHODS

A consecutive cohort of 165 PWE was invited to participate in this study. Each participant completed the Kilifi Stigma Scale of Epilepsy (KSSE), Depression Inventory for Epilepsy (NDDI-E), and Quality of Life in Epilepsy Inventory (QOLIE-31). Mediation analysis was employed to assess whether depression severity mediates the relationship between perceived stigma and quality of life.

RESULTS

Perceived stigma was positively associated with depression severity and negatively associated with quality of life in PWE. The mediation analysis confirmed that perceived stigma had an indirect effect on the quality of life through the mediating variable of depression severity in PWE (B = -0.576, SE = 0.097, Bootstrap95% CI = -0.784 to -0.405). The indirect effects of perceived stigma on quality of life through depression severity accounted for 57.7% of the total effects of perceived stigma on quality of life.

CONCLUSION

This study provided evidence that depression severity mediates the impact that perceived stigma has on quality of life, indicating that assessment of and interventions targeting depression may be appropriate for PWE.