Accounting for comorbidity in assessing the burden of epilepsy among US adults: results from the National Comorbidity Survey Replication (NCS-R)

Elevated suicide risk in individuals with epilepsy: a systematic review and meta-analysis

OBJECTIVE

Suicide is among the top 10 leading causes of death. Epilepsy is associated with increased diagnoses of psychiatric conditions. Approximately 5% of deaths in people with epilepsy (PwE) are caused by suicide. We aim to compare the suicide incidence in PwE vs. people without epilepsy.

METHODS

A systematic review was performed looking at suicide incidence among PwE compared to persons without epilepsy. The reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed in this study. The search included records until February 2024 in Ovid® MEDLINE, Embase®, and PsycINFO. Abstracts were screened in duplicate and extracted using standard proforma. Data were recorded on the incidence of suicide ideation, attempt, or completed suicide in PwE compared to persons without epilepsy. Meta-analyses were performed along with descriptive analyses.

RESULTS

Out of a total of 7,371 records identified from the systematic search, 13 met the eligibility criteria. Meta-analysis showed a significantly higher incidence proportion of suicide ideation in PwE than those without epilepsy (risk ratio [RR]: 2.06, 95% CI 1.47-2.89). For suicide attempts, incidence proportion (RR: 3.62, 95% CI 2.88-4.55), incidence rate (incidence rate ratio [IRR]: 4.94, 95% CI 4.44-5.50) and hazard (adjusted hazard ratio [HR]: 2.32, 95% CI 2.17-2.48) were all significantly higher in PwE vs. people without epilepsy. Lastly, incidence proportion (RR: 2.39, 95% CI 1.28-4.47), incidence rate (IRR: 2.26, 95% CI 2.13-2.40), and hazard (adjusted HR: 2.50, 95% CI 1.99-3.16) of completed suicide were all significantly higher in PwE than those without epilepsy.

SIGNIFICANCE

The incidence of suicide ideation, suicide attempt, and completed suicide were significantly higher in PwE compared to people without epilepsy. Comprehensive support systems to educate, diagnose, and manage epilepsy and concurrent psychiatric conditions in PwE are highly suggested.

Psychiatric Comorbidities in Persons With Epilepsy Compared With Persons Without Epilepsy: A Systematic Review and Meta-Analysis

Importance

Several psychiatric disorders have been found to occur more frequently in persons with epilepsy (PWE) than in persons without epilepsy.

Objective

To summarize the prevalence of 20 psychiatric disorders in PWE compared with persons without epilepsy.

Data Sources

The search included records from inception to February 2024 in Ovid, MEDLINE, Embase, and PsycINFO.

Study Selection

Published epidemiological studies examining the prevalence of psychiatric disorders among PWE compared with persons without epilepsy were systematically reviewed. There were no restrictions on language or publication date.

Data Extraction and Synthesis

Abstracts were reviewed in duplicate, and data were extracted using a standardized electronic form. Descriptive statistics and meta-analyses are presented.

Main Outcomes and Measures

Data were recorded on the prevalence of 20 psychiatric disorders among PWE compared with persons without epilepsy. Meta-analyses were performed along with descriptive analyses.

Results

The systematic search identified 10 392 studies, 27 of which met eligibility criteria. The meta-analyses included 565 443 PWE and 13 434 208 persons without epilepsy. The odds of most psychiatric disorders studied were significantly increased in PWE compared with those without epilepsy, including anxiety (odds ratio [OR], 2.11; 95% CI, 1.73-2.58); depression (OR, 2.45; 95% CI, 1.94-3.09); bipolar disorder (OR, 3.12; 95% CI, 2.23-4.36); suicidal ideation (OR, 2.25; 95% CI, 1.75-2.88) but not suicide attempt (OR, 3.17; 95% CI, 0.49-20.46); psychotic disorder (OR, 3.98; 95% CI, 2.57-6.15); schizophrenia (OR, 3.72; 95% CI, 2.44-5.67); obsessive-compulsive disorder (OR, 2.71; 95% CI, 1.76-4.15); posttraumatic stress disorder (OR, 1.76; 95% CI, 1.14-2.73); eating disorders (OR, 1.87; 95% CI, 1.73-2.01); alcohol misuse (OR, 3.64; 95% CI, 2.27-5.83) and alcohol dependence (OR, 4.94; 95% CI, 3.50-6.96) but not alcohol abuse (OR, 2.10; 95% CI, 0.60-7.37); substance use disorder (OR, 2.75; 95% CI, 1.61-4.72); autism spectrum disorder (OR, 10.67; 95% CI, 6.35-17.91); and attention-deficit/hyperactivity disorder (OR, 3.93; 95% CI, 3.80-4.08).

Conclusions and Relevance

In this comprehensive study, most psychiatric comorbidities examined were significantly more prevalent in PWE than in those without epilepsy. These findings show the high burden of psychiatric comorbidities in PWE. This, in turn, underscores the need for appropriately identifying and treating psychiatric comorbidity in epilepsy to manage patients effectively and improve quality of life.

Multipsychiatric Comorbidity in People With Epilepsy Compared With People Without Epilepsy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Persons with epilepsy (PwE) have a higher risk of developing psychiatric comorbidities compared with the general population. There is limited knowledge about the prevalence of multiple psychiatric conditions in PwE. We summarize the current evidence on the prevalence of multipsychiatric comorbidities in PwE compared with persons without epilepsy.

METHODS

A systematic review of multipsychiatric comorbidities in PwE compared with persons without epilepsy was performed, and the results were reported using the Preferred Reporting Items of Systematic Reviews and Meta-analyses reporting standards. The search was conducted from January 1945 to June 2023 in Ovid MEDLINE. Embase, and PsycINFO, using the search terms related to "epilepsy," "psychiatric comorbidity," and "multimorbidity," combined with psychiatric disorders. Abstracts were reviewed in duplicate, and data were independently extracted using standard proforma. Data describing multipsychiatric comorbidities in PwE compared with persons without epilepsy were recorded. Descriptive statistics and, when feasible, meta-analyses are presented. The risk of bias of the studies was assessed using the Newcastle-Ottawa Scale and the International League Against Epilepsy tool.

RESULTS

A total of 12,841 records were identified from the systematic database search, and 15 studies met the eligibility criteria. All included studies were deemed high-quality in risk of bias according to both tools. The prevalence of multipsychiatric comorbidity was greater in persons with compared with those without epilepsy. The pooled prevalence of concomitant depression and anxiety disorder in PwE in 2 population-based studies was 15 of 163 (9.2%), which was significantly higher than 250 of 10,551 (2.4%) in patients without epilepsy (odds ratio [OR] 3.7, 95% CI 2.1-6.5, p-value <0.001, I2 = 0%, Cochran Q p-value for heterogeneity = 0.84). In 2 hospital-based studies, the prevalence of concomitant depression and attention-deficit/hyperactivity disorder in PwE (14/97, 14.4%) was significantly higher than in patients without epilepsy (5/126, 3.9%), with an OR 5.2 (95% CI 1.8-15.0, p-value = 0.002, I2 = 0%, Cochran Q p-value for heterogeneity = 0.79).

DISCUSSION

PwE experience elevated levels of multipsychiatric comorbidity compared with those without epilepsy. However, very few studies have empirically evaluated the extent of multipsychiatric comorbidity in PwE compared with persons without epilepsy nor their associations and consequences to prognosis in PwE.

Stress and Epilepsy: Towards Understanding of Neurobiological Mechanisms for Better Management

Stress has been identified as a major contributor to human disease and is postulated to play a substantial role in epileptogenesis. In a significant proportion of individuals with epilepsy, sensitivity to stressful events contributes to dynamic symptomatic burden, notably seizure occurrence and frequency, and presence and severity of psychiatric comorbidities [anxiety, depression, posttraumatic stress disorder (PTSD)]. Here, we review this complex relationship between stress and epilepsy using clinical data and highlight key neurobiological mechanisms including the hypothalamic-pituitary-adrenal (HPA) axis dysfunction, altered neuroplasticity within limbic system structures, and alterations in neurochemical pathways such as brain-derived neurotrophic factor (BNDF) linking epilepsy and stress. We discuss current clinical management approaches of stress that help optimize seizure control and prevention, as well as psychiatric comorbidities associated with epilepsy. We propose that various shared mechanisms of stress and epilepsy present multiple avenues for the development of new symptomatic and preventative treatments, including disease modifying therapies aimed at reducing epileptogenesis. This would require close collaborations between clinicians and basic scientists to integrate data across multiple scales, from genetics to systems biology, from clinical observations to fundamental mechanistic insights. In future, advances in machine learning approaches and neuromodulation strategies will enable personalized and targeted interventions to manage and ultimately treat stress-related epileptogenesis.

Project UPLIFT: Adoption and implementation experiences of an epilepsy self-management program

RATIONALE

Project UPLIFT is an evidence-based epilepsy self-management program shown to prevent and treat depression through an 8-session, group telehealth intervention. Since 2012, the program has been disseminated by training community-based providers to deliver UPLIFT to people with epilepsy (PWE). Limited research has described the adoption, implementation, and practice-based maintenance of self-management programs like UPLIFT. We sought to gain a better understanding of this process from trained program adopters.

METHODS

A cross-sectional evaluation of adoption and implementation experiences was conducted. An online survey with closed- and open-ended questions was distributed to 120 UPLIFT program adopters to collect information about reasons for being trained and experiences implementing the program. Survey items were developed based on the RE-AIM model to assess program reach, effectiveness, adoption, implementation, and maintenance. For closed-ended responses, frequencies and cross-tabs were calculated. Open-ended responses were reviewed and grouped by theme.

RESULTS

41 respondents completed the survey (34% response rate). Respondents were from a variety of organizations including clinical (39%, n = 16), educational/research (17%, n = 7), and Epilepsy Foundation affiliates/chapters (12%, n = 5), among others. The most frequently endorsed reason for training in UPLIFT was an interest in supporting PWE (73%, n = 30). Most respondents rated delivering UPLIFT as very important (49%, n = 20) or important (32%, n = 13) to the organization. Sixty-one percent (n = 25) of respondents reported implementing (implementors) UPLIFT. Of those who had not yet implemented UPLIFT, 50% (n = 8) planned on implementing it at some point. Among program implementors, the most frequently reported implementation facilitators included participant interest (68%, n = 17), training (68%, n = 17), and organizational support (64%, n = 16). Program implementors indicated having program champions (80%, n = 20). The most frequently reported implementation challenge reported was recruitment (72%, n = 18). In open-ended responses, funding was a key theme that would facilitate continued implementation, but 48% (n = 12) responded that did not have access to resources and/or funding to help continue offering UPLIFT. Developing partnerships was recommended to improve the reach and maintenance of the program. Despite challenges, implementors agreed (44%, n = 11) or strongly agreed (36%, n = 9) that UPLIFT was effective in addressing mental health problems among program participants, and 76% (n = 19) plan on continuing to offer UPLIFT.

CONCLUSION

Implementation surveys increase understanding of program adoption and impact for dissemination trainees. Implementation benefits from program champions, strong partnerships, and sustained funding. Continued refinement of implementation support, such as developing a sustained referral system, maintaining relationships with trainees, supporting evaluation activities, and exploring opportunities for program updates to further enhance adoption, implementation, and maintenance.

Anxiety, depression, and psychosocial adjustment in people with epilepsy

Objective

Effect of psychological disorders on social functioning in people with epilepsy (PWE) is not extensively reported. We evaluate psychosocial functioning in PWE attending an outpatient clinic and aim to understand the differences in psychosocial functioning between anxiety, depression, and coexisting anxiety and depression in PWE.

Materials and Methods

A prospective evaluation of psychosocial functioning of 324 consecutive adult PWE attending outpatient epilepsy clinic was done using self-reported Washington Psychosocial Seizure Inventory. The study population was divided in four groups - without psychological disorders, anxiety, depression, and both anxiety and depression.

Results

The mean age of study population was 25.90 ± 6.22 years. Anxiety was noted in 73 (22.5%), depression in 60 (18.5%), and both anxiety and depression were seen in 70 (21.6%) and the rest had normal psychosocial function. There were no significant differences across all the four sub-groups for sociodemographics. Psychosocial functioning did not differ significantly between PWE with normal psychosocial function and PWE with anxiety alone. However, psychosocial functioning scores were worse in PWE with depression and PWE with both anxiety and depression when compared to PWE with normal psychosocial function.

Conclusion

In the present study of PWE attending an outpatient epilepsy clinic, one-fifth of PWE had both anxiety and depression. Psychosocial functioning in PWE with anxiety was similar to otherwise healthy/normal PWE, whereas PWE with depression showed poor psychosocial functioning. Role of psychological interventions on psychosocial aspects of epilepsy should be studied extensively in future.

Shame, stigma, and social exclusion: The lived experiences of epileptic patients in a health facility in Ilorin, Nigeria

BACKGROUND

The highest number of persons living with epilepsy (PLWE) are in Africa and the majority live in deplorable conditions, while dealing with varying layers of stigma, social exclusion, and discrimination.

OBJECTIVE

This study explored the lived experiences of PLWE in Ilorin.

METHODS

Adopting a qualitative design and a phenomenological lens, 10 PLWE between the ages of 18 and 60 were purposively selected from the University of Ilorin Teaching Hospital (UITH) for in-depth interviews.

RESULTS

Findings suggest that PLWE bear multiple and intersecting burdens, including physical injuries; institutional, cultural, and economic constraints; psychological strain; social exclusion; and stigma. These disadvantages are often sustained and reproduced by various assumptions about epilepsy; as such, PLWE conceal their condition, and this implicatively reinforce stigma. Difficulty sustaining intimate relationships, overt physical scars, and inferiority complexes are recurrent challenges for PLWE. The study showed that adherence to drugs, self-management, personal precautions towards seizure signs, and family support are important coping strategies.

CONCLUSION

The study recommends that it is imperative to enhance and sustain systems, processes, and attitudes that prioritise the physical, social, and emotional needs of PLWE, because this is significant for their enhanced quality of life (QoL).

Postoperative Evaluation of the Quality of Life, Depression, and Anxiety of Temporal Lobe Epilepsy Cohort: A Single Institute Experience in Indonesia

Background: Besides seizure control, quality of life (QoL) should be considered as an equally important outcome for epilepsy surgery service providers. The paucity of QoL reports from developing countries has enlarged the representation gap between wealthy countries and countries with fewer resources. In this study, we evaluated postoperative QoL in the Indonesian drug-resistant epilepsy cohort where the epilepsy surgery service faces limited resource availability.

Methods: We evaluated the QoL in patients with temporal lobe epilepsy who underwent surgery in our epilepsy surgery center in Semarang, Indonesia, from 2001 until 2015. The follow–up period started in 2018 through 2019. Postoperative QoL, depression, and anxiety were evaluated with self-reporting questionnaires including the Quality of Life in Epilepsy Inventory-31, Beck Depression Inventory-II, and Zung Self-Rating Anxiety Scales.

Results: Forty returned questionnaires were included in the analysis (male 25, 62.5%; mean age 27.6 ± 9.05 years). The seizure-free cohort (n = 22, 55.0%) reported higher scores in most QoL dimensions particularly adjustment, overall QoL, and seizure worry compared to those with persistent seizures. The overall QoL level was correlated with seizure freedom and surgery type. QoL dimensions were negatively correlated with anxiety and depression levels.

Conclusions: Postoperative seizure freedom was a major factor of postoperative QoL level. Besides seizure freedom, anxiety and depression levels were also negatively correlated with QoL levels in the Indonesian population.

Smokers with and without Epilepsy show Similar Smoking Rate, Dependence Level, Cessation Attempts, and Motives

BACKGROUND

Individuals with epilepsy are up to twice as likely to be current cigarette smokers compared to those without. Moreover, one study showed current smoking is associated with an increased likelihood of seizures. However, outside of this one study, there is limited data on the presentation of specific smoking-related behaviors and cognitions in people with epilepsy, inhibiting our understanding of the severity of this behavior and our ability to formulate effective treatments for this population.

PURPOSE

The current study examined smoking-related behaviors and cognitions among smokers with epilepsy compared to smokers without epilepsy.

METHODS

Participants were 43 smokers with (Mage = 43.4, SD = 11.6) and 43 smokers without (Mage = 45.5, SD = 8.8) epilepsy recruited from an urban, academic setting within the U.S. Separate Analyses of Covariance (ANCOVAs) were conducted to evaluate differences between smokers with and without epilepsy in terms of smoking behavior (i.e., daily smoking rate, nicotine dependence, number of quit attempts, smoking duration, age of smoking onset) and smoking-related cognitive processes (i.e., smoking motives, perceived barriers to smoking cessation, cessation motives) after controlling for race and problematic alcohol use.

RESULTS

Smokers with epilepsy did not differ from smokers without epilepsy in terms of smoking rate (p = .51, ηp2 = .01), nicotine dependence (p = .12, ηp2 = .03), age of smoking onset (p = .42, ηp2 = .01), number of quit attempts (p = .43, ηp2 = .01), barriers to cessation (p = .30 to .80, ηp2 = .00 to .01), or cessation motives (p = .28 to .60, ηp2 = .00 to .02). Smokers without epilepsy reported higher levels of smoking for sensorimotor manipulation reasons (p = .03, ηp2 = .06) and longer smoking duration (p = .03, ηp2 = .06) than smokers with epilepsy.

CONCLUSIONS

Smokers with epilepsy do not appear to differ significantly from smokers without epilepsy in terms of smoking-related behaviors and cognitions, and may therefore benefit from current evidence-based treatments for smoking cessation that are not contraindicated for epilepsy (i.e., bupropion, varenicline).

Post-traumatic stress disorder (PTSD) in patients with epilepsy

Anxiety and depression in epilepsy are strongly documented but post-traumatic stress disorder (PTSD) is underestimated and poorly known. We studied the links between psycho-traumagenic events (TE), onset of epilepsy, and severity of PTSD symptoms in patients with epilepsy. The study included 54 patients with epilepsy and 61 controls. We used validated questionnaires to screen for anxiety, depression, and PTSD symptoms and we conducted an interview to measure the prevalence of TE. We developed an original exploratory questionnaire to assess the presence of PTSD during interictal and peri-ictal periods. The results show that patients reported more exposure to a TE and presented significantly more severe PTSD symptoms than controls. Seventy-eight percent of patients (vs. 52% of controls) had been exposed to a TE, and 26% (vs. 7%) had a score above the diagnostic threshold of the PTSD scale. In addition, 18.6% of patients reported that their epilepsy began at the same time as they began to experience PTSD symptoms following a TE. Patients with high PTSD scores (above the threshold, n = 14) reported significantly more depression symptoms than patients without PTSD and reported PTSD symptoms both during the ictal and peri-ictal periods. Within the whole group of patients, anxiety (72%) and depression (33%) symptoms significantly correlated with PTSD symptoms reported by the scale. This study shows that patients with epilepsy have increased prevalence of self-reported PTSD symptoms. We describe the clinical picture specific to patients with epilepsy, which may include classical PTSD symptoms but also specific peri-ictal symptoms.

Patients' perceptions of orthodontic treatment experiences during COVID-19: a cross-sectional study

BACKGROUND

COVID-19 has impacted the care of patients undergoing orthodontic treatment. We aimed to provide an overall view of patients' perspectives, concerns, and expectations towards their treatment throughout the clinic lockdown during the pandemic; and to assess patients' levels of mental distress and its association with their confidence in resuming care.

METHODS

An anonymous, validated, in-person paper questionnaire was distributed to adult orthodontic patients' post-lockdown at an academic institution. The survey focused on the clinical aspects and patients' perspectives regarding orthodontic treatment during the pandemic. The Kessler Mental Distress Scale (K10) was used to evaluate their psychological status. Survey responses were descriptively summarized and confidence in resuming care was compared between normal patients and patients with mental distress using Mann-Whitney tests.

RESULTS

One hundred fifty-four patients were surveyed from July to October 2020. Mean age of the participants was 29.30 (SD = 12.01) years and 62% were females. Emergencies during the closure (21%, 32/154) involved primarily irritation with protruding wires. Patients were neutral regarding tele-dentistry and preferred their current fixed appliances over clear aligners. Upon resuming care, 80.51% were extremely pleased with the restrictive protocols and with high level of confidence in resuming treatment. The average level of anxiety was low, and a modest association was found between mental distress and reduced confidence in resuming treatment.

CONCLUSIONS

Few numbers of minor emergencies occurred during the clinic closure. Despite the rising interest in tele-dentistry, patients were neutral on considering this option to monitor treatment and were content with fixed appliances. Patients had high confidence levels to resume their care based on the protocols established upon reopening. The association of mental distress and confidence in resuming care is suggestive and needs further investigation.

Addressing neuropsychological diagnostics in adults with epilepsy: Introducing the International Classification of Cognitive Disorders in Epilepsy: The IC CODE Initiative

This paper addresses the absence of an international diagnostic taxonomy for cognitive disorders in patients with epilepsy. Initiated through the 2020 Memorandum of Understanding between the International League Against Epilepsy and the International Neuropsychological Society, neuropsychological representatives from both organizations met to address the problem and consequences of the absence of an international diagnostic taxonomy for cognitive disorders in epilepsy, overview potential solutions, and propose specific solutions going forward. The group concluded that a classification of cognitive disorders in epilepsy, including an overall taxonomy and associated operational criteria, was clearly lacking and sorely needed. This paper reviews the advantages and shortcomings of four existing cognitive diagnostic approaches, including taxonomies derived from the US National Neuropsychology Network, DSM-V Neurocognitive Disorders, the Mild Cognitive Impairment classification from the aging/preclinical dementia literature, and the Research Domain Criteria Initiative. We propose a framework to develop a consensus-based classification system for cognitive disorders in epilepsy that will be international in scope and be applicable for clinical practice and research globally and introduce the International Classification of Cognitive Disorders in Epilepsy (IC-CODE) project.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Evolution of interictal spiking during the latent period in a mouse model of mesial temporal lobe epilepsy

Interictal spikes and high-frequency oscillations (HFOs, ripples: 80–200 ​Hz, fast ripples: 250–500 ​Hz) occur in epileptic patients and in animal models of mesial temporal lobe epilepsy (MTLE). In this study, we explored how type 1 and type 2 interictal spikes as well as ripples and fast ripples evolve during the latent period in the hippocampus of pilocarpine-treated mice. Depth EEG recordings were obtained from the hippocampus CA3 subfield of adult male mice (n ​= ​5, P60–P100) starting one day before pilocarpine-induced status epilepticus up to the first spontaneous seizure, the so-called latent period. We found that rates of type 1 (n ​= ​1 655) and type 2 (n ​= ​2 309) interictal spikes were significantly lower during the late phase of the latent period compared to its early and mid phase (p ​< ​0.001). However, rates of type 1 spikes associated with ripples (n ​= ​266) or fast ripples (n ​= ​106), as well as rates of type 2 interictal spikes associated with ripples (n ​= ​233), were significantly higher during the late phase compared to the early and mid phases (p ​< ​0.05). Our findings reveal that an increase of type 1 interictal spikes co-occurring with ripples or fast ripples and an increase of type 2 interictal spikes co-occurring with ripples mark the end of the latent period. We propose that changes in the occurrence of interictal spike associated with HFOs represent a biomarker of epileptogenicity in this mouse model of MTLE.

•

We studied interictal spike types in a model of mesial temporal lobe epilepsy.

•

Type 1 and type 2 spike rates were lower in the late phase of the latent period.

•

Rates of type 1 spikes with ripples or fast ripples were higher in the late phase.

•

Rates of type 2 spikes with fast ripples were also higher during the late phase.

•

These changes in interictal spike types mark the end of the latent period.

Behavioral, Physiological and EEG Activities Associated with Conditioned Fear as Sensors for Fear and Anxiety

Anxiety disorders impose substantial costs upon public health and productivity in the USA and worldwide. At present, these conditions are quantified by self-report questionnaires that only apply to behaviors that are accessible to consciousness, or by the timing of responses to fear- and anxiety-related words that are indirect since they do not produce fear, e.g., Dot Probe Test and emotional Stroop. We now review the conditioned responses (CRs) to fear produced by a neutral stimulus (conditioned stimulus CS+) when it cues a painful laser unconditioned stimulus (US). These CRs include autonomic (Skin Conductance Response) and ratings of the CS+ unpleasantness, ability to command attention, and the recognition of the association of CS+ with US (expectancy). These CRs are directly related to fear, and some measure behaviors that are minimally accessible to consciousness e.g., economic scales. Fear-related CRs include non-phase-locked phase changes in oscillatory EEG power defined by frequency and time post-stimulus over baseline, and changes in phase-locked visual and laser evoked responses both of which include late potentials reflecting attention or expectancy, like the P300, or contingent negative variation. Increases (ERS) and decreases (ERD) in oscillatory power post-stimulus may be generalizable given their consistency across healthy subjects. ERS and ERD are related to the ratings above as well as to anxious personalities and clinical anxiety and can resolve activity over short time intervals like those for some moods and emotions. These results could be incorporated into an objective instrumented test that measures EEG and CRs of autonomic activity and psychological ratings related to conditioned fear, some of which are subliminal. As in the case of instrumented tests of vigilance, these results could be useful for the direct, objective measurement of multiple aspects of the risk, diagnosis, and monitoring of therapies for anxiety disorders and anxious personalities.

Neuroticism in temporal lobe epilepsy is associated with altered limbic-frontal lobe resting-state functional connectivity

Neuroticism, a core personality trait characterized by a tendency towards experiencing negative affect, has been reported to be higher in people with temporal lobe epilepsy (TLE) compared with healthy individuals. Neuroticism is a known predictor of depression and anxiety, which also occur more frequently in people with TLE. The purpose of this study was to identify abnormalities in whole-brain resting-state functional connectivity in relation to neuroticism in people with TLE and to determine the degree of unique versus shared patterns of abnormal connectivity in relation to elevated symptoms of depression and anxiety. Ninety-three individuals with TLE (55 females) and 40 healthy controls (18 females) from the Epilepsy Connectome Project (ECP) completed measures of neuroticism, depression, and anxiety, which were all significantly higher in people with TLE compared with controls. Resting-state functional connectivity was compared between controls and groups with TLE with high and low neuroticism using analysis of variance (ANOVA) and t-test. In secondary analyses, the same analytics were performed using measures of depression and anxiety and the unique variance in resting-state connectivity associated with neuroticism independent of symptoms of depression and anxiety identified. Increased neuroticism was significantly associated with hyposynchrony between the right hippocampus and Brodmann area (BA) 9 (region of prefrontal cortex (PFC)) (p < 0.005), representing a unique relationship independent of symptoms of depression and anxiety. Hyposynchrony of connection between the right hippocampus and BA47 (anterior frontal operculum) was associated with high neuroticism and with higher depression and anxiety scores (p < 0.05), making it a shared abnormal connection for the three measures. In conclusion, increased neuroticism exhibits both unique and shared patterns of abnormal functional connectivity with depression and anxiety symptoms between regions of the mesial temporal and frontal lobe.

Prevalence and psychopathologic significance of hallucinations in individuals with a history of seizures

OBJECTIVE

A relationship between seizure activity and hallucinations is well established. The psychopathologic significance of hallucinations in individuals with seizures, however, is unclear. In this study, we assessed the prevalence of auditory and visual hallucinations in individuals who reported a seizure history and investigated their relationship with a number of mental disorders, suicidal ideation, and suicide attempts.

METHODS

Data were from the "Adult Psychiatric Morbidity Survey," a population-based cross-sectional survey. Auditory and visual hallucinations were assessed using the Psychosis Screening Questionnaire. Mental health disorders were assessed using the Clinical Interview Schedule. Logistic regressions assessed relationships between hallucinatory experiences and mental disorders, suicidal ideation, and suicide attempts.

RESULTS

A total of 14 812 adults (58% female; mean [standard error of the mean; SEM] age 51.8 [0.15]) completed the study; 1.39% reported having ever had seizures (54% female), and 8% of individuals with a seizure history reported hallucinatory experiences (odds ratio [OR] 2.05, 95% confidence interval [CI] 1.24-3.38). Individuals with seizures had an increased odds of having any mental disorder (OR 2.34, 95% CI 1.73-3.16), suicidal ideation (OR 2.38, 95% CI 1.77-3.20), and suicide attempt (OR 4.15, 95% CI 2.91-5.92). Compared to individuals with seizures who did not report hallucinatory experiences, individuals with seizures who reported hallucinatory experiences had an increased odds of any mental disorder (OR 3.47, 95% CI 1.14-10.56), suicidal ideation (OR 2.58, 95% CI 0.87-7.63), and suicide attempt (OR 4.61, 95% CI 1.56-13.65). Overall, more than half of individuals with a seizure history who reported hallucinatory experiences had at least one suicide attempt. Adjusting for psychopathology severity did not account for the relationship between hallucinatory experiences and suicide attempts.

SIGNIFICANCE

Hallucinatory experiences in individuals with seizures are markers of high risk for mental health disorders and suicidal behavior. There is a particularly strong relationship between hallucinations and suicide attempts in individuals with seizures. Clinicians working with individuals with seizures should routinely ask about hallucinatory experiences.

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.

Association of HIV Infection with Epilepsy and Other Comorbid Conditions

Here, we aimed to investigate the associations of comorbidities in HIV patients given antiepileptic drugs. HIV patients given antiepileptic drugs for at least 6 months were considered. Comorbidities of the epileptic, HIV-positive patients were stratified according to patients' age and causes of epilepsy. Seventy-four of the 97 HIV patients identified had at least one comorbidity. Patients more than 50-years old had more comorbidities (1.9 ± 1.5 vs. 1.1 ± 1.2, p < 0.01) compared with younger subjects. The distribution of the psychiatric disorders was comparable between age-related categories. A marginally significant trend for higher frequency of psychiatric disorders was observed in patients with idiopathic epilepsy versus other causes of epilepsy (43% vs. 24%), Because the presence of comorbid disorders is a major driver for premature mortality both in HIV infection and epilepsy, strategies aimed at favoring prevention, early identification, and adequate treatment in these clinical settings should be pursued at all levels of care.

Correlates of Stigma in People with Epilepsy

Background and Purpose

Epilepsy is often associated with substantial stigma. This study evaluated clinical correlates of stigma in a sample of people living with epilepsy (PLWE) considered high risk due to frequent seizures or other negative health events.

Methods

Data were derived from an epilepsy self-management clinical trial. Standardized measures assessed socio-demographics, epilepsy stigma, epilepsy severity, self-efficacy, self-management competency, health literacy, depressive symptoms severity, functional status, social support and quality of life.

Results

There were 120 individuals, mean age of 41.73 (SD=17.08), 81 men (66.9%), and 79 (65.3%) African-American. Individual factors correlated with worse stigma w ere indicative of more severe or poorly controlled seizures (frequent seizures, worse seizure severity scores, more antiepileptic drugs), mental health comorbidity (worse depression severity, other comorbidities) and factors related to individual functioning and perceived competency in managing their health (health literacy, health functioning, self-efficacy, quality of life). Multivariable linear regression found that worse quality of life, and having a mental condition were associated with more stigma (β=6.4 and 6.8, respectively), while higher self-efficacy, health literacy and social support were associated with less stigma (β=−0.06, −2.1, and −0.3, respectively). These five variables explained 50% of stigma variation.

Conclusions

Stigma burden can be substantial among PLWE and may vary depending on contextual factors such as mental health comorbidity. Care approaches that screen for psychiatric comorbidities, address low health literacy, institute promising self-management programs, and employ effective health communication strategies about epilepsy misconceptions, may reduce epilepsy related burden.

Post-traumatic Stress Disorder With Flashbacks of an Old Childhood Memory Triggered by Right Temporal Lobe Epilepsy Surgery in Adulthood

BACKGROUND

A plethora of data show that the hippocampus and the amygdala are involved in post-traumatic stress disorder (PTSD). Neural dysfunctions leading to PTSD (e.g. how the amygdala and the hippocampus are altered) are only partially known. The unusual case of a patient presenting with refractory epilepsy and developing PTSD immediately after surgery is described. Such symptoms in epileptic patients may help to explore PTSD mechanisms.

CASE REPORT

A 41-year-old male suffering from partial refractory temporal lobe epilepsy was operated in May 2017. A right amygdala, hippocampus, and temporal pole selective resection was performed. He experienced intense PTSD symptoms 1 month after surgery. He complained about repetitive intrusive memories of abuse. The PTSD checklist score was equal to 62/80. He reported a history of childhood abuse: physical and emotional abuse as well as emotional negligence, assessed with the Childhood Trauma Questionnaire. No other medical history was recorded. He never complained about PTSD or any other psychiatric symptoms before surgery.

CONCLUSION

this case indicates that PTSD may occur after temporal lobe epilepsy surgery and may specifically stem, as in this context, from the excision of part of the medial temporal lobe structures. Although rarely reported, PTSD may be undiagnosed when not selectively detected via multi-disciplinary neurological and psychiatric management, in the preoperative period and the immediate and delayed postoperative period.

Depression and quality of life among African Americans with epilepsy: Findings from the Managing Epilepsy Well (MEW) Network integrated database

Depression and worse quality of life (QOL) are significantly associated with epilepsy. However, limited descriptive data on depression and quality of life among African Americans with epilepsy are available. This study sought to describe the prevalence of depression among African Americans with epilepsy participating in self-management studies and to examine the relationship between depression and QOL. Using data from the Managing Epilepsy Well (MEW) research network, a subgroup of African Americans with epilepsy were selected for the analytic sample. Descriptive statistics indicated the prevalence of depression (Patient Health Questionnaire-9 [PHQ-9]) and reports of epilepsy-specific QOL (Quality of Life in Epilepsy-10 [QOLIE-10]) in the sample. Multiple linear regression examined the relationship between depression and QOL while controlling for sociodemographic characteristics and seizure frequency. The prevalence of depression (PHQ-9 ≥; 10) was 47.7%. Quality of life was the only variable significantly associated with depressive symptoms in multivariable analyses, suggesting that depressive symptoms have a stronger relationship with QOL than seizure frequency. With the high levels of depression and the significant relationship with QOL, regular screening of depression is needed among African Americans with epilepsy. Self-management programs that improve mood may also play an important role in improving the lives of African Americans with epilepsy.

Coping with stress: A pilot study of a self-help stress management intervention for patients with epileptic or psychogenic nonepileptic seizures

PURPOSE

Many patients with epilepsy or psychogenic nonepileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness.

METHOD

Patients were recruited from outpatient neurology clinics and randomized to an immediate intervention group (n = 39), who received the intervention at baseline, or a delayed intervention group (n = 43), who received the intervention one-month postbaseline. Participants completed self-report questionnaires measuring stress (Smith Stress Symptom Inventory [SSSI]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]), quality of life (European Quality of Life - 5 Dimensions [EQ-5D]), and seizure severity and frequency (Liverpool Seizure Severity Scale [LSSS-3]) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework.

RESULTS

Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (P = .01) with a medium effect size (d_z = 0.51) was observed one-month postintervention. There were no significant changes in any other measures.

CONCLUSION

The intervention was perceived to be acceptable, safe, and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted.

Disability patterns over the first year after a diagnosis of epilepsy

OBJECTIVE

To determine the patterns and predictors of disability over the first 12 months after a diagnosis of epilepsy.

PATIENTS AND METHODS

The Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC) was a prospective, multicenter, community-based study of people with newly diagnosed epilepsy in Sydney, Australia. Disability was assessed using the World Health Organization's, Disability Assessment Schedule (WHODAS) 2.0 12-item version, at baseline (i.e. within 28 days of diagnosis) and 12 months post-diagnosis. Demographic, socioeconomic, clinical and epilepsy-related data, obtained through structured interviews, were entered into multivariable linear regression and shift analysis to determine predictors of greater disability.

RESULTS

Of 259 adults (≥18 years), 190 (73%) had complete WHODAS at baseline (mean ± SD scores 4 ± 6) and follow-up (4 ± 8). After adjustment for age, sex and co-morbidity, greater overall disability at 12 months was associated with lower education (P = 0.05), economic hardship (P = 0.004), multiple antiepileptic medications (P = 0.02) and greater disability (P < 0.001) at the time of diagnosis; these variables explained 38.3% of the variance. Among the 12 WHODAS items, "being emotionally affected by health problems" was the most frequent disability problem identified at both time points (all P < 0.0001). The proportion of participants without problems in that domain improved over 12 months (from 24% to 50%, P < 0.0001), whereas the other 11 items remained relatively stable. Independent baseline predictors of a worse emotional outcome at 12 months were severe/extreme emotional distress (odds ratio [OR] 4.52, 95% confidence intervals [CI] 1.67-12.24), economic hardship (OR 2.30, 95% CI 1.24-4.25) and perceived stigma (OR 2.02, 95% CI 1.03-3.93).

CONCLUSION

Most people report problems with emotional health after a diagnosis of epilepsy but many recover over the next 12 months. Services addressing the social and psychological impact of diagnosis may be needed to improve outcome.

Panic and epilepsy in adults: A systematic review

The purpose of the current paper was to review the empirical literature on the cooccurrence of panic and epilepsy, in order to determine whether there is an increased risk of panic attacks and panic disorder among adults with epilepsy and an increased risk of epilepsy among adults with panic disorder. Given the overlap between panic and ictal fear, a preliminary aim of the current review was to critically evaluate the methodology used to differentiate between diagnoses of panic disorder and epilepsy in existing research. A literature search was conducted in relevant electronic databases, and articles that directly focused on panic and epilepsy among adults were selected for the current review (n = 17). Overall, results suggest that rates of epilepsy are elevated among individuals with panic disorder and that panic attacks are elevated among individuals with epilepsy, but rates of panic disorder among people with epilepsy are inconsistent. However, most studies did not use sufficiently rigorous methods to differentiate between panic disorder and epilepsy. Therefore, a critical next step in this area of research is to develop a standard procedure for differentiating ictal fear from panic attacks and panic disorder.

Risk of Epilepsy in Individuals With Posttraumatic Stress Disorder: A Nationwide Longitudinal Study

OBJECTIVE

Several cross-sectional studies have reported a relationship between posttraumatic stress disorder (PTSD) and epilepsy. However, the temporal association between PTSD and epilepsy has rarely been investigated. We hypothesized that the risk of developing epilepsy later in life would be higher in patients with PTSD than in those without PTSD.

METHODS

Using the Taiwan National Health Insurance Research Database, 6425 individuals with PTSD and 24,980 age-/sex-matched controls were enrolled between 2002 and 2009 in our study and followed up to the end of 2011. Those who developed epilepsy during the follow-up period were identified.

RESULTS

Individuals with PTSD had a higher incidence of developing epilepsy (2.65 versus 0.33 per 1000 person-years, p < .001), with an earlier onset of epilepsy (37.53 years [15.80 years] versus 48.11 years [23.97 years], p = .002) than did the controls. Individuals with PTSD had an elevated risk of developing epilepsy (hazard ratio [HR] = 3.72, 95% confidence interval [CI] = 2.27-6.11) during the follow-up after adjustment for demographic data and medical and psychiatric comorbidities. Sensitivity analyses after excluding the observation in the first year (HR = 2.53, 95% CI = 1.44-4.47) and the first 3 years (HR = 2.14, 95% CI = 1.15-4.01) revealed consistent results.

CONCLUSIONS

These results supported a temporal association between PTSD and the development of epilepsy. Further studies are warranted to investigate the underlying pathophysiological pathways that explain the longitudinal association of PTSD with subsequent epilepsy.

Case report: Epilepsy surgical outcome for epileptic and non epileptic seizures with posttraumatic stress disorder and depression

A 48-year-old male was diagnosed with both drug resistant epilepsy and psychogenic nonepileptic seizures. Both diagnoses were confirmed by video-EEG monitoring. His epileptic seizures were a consequence of right mesial temporal sclerosis. He was diagnosed by a psychiatrist to have depression and posttraumatic stress disorder (PTSD). Following a right anterior temporal resection he became seizure free (both epileptic and nonepileptic) with a remarkable improvement in his psychiatric comorbidities leading to significant reduction in his psychotropic medications.

No reports have been identified in the literature of patients with epilepsy and PNES with coexisting PTSD having epilepsy surgery.

Diurnal patterns and relationships between physiological and self-reported stress in patients with epilepsy and psychogenic non-epileptic seizures

PURPOSE

Patients with epilepsy and those with psychogenic non-epileptic seizures (PNES) experience high levels of stress and stress is one of the most frequently self-identified seizure precipitants. Although stress is a multifaceted phenomenon, few studies have systematically examined its different components in patients with seizures. The aim of this study was therefore to describe diurnal patterns of psychological and physiological measures of stress in patients with epilepsy and patients with PNES, and explore their relationships to each other in order to improve our understanding of the mechanisms underlying stress and seizure occurrence in these patients.

METHOD

A range of stress markers including self-reported stress, salivary cortisol, and heart rate variability (HRV) were explored in adult patients with refractory epilepsy (N=22) and those with PNES (N=23) undergoing three- to five-day video-telemetry.

RESULTS

A diurnal pattern was observed in the physiological measures, characterized by higher levels of physiological arousal in the mornings and lower levels at night in both patients with epilepsy and PNES. The physiological measures (cortisol and HRV) were associated with each other in patients with epilepsy; no close relationship was found with self-reported stress in either of the two patient groups.

CONCLUSION

The findings contribute to and expand on previous studies of the patterns of stress in patients with seizures. The results also indicate a discrepancy between patients' physiological responses and their subjective stress perceptions, suggesting that simple self-reports cannot be used as a proxy of physiological arousal in patients with seizures and stress. Stress in these patient groups should be studied using a combination of complementary measures.

The epileptic multifactorial patient’s burden. Review of the topic

Background. Approximately 26% of the burden of neurologic diseases is due to epilepsy. Its negative impact reflects mainly on people with epilepsy (PWE) themselves.

Aims. To highlight the negative impacts of epilepsy on the lives of PEW’s so as to identify a realistic approach to their individual needs.

Methods. For recently published papers PubMed and MEDLINE databases were used. In addition relevant references mentioned in the searched articles were also considered.

Review and discussion. Generalized tonic-clonic seizures and refractory epilepsy are the most important factors burdening PWE’s, resulting in increased injuries and mortality, including Sudden Unexpected Death in Epilepsy (SUDEP). The need of chronic intake of antiepileptic drugs (AEDs) and of epilepsy surgery are also important with regards to potential for side effects, drug interactions, and different surgery risks. PWE harbour more medical and psychiatric comorbidities than the general population and results in a decreased quality of life. Decreased self-esteem and major stigma are also frequent, linked to social, economic and personal negative consequences.

Age also plays a role, younger people being more stigmatized given the interdiction to drive or difficulty in getting a job. In the elderly, seizures may have an impact on mental status, mood and sleep. Gender may also contribute, particularly involving women in childbearing age, linked to the fear or depression due to the possibility of AED-induced fertility disturbances, foetal malformations, or breast feeding side-effects.

Conclusions. The burden that PWE face must be considered by all people involved in the management of their epilepsy. The causes may be multifactorial, all interconnected and each one influencing the others.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Excess mortality and hospitalized morbidity in newly treated epilepsy patients

OBJECTIVE

To assess the burden of mortality and hospitalized morbidity in newly treated epilepsy patients.

METHODS

We extracted relevant data of patients with newly treated epilepsy between September 16, 2005, and September 15, 2010, from the data repository covering all public hospitals in Hong Kong. Patients were followed up until September 15, 2011. Mortality and hospitalized morbidity were assessed, stratified by baseline comorbidities, number of antiepileptic drugs (AEDs) used, and treatment with enzyme-inducing AEDs (EIAEDs). Mortality was compared to the age- and sex-specific general population in Hong Kong.

RESULTS

Of the 7,461 newly treated epilepsy patients (55% male; median age 60 years), 2,166 (29%) died during the study period. The standardized mortality ratio was 5.09 (95% confidence interval [CI] 4.88-5.31), and was higher among those with physical or psychiatric baseline comorbidity (5.46; 95% CI 5.22-5.71) than those without (3.28; 95% CI 2.87-3.73). Standardized hospitalization ratio was 6.76 (95% CI 6.70-6.82). Baseline physical comorbidity-free patients (n = 3,514) exhibited higher risk of developing stroke (standardized incidence ratio [SIR] 4.96; 95% CI 4.19-5.84) and ischemic heart disease (SIR 4.18; 95% CI 3.54-4.91), and male patients had elevated risk of developing cancer (SIR 2.30; 95% CI 1.75-2.97). Patients treated with EIAEDs had higher risk of being subsequently recorded with new physical comorbidities than those with non-EIAEDs (relative risk [RR] 1.48; 95% CI 1.19-1.85), especially for cerebrovascular disease (RR 1.78; 95% CI 1.14-2.77).

CONCLUSIONS

Newly treated epilepsy patients bear excess mortality and hospitalization risks. They have higher risk of developing stroke, ischemic heart disease, and cancer. Treatment with EIAEDs was associated with increased overall morbidity.

Glo1 inhibitors for neuropsychiatric and anti-epileptic drug development

Many current pharmacological treatments for neuropsychiatric disorders, such as anxiety and depression, are limited by a delayed onset of therapeutic effect, adverse side effects, abuse potential or lack of efficacy in many patients. These off-target effects highlight the need to identify novel mechanisms and targets for treatment. Recently, modulation of Glo1 (glyoxalase I) activity was shown to regulate anxiety-like behaviour and seizure-susceptibility in mice. These effects are likely to be mediated through the regulation of MG (methylglyoxal) by Glo1, as MG acts as a competitive partial agonist at GABA(A) (γ-aminobutyric acid A) receptors. Thus modulation of MG by Glo1 represents a novel target for treatment. In the present article, we evaluate the therapeutic potential of indirectly modulating MG concentrations through Glo1 inhibitors for the treatment of neuropsychiatric disorders.

Days out of role due to mental and physical illness in the South African stress and health study

BACKGROUND

Both mental and physical disorders can result in role limitation, such as 'days out of role', which have an important impact on national productivity losses. This paper analyses data from the South African Stress and Health Study (SASH) on the association of both mental and physical disorders with days out of role.

METHODS

Face-to-face interviews were conducted with a representative sample of 4,351 adult South Africans. The World Health Organization's Composite International Diagnostic Interview (WHO-CIDI) was used to assess the presence of 21 mental and physical disorders that were grouped into 10 disorder categories for the analysis: major depressive disorder, any anxiety disorders, any substance abuse disorders, headaches or migraine, arthritis, chronic pain, cardiovascular, respiratory, diabetes and digestive disorders. Multiple regression techniques were used to explore associations between individual disorders, comorbid conditions, and annual days spent out of role. The estimated societal effects of the disorders [population attributable risk proportion (PARP)] were obtained.

RESULTS

The majority of respondents who reported a mental or physical disorder also reported another disorder (62.98 %). The average number of disorders reported by respondents who had at least one disorder was 2.3. Overall 12.4 % of respondents reported any days out of role due to mental or physical disorder. Anxiety disorders and depression were associated with highest days out of role (28.2 and 27.2, respectively) followed closely by arthritis and pain (24.7 and 21.7, respectively). Any mental disorder was associated with 23.6 days out of role, while any physical disorder was associated with 15.5 days out of role. Of the mental disorders, anxiety disorders had the highest PARP in relation to days out of role (9.0 %) followed by depression (4.8 %) and substance disorder (3.3. %). More than one-third (37.6 %) of days out of role are attributable to physical disorders and 16.1 % to mental disorders.

CONCLUSIONS

Comorbidity is common in both mental and physical disorders, and both are associated with substantial days out of role in South Africa. These data indicate substantial social and economic loss associated with these conditions, and emphasize the need to integrate health services to include common mental disorders in all basic packages of care and to assess for and manage comorbid conditions.

Diagnoses, procedures, drug utilization, comorbidities, and cost of health care for people with epilepsy in 2012

Our objective was to identify the top MD-office, inpatient and outpatient diagnoses, procedures, drug classes, comorbidities, and cost of health care for people with epilepsy. We examined health insurance claims for 8388 persons with epilepsy (females = 52%, males = 48%; average age = 35 years; privately insured = 78%, and Medicaid-insured = 22%) from eight health insurance plans for the year 2012. All of the top three diagnoses for MD-office place of service were either for other convulsions (780.39) or for epilepsy (345.90 and 345.40). Two of the top three primary diagnosis codes from the inpatient hospital and emergency department places of service were 780.39 and 345.90 for convulsions and epilepsy, respectively, while the third code was 786.50 for chest pain. The top three procedures from the MD-office setting were for immunizations (90471 and 90658) and blood counts (85025). The top three procedure codes from the outpatient hospital setting were 85025 for complete blood count, 80053 for comprehensive metabolic panel, and 80048 for basic metabolic panel. In the emergency department, the top three procedures were electrocardiogram (93010), computed tomography (70450), and chest X-ray (71020). The top five drug classes among prescription drugs billed using an NDC code were (1) anticonvulsants, (2) analgesic-opioids, (3) antidepressants, (4) penicillins, and (5) dermatologicals. The mean monthly health plan paid cost for each patient with epilepsy in 2012 was $1028 (SD = $3181). Of this total, $761 (SD = $2988; 74%) was for medical, and $267 (SD = $760; 26%) was for prescription pharmacy claims. Fifty-eight percent (58%) of the patients had one or more of 29 prespecified comorbidities, while 42% had none. Monthly health-care costs increased markedly as the number of comorbidities increased. This information should help guide cost estimates and resource allocation in order to optimally care for people with epilepsy.

Treating anxiety disorders in children and adolescents with epilepsy: what do we know?

Children with epilepsy are at significant risk of psychiatric disorders, which can in turn negatively impact social skills development, academic achievement, and quality of life. The most commonly reported psychiatric comorbidities in pediatric epilepsy are ADHD, depression, and anxiety. The prevalence rates of anxiety disorders in pediatric epilepsy range from 5 to 49%, and in the general population, anxiety disorders are the most common psychiatric disorder in childhood. For the purposes of this review, anxiety disorders will be examined in order to 1) examine rates of anxiety disorders in children and adolescents with epilepsy, 2) review treatment options for anxiety disorders in children with epilepsy, and 3) identify future avenues for the development of evidence-based practices for the treatment of anxiety disorders in youth with epilepsy.

Choice and control: how involved are people with epilepsy and their families in the management of their epilepsy? Results from an Australian survey in the disability sector

This study explored the extent to which people with epilepsy and their families have choice and control over the management of their epilepsy and the support provided in the Australian disability sector. It measured the level of direct involvement in planning and recording of their epilepsy health-care needs and support required through the use of epilepsy management plans. An Australian online survey was completed by 118 adults with epilepsy and 171 family members of children and adults with epilepsy, providing demographic and diagnostic data and details of their epilepsy management plan, whether they were involved in writing the plan and the extent to which it included their views on how they want to be supported. Results indicate that just over half of all respondents had an epilepsy management plan, with 83% revised within the past 12 months. Although the majority of respondents were directly involved in writing their plan (87%), only two-thirds (66%) felt that their plan included their views on how they wanted to be supported. Open-ended comments from 111 respondents indicated their desire to be actively involved in this process, as either collaborative team members or 'in charge' of the process. In spite of a move towards person-centered approaches and greater choice and control, further emphasis must be placed on actively involving the person with epilepsy and their family in writing and incorporating their views on support within their epilepsy management plans. This research was undertaken by the Epilepsy Foundation to inform the development of epilepsy support resources for the newly introduced Australian National Disability Insurance Scheme.

Substance use disorders and psychotic disorders in epilepsy: a population-based registry study

BACKGROUND

Epilepsy affects around 70 million people worldwide. Psychiatric comorbidity may add to the burden of the disease. We studied substance use disorders and psychotic disorders among people with epilepsy from a population-based perspective.

METHODS

Norwegian specialist health services (hospitals and outpatient clinics) report diagnoses for individual patients to the Norwegian Patient Register. We used information on subjects born in 1930-1994 who were registered with a diagnosis of epilepsy at least once during the five-year period of 2008-2012. We compared the proportion of people with epilepsy registered with substance use disorders (alcohol use disorders or non-alcohol drug use disorders) and psychotic disorders (schizophrenia spectrum disorders or bipolar disorder) with similar figures in the population without epilepsy. We applied chi-square tests and log-binomial regression for analysis.

RESULTS

Overall, 0.90% of the Norwegian adult population was registered with epilepsy in somatic hospitals during 2008-2012. The total proportion registered with alcohol use disorder was 5.74% among people with epilepsy and 1.29% in the population without epilepsy (age- and sex-adjusted relative risk [RR]: 4.42, 95% confidence interval [CI]: 4.22-4.62). The corresponding figures were 4.32% and 1.22% (RR 3.86 [95% CI: 3.67-4.06] for drug use disorder, 1.72% and 0.60% (RR 2.94 [95% CI: 2.71-3.19]) for schizophrenia spectrum disorders, and 1.50% and 0.68% (RR 2.29 [95% CI: 2.10-2.49]) for bipolar disorder.

CONCLUSION

People with epilepsy were more often registered with substance use disorders and psychotic disorders than people without epilepsy. Psychiatric comorbidity requires particular attention in both diagnostic work-up and management of epilepsy, and creates complex medical challenges that require close cooperation between neurologists and psychiatrists. These findings may have implications for the organization and further development of comprehensive epilepsy care.

Risk factors for psychological distress in community-treated epilepsy

The study aimed to determine risk factors for psychological distress in a community-treated sample of patients with epilepsy. This study investigated the Tasmanian Epilepsy Register participants. Participants included were as follows: aged 13 years and over, able to complete the individual computer-assisted participant interview, and diagnosed with epilepsy following an epilepsy specialist review of the diagnostic epilepsy interview, which was interpreted using standardized diagnostic guidelines. Psychological distress was assessed with the Kessler-10 questionnaire. Risk factors were grouped into four domains: sociodemographic factors, disease-related factors, psychological factors, and treatment-related factors. High or very high levels of psychological distress were reported by 22% of the participants, with 7.8% having very high distress. The regression model showed that psychological distress was significantly associated with female gender (F=18.1, p<0.001), diabetes mellitus (F=8.7, p=0.003), intellectual disability (F=7.1, p=0.06), and not receiving phenytoin (F=5.1, p=0.02). While the model was significant (F=5.78, p<0.001), only 11% of the variance of the K-10 score was explained by these factors (adjusted R-squared=0.11). This study identifies female gender and comorbid medical conditions as risk factors for psychological distress and the use of phenytoin as a protective factor. The few factors identified and the limited variance explained suggest that a focus on epilepsy-related variables is unlikely to explain key influences underlying psychiatric comorbidity in patients with epilepsy.

Common comorbidities in women and men with epilepsy and the relationship between number of comorbidities and health plan paid costs in 2010

The objectives of this observational study were to determine the prevalence of the most common comorbidities in women and men with epilepsy and to demonstrate the relationship of these comorbidities to health plan paid costs. Data for 6621 members with epilepsy (52% women, 48% men) from eight commercial health plans were analyzed. The presence of comorbidities in people with epilepsy was identified by searching health insurance claims for 29 prespecified comorbidity-specific diagnosis codes. More women (50%) than men (43%) with epilepsy had one or more of the 29 comorbidities (p<0.05). The top 10 comorbidities for women and their relative prevalences were psychiatric diagnosis (16%), hypertension (12%), asthma (11%), hyperlipidemia (11%), headache (7%), diabetes (6%), urinary tract infection (5%), hypothyroidism (5%), anemia (5%), and migraine (4%). For men, the top 10 comorbidities and their relative prevalences were psychiatric diagnosis (15%), hyperlipidemia (12%), hypertension (12%), asthma (8%), diabetes (5%), headache (4%), cancer (4%), coronary artery disease (3%), anemia (3%), and gastroesophageal reflux disease (3%). Seven of the top 10 comorbidities were common to both women and men. Psychiatric diagnosis was the only comorbidity among the top five comorbidities for all age groups. The presence of one comorbidity approximately tripled the health-care cost for that member compared with the cost for members who had no comorbidities. Additional comorbidities generally further increased costs. The increase in health-care cost per member per month ($) with increase in number of comorbidities was greater for men than for women (p<0.05).

Screening for suicidal ideation in children with epilepsy

Given the FDA's warning regarding the potential connection between suicidal behavior and antiepileptic drugs, this study examined methods by which to detect suicidal ideation in children with epilepsy. It compared the sensitivity, specificity, and area under the curve for identifying children with suicidal behavior using the Child Behavior Checklist (CBCL) and a structured psychiatric interview. Parent-completed CBCLs provided behavioral problem scores on 177 children with epilepsy, aged 5-16years. Psychiatric diagnoses were made based on separate child and parent structured psychiatric interviews about the child. The children answered questions on suicidal behaviors during the interview. A clinically elevated score in the CBCL Total Problems scale and having more than one psychiatric diagnosis, irrespective of the type of diagnosis, were significant predictors and correctly classified children with suicidal ideation in 79% of the cases based on the CBCL and 80% of the cases with more than one psychiatric diagnosis. These findings indicate that elevated CBCL Total Problems scores, a commonly used instrument, can screen and identify risk for suicidal behavior in children with epilepsy. Additionally, irrespective of diagnosis, if a child with epilepsy has more than one psychiatric diagnosis, further assessment of suicidal behavior is warranted. Importantly, the results underscore the utility of having parents complete a questionnaire in the waiting room in order to identify children with epilepsy at risk for suicidal behavior.

High risk of gastrointestinal hemorrhage in patients with epilepsy: a nationwide cohort study

OBJECTIVE

To examine the association between epilepsy and gastrointestinal hemorrhage.

PATIENTS AND METHODS

We conducted a nationwide retrospective cohort study by using data from Taiwan's National Health Insurance Research Database. Patients 20 years and older newly diagnosed as having epilepsy and nonepileptic adults were identified between January 1, 2000, and December 31, 2003, and were observed through December 31, 2008. Cox proportional hazards models were performed to calculate adjusted hazard ratios (HRs) and 95% CIs of gastrointestinal hemorrhage associated with epilepsy.

RESULTS

Compared with the nonepileptic group (n=449,541), epileptic patients (n=1412) had a higher incidence of gastrointestinal hemorrhage (13.4 vs 2.9 per 1000 person-years), with an HR of 2.97 (95% CI, 2.49-3.53). The HRs of gastrointestinal hemorrhage for patients with generalized epilepsy, inpatient care, emergency care, and frequent outpatient visits for epilepsy were 3.50 (95% CI, 2.59-4.72), 3.96 (95% CI, 2.85-5.50), 4.35 (95% CI, 3.15-6.01), and 4.96 (95% CI, 3.97-6.21), respectively. Risks were significantly higher in epileptic patients with mental disorders (HR, 3.20; 95% CI, 2.55-4.01), aged 70 years and older (HR, 4.08; 95% CI, 2.89-5.77), and in the first year after epilepsy (HR, 4.81; 95%, CI, 3.14-7.34).

CONCLUSION

Epilepsy is an independent determinant for gastrointestinal hemorrhage in a chronological and severity-dependent pattern. We urge the development of an adequate surveillance policy and strategy for the early prevention of gastrointestinal hemorrhage in epileptic patients.

The impact of epilepsy on patients' lives

The impact of epilepsy is multifaceted and extensive on its effects. The occurrence of seizures is unpredictable and often dangerous, increasing the risk of injury, hospitalization and mortality, and adversely affecting a patient's mental health, often resulting in anxiety, depression or cognitive impairment. Seizures can also result in stigmatization and social exclusion, with detrimental effects on an individual's confidence and self-esteem. However, the burden of epilepsy extends beyond the effects of seizures themselves. In particular, individuals with epilepsy are significantly more likely to have medical or psychiatric comorbidities than those without epilepsy, and comorbidity in patients with epilepsy has been shown to be strongly correlated with negative impacts on subjective health status and quality of life (QoL). In addition, antiepileptic drug (AED) treatment is commonly associated with side effects, which further impair patients' QoL. Patient surveys provide valuable insights into what matters to patients in their daily lives and highlight important discrepancies between the perceptions of patients and their physicians. For example, survey data show that physicians underestimate the number of patients experiencing AED side effects and the impact of these on patients. Screening questionnaires can help physicians to quickly identify problems with treatment side effects; also, to recognize comorbidities such as depression that are otherwise difficult to identify in a time-limited consultation. Ultimately, successful management of epilepsy requires a holistic approach to care, with treatment tailored to the individual patient's needs; this can only be achieved through effective doctor-patient communication and the full involvement of a multidisciplinary care team.

Ideal characteristics of an antiepileptic drug: how do these impact treatment decisions for individual patients?

Effective management of epilepsy requires a holistic approach that takes into account the needs of the individual patient. Antiepileptic drug (AED) treatment must therefore look beyond efficacy to ensure that the patient's overall health status and quality of life (QoL) are optimized. Because the primary objective of AED treatment is to control seizures over the long term, the ideal AED should, first and foremost, demonstrate sustained efficacy and favourable tolerability. In addition, it should have a broad spectrum of activity; its pharmacokinetic profile should be stable and predictable and allow the option of once-daily dosing; and it should not interact with other medications and concomitant AEDs. Because the efficacy of first-line AEDs is broadly comparable, choice of treatment should be based on the individual patient's specific clinical characteristics. In particular, the primary and secondary prevention of comorbid conditions should be taken into consideration, because this can reduce the risk of mortality and improve health outcomes and QoL. Treatment selection must also take into account the patient's particular lifestyle and priorities, to maximize the likelihood of long-term treatment adherence. Advances in genetic testing may help inform choice of treatment - not only by elucidating a patient's underlying aetiology, but also by helping to avoid unnecessary side effects. Although certain patient populations (e.g. women of childbearing potential, adolescents, the elderly) require particular consideration when choosing the most appropriate treatment, every patient's unique clinical characteristics and personal circumstances must be taken into account to ensure treatment success and optimize their QoL.

Economic differences in direct and indirect costs between people with epilepsy and without epilepsy

OBJECTIVE

To provide generalizable estimates of economic burden in epilepsy and nonepilepsy populations and a comprehensive accounting for employment-based lost productivity associated with epilepsy in current US health care systems as compared with other chronic diseases.

RESEARCH DESIGN

We use the nationally representative data source (Medical Expenditure Panel Survey) from 1998 to 2009 to create a retrospective cohort of people diagnosed with epilepsy by a health professional and a comparison cohort of people with no epilepsy.

MEASURES

Health care utilization and direct costs for all components of treatment, including prescription medications, wages, employment, educational attainment, family income, and lost productivity were outcomes.

RESULTS

We observed economic disparities associated with epilepsy in the United States despite high rates of modern treatments (89% on anticonvulsant therapies). Only 42% of the people with epilepsy over age 18 reported employment compared with 70% of people with no epilepsy; among those, people with epilepsy reported missing an average of 12 days of work because of illness or injury as compared with 4 days in the nonepilepsy cohort. Holding other variables constant, people with epilepsy had a loss of productivity of $9504 in 2011 dollars compared with people with no epilepsy. In comparison, diabetes was associated with annual average lost productivity valued at $3358 and depression at $3182.

CONCLUSIONS

Lost wage-based productivity associated with epilepsy was nearly equal to combined wage losses associated with diabetes, depression, anxiety, and asthma together. To evaluate societal burden of illness, results illustrate the importance of indirect costs in addition to treated prevalence and direct medical costs.

Uncovering the neurobehavioural comorbidities of epilepsy over the lifespan

Epilepsy is a common neurological disorder that is complicated by psychiatric, cognitive, and social comorbidities that have become a major target of concern and investigation in view of their adverse effect on the course and quality of life. In this report we define the specific psychiatric, cognitive, and social comorbidities of paediatric and adult epilepsy, their epidemiology, and real life effects; examine the relation between epilepsy syndromes and the risk of neurobehavioural comorbidities; address the lifespan effect of epilepsy on brain neurodevelopment and brain ageing and the risk of neurobehavioural comorbidities; consider the overarching effect of broader brain disorders on both epilepsy and neurobehavioural comorbidities; examine directions of causality and the contribution of selected epilepsy-related characteristics; and outline clinic-friendly screening approaches for these problems and recommended pharmacological, behavioural, and educational interventions.