Serious psychological distress among persons with epilepsy based on the 2005 California Health Interview Survey

Frequency and risk factors of psychological distress among individuals with epilepsy before and during the outbreak of the SARS-CoV-2 Omicron variant in China: an online questionnaire survey

BACKGROUND

The COVID-19 pandemic substantially increases the risk of severe psychological distress among people with epilepsy (PWE), especially those with monthly household income < 5000 RMB or with uncontrolled seizures. Patients with Kessler scores > 12 should consult a psychiatrist, especially during major disasters. This study was aimed to compare the frequency of psychological distress among Chinese PWE before and during the outbreak of the SARS-CoV-2 Omicron variant, and to identify risk factors for such distress.

METHODS

In this prospective study, we collected sociodemographic data of PWE aged > 14 years, who were treated at our center during December 1 to 15, 2022. All participants completed the 6-item Kessler Psychological Distress Scale before the outbreak and again during the outbreak. Health visitors who were unrelated to those patients during the outbreak were included as a control. Multivariate logistic regression analysis was performed to identify risk factors of severe psychological distress and its exacerbation.

RESULTS

Of the 223 PWE, 127 were tested positive for SARS-CoV-2, while 174 of 218 controls were positive for SARS-CoV-2. The neurological symptoms were similar between PWE and controls with SARS-CoV-2. The average Kessler score of PWE was significantly higher during the outbreak than before it (9.93 ± 3.98 vs. 8.52 ± 0.23, P < 0.001). The average score of controls during the outbreak (5.146 ± 0.35, P < 0.001) was significantly lower than that of the PWE. We identified three independent predictors for severe psychological distress in PWE during the outbreak, i.e., monthly household income < 5000 RMB (OR = 0.252, 95%CI 0.064-0.998, P = 0.048), severe psychological distress before the outbreak (OR = 0.067, 95%CI 0.026-0.174, P < 0.001), and seizure onset within 30 days before the assessment during the outbreak (OR = 0.356, 95%CI 0.157-0.805, P = 0.013). Of the three predictors, the last one was also an independent predictor for exacerbation of psychological distress during the outbreak (OR = 0.302, 95%CI 0.123-0.741, P = 0.009).

CONCLUSIONS

Our analysis suggests that the COVID-19 pandemic has substantially increased psychological distress of individuals with epilepsy, regardless of the viral infection or not. Various neurological symptoms similar to those of "long COVID" appeared for the first time among these individuals during the Omicron outbreak, highlighting the need for clinicians to screen carefully for this condition. Management of epilepsy during the pandemic or a similar major disaster should focus on the control of seizures and maintenance of mental health, especially among those with monthly household incomes below 5000 RMB, suffering uncontrolled seizures and having a history of severe psychological distress.

Physician distress when treatments fail. Survey on physician distress when treating persons with drug-resistant epilepsy and knowledge of neuropalliative care

OBJECTIVE

Drug-resistant epilepsy can be difficult to cure and may pose emotional challenges for epilepsy providers. Neuropalliative care (NPC) can augment quality of life (QOL) in persons with neurological diseases and may add meaningful elements to the treatment repertoire of epilepsy specialists even if seizures continue. However, NPC has not been widely implemented in epilepsy. Our study aimed to determine whether physicians of persons with drug-resistant epilepsy (PWDRE) experience distress when faced with treatment failure (Engel class ≥ 2), either failure of medications-only (PWDREmo) or of both medications and surgery (procedures with curative intent (PWDREms)). Furthermore, we evaluated physician knowledge about and referrals to NPC following treatment failures to help improve patient QOL despite ongoing seizures.

METHODS

An anonymous online survey was distributed to US epilepsy physicians through the American Epilepsy Society website and personal email to assess levels of distress experienced when caring for PWDREmo and PWDREms (7-point Likert scale ["1" = "no distress", "7" = "most distress ever felt"]), and knowledge and use of NPC.

RESULTS

Eighty-two physicians completed the survey. Most experienced distress when epilepsy treatments failed: 59% felt moderate distress (≥4) with PWDREmo (median "4", mean 3.74, range 1-7), 90% suffered moderate to severe distress (5, 5.17, 1-7) with PWDREms. Distress over PWDREms was significantly greater than distress over PWDREmo (p < 0.0001). Forty-three percent reported confidence in their knowledge about NPC. Only 15% were likely to refer PWDREmo to NPC, while 44% would consider it for PWDREms.

CONCLUSION

Among survey responders, physician distress was high when confronted with treatment failures, especially the failure of epilepsy surgery. Fewer than half of responders were likely to refer patients to NPC. Further research is necessary to determine extent, reasons, and effects of physician distress and whether improved understanding of and patient access to NPC would help alleviate physician distress when faced with treatment failures in PWDRE.

People with epilepsy have poor life satisfaction and self-rated health: Findings from the United Kingdom

Epilepsy is a neurological disorder characterized by brief, recurrent disturbances in the normal electrical functions of the brain that result in seizures. Although epilepsy is closely related to wellbeing, much less is known about how life satisfaction and SRH are affected by epilepsy in a nationally representative sample from the United Kingdom. The current research aims to investigate the difference in life satisfaction and SRH between people with epilepsy and people without epilepsy by using an innovative train-and-test approach on data collected between 2009 and 2010 from 428 people with epilepsy and 39,024 healthy controls while taking demographics into account. The results showed that people with epilepsy have both poorer life satisfaction and SRH compared to the scores that would be predicted by their demographics. This study implies that both life satisfaction and SRH are valid measures of wellbeing in people with epilepsy. Health professionals may utilize findings from the current study to come up with ways that can benefit wellbeing of people with epilepsy.

Psycho-socio-clinical profiles and quality of life in seizure disorders: A cross-sectional registry study

OBJECTIVE

This prospective study aimed at comparing quality of life (QoL) and psycho-socio-clinical profiles between patients with epilepsy, psychogenic nonepileptic seizures (PNES), and syncope. We also intended to identify predictors of QoL in these three seizure disorders.

METHODS

A total of 245 inpatients (epilepsy n = 182, PNES n = 50, syncope n = 13) from a tertiary epilepsy clinic were included. Information on QoL as well as on psychological, sociodemographic, and clinical profiles was retrieved using questionnaires and medical records. Group comparisons on QoL and psycho-socio-clinical profiles were performed via analyses of variance, chi-square tests, and related post hoc tests. Predictors of QoL in epilepsy and PNES were determined using general linear modeling, which was not possible for syncope due to a small sample size.

RESULTS

Patients with epilepsy, PNES, and syncope reported levels of QoL impairment that did not differ significantly between groups (p = 0.266). However, there were significant group differences regarding sex distribution (p < 0.001), seizure disorder duration (p = 0.004), seizure frequency (p = 0.019), current treatment with antiseizure medications (ASM) (p < 0.001), number of current ASM (p < 0.001), and adverse ASM events (p = 0.019). More depressive symptoms (p = 0.001), more adverse ASM events (p = 0.036), and unemployment (p = 0.046) (in this order) independently predicted a diminished QoL in epilepsy. For PNES, more depressive symptoms were the only independent predictor of lower QoL (p = 0.029).

CONCLUSIONS

Patients with epilepsy, PNES, and syncope experience similarly diminished QoL and show a general psycho-socio-clinical burden with a specific pattern for each seizure disorder diagnosis. Although clinical aspects play an undisputed role for QoL in epilepsy, the psychosocial aspects and consequences are equally, or for PNES probably even more, meaningful. A comprehensive approach to research and treatment of seizure disorders seems mandatory to increase QoL for these patients. More research on QoL in syncope is needed.

Age Moderates the Link between Epilepsy and Self-Rated Health (SRH)

Epilepsy is one of the most severe neurological diseases that affect people around the globe. Self-rated health (SRH) refers to one’s subjective evaluation of their own health and is associated with various outcomes such as morbidity and mortality. Thus, understanding the association between epilepsy and SRH is of great importance. Moreover, SRH generally decreases with age. The aim of the current study is to test whether age moderates the link between epilepsy and SRH. The current study used a hierarchical regression and three multiple regressions to analyze the associations between epilepsy and SRH in 529 epilepsy patients and 46,978 healthy controls from the United Kingdom. The current study found that age significantly moderates the association between epilepsy and SRH. Specifically, epilepsy status was negatively related to SRH in young people (b = −0.69, p < 0.001, 95% C.I. [−0.84, −0.54]), more strongly in middle-aged adults (b = −0.81, p < 0.001, 95% C.I. [−0.95, −0.66]), and most strongly in older adults (b = −0.89, p < 0.001, 95% C.I. [−1.09, −0.69]). The current study may imply that older adults need more attention in terms of their SRH, which is closely associated with outcomes. Clinicians and health professionals should come up with ways that improve SRH in people with epilepsy, especially for older adults with epilepsy.

Epileptogenic networks in drug-resistant epilepsy with amygdala enlargement: Assessment with stereo-EEG and 7 T MRI

OBJECTIVE

Amygdala enlargement is increasingly described in association with temporal lobe epilepsies. Its significance, however, remains uncertain both in terms of etiology and its link with psychiatric disorders and of its involvement in the epileptogenic zone. We assessed the epileptogenic networks underlying drug-resistant epilepsy with amygdala enlargement and investigated correlations between clinical features, epileptogenicity and morphovolumetric amygdala characteristics.

METHODS

We identified 12 consecutive patients suffering from drug-resistant epilepsy with visually suspected amygdala enlargement and available stereoelectroencephalographic recording. The epileptogenic zone was defined using the Connectivity Epileptogenicity Index. Morphovolumetric measurements were performed using automatic segmentation and co-registration on the 7TAMIbrain Amygdala atlas.

RESULTS

The epileptogenic zone involved the enlarged amygdala in all but three cases and corresponded to distributed, temporal-insular, temporal-insular-prefrontal or prefrontal-temporal networks in ten cases, while only two were temporo-mesial networks. Morphovolumetrically, amygdala enlargement was bilateral in 75% of patients. Most patients presented psychiatric comorbidities (anxiety, depression, posttraumatic stress disorder). The level of depression defined by screening questionnaire was positively correlated with the extent of amygdala enlargement.

CONCLUSIONS

Drug-resistant epilepsy with amygdala enlargement is heterogeneous; most cases implied "temporal plus" networks.

SIGNIFICANCE

The enlarged amygdala could reflect an interaction of stress-mediated limbic network alterations and mechanisms of epileptogenesis.

Interictal Activity Is Associated With Slower Binocular Rivalry in Idiopathic Generalized Epilepsy

Objective: Perceptual alternations evoked by binocular rivalry (BR) reflect cortical dynamics strongly dependent on the excitatory-inhibitory balance, suggesting potential utility as a biomarker for epileptogenesis. Therefore, we investigated the characteristics of BR in patients with idiopathic generalized epilepsy (IGE) and potential associations with clinical variables. Methods: Sixty-two healthy controls (HCs) and 94 IGE patients completed BR task. Perceptual alternation rates were compared between HC and IGE groups as well as among the HC group and IGE patients stratified according to the presence or absence of interictal activity on the ambulatory electroencephalogram (EEG), termed the abnormal ambulatory EEG group (AB-AEEG, n = 64) and normal ambulatory EEG group (N-AEEG, n = 30), respectively. Results: The IGE patients demonstrated a slower rate of BR perceptual alternation than HC subjects (t = -4.364, p < 0.001). The alternation rate also differed among the HC, AB-AEEG, and N-AEEG groups (F = 44.962, df = 2, p < 0.001), and post hoc comparisons indicated a significantly slower alternation rate in the AB-AEEG group compared with the N-AEEG and HC groups (0.28 vs. 0.46, and 0.43 Hz). Stepwise linear regression revealed positive correlations between the BR alternation rate and both the ambulatory EEG status (β, 0.173; standard error, 0.022 p < 0.001) and Montreal Cognitive Assessment score (β, 0.013; standard error, 0.004; p = 0.003). Receiver operating characteristic curve analysis of the BR alternation rate distinguished AB-AEEG from N-AEEG subjects with 90.00% sensitivity and 76.90% specificity (area under the curve = 0.881; 95% confidence interval = 0.801- 0.961, cut-off = 0.319). Alternatively, Montreal Cognitive Assessment score did not accurately distinguish AB-AEEG from N-AEEG subjects and the area under the receiver operating characteristic curve combining the BR alternation rate and Montreal Cognitive Assessment score was not markedly larger than that of the BR alternation rate alone (0.894, 95% confidence interval = 0.822-0.966, p < 0.001). K-fold cross-validation was used to evaluate the predictive performance of BR alternation rate, MoCA score, and the combination of both, which yielded average AUC values of 0.870, 0.584 and 0.847, average sensitivity values of 89.36, 92.73, and 91.28%, and average specificity values of 62.25, 13.42, and 61.78%, respectively. The number of interictal epileptiform discharges was significantly correlated with the alternation rate in IGE patients (r = 0.296, p = 0.018). A forward stepwise linear regression model identified the number of interictal epileptiform discharges (β, 0.001; standard error, 0.001; p = 0.025) as an independent factor associated with BR alternation rate in these patients. Conclusion: These results suggest that interictal epileptiform discharges are associated with disruptions in perceptual awareness, and that the BR may be a useful auxiliary behavioral task to diagnosis and dynamically monitor IGE patients with interictal discharge.

Epilepsy care during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has affected the care of all patients around the world. The International League Against Epilepsy (ILAE) COVID-19 and Telemedicine Task Forces examined, through surveys to people with epilepsy (PWE), caregivers, and health care professionals, how the pandemic has affected the well-being, care, and services for PWE. The ILAE included a link on their website whereby PWE and/or their caregivers could fill out a survey (in 11 languages) about the impact of the COVID-19 pandemic, including access to health services and impact on mental health, including the 6-item Kessler Psychological Distress Scale. An anonymous link was also provided whereby health care providers could report cases of new-onset seizures or an exacerbation of seizures in the context of COVID-19. Finally, a separate questionnaire aimed at exploring the utilization of telehealth by health care professionals since the pandemic began was available on the ILAE website and also disseminated to its members. Seventeen case reports were received; data were limited and therefore no firm conclusions could be drawn. Of 590 respondents to the well-being survey (422 PWE, 166 caregivers), 22.8% PWE and 27.5% caregivers reported an increase in seizure frequency, with difficulty in accessing medication and health care professionals reported as barriers to care. Of all respondents, 57.1% PWE and 21.5% caregivers had severe psychological distress (k score >13), which was significantly higher among PWE than caregivers (p<0.01). An increase in telemedicine use during the COVID-19 pandemic was reported by health care professionals, with 40% of consultations conducted by this method. Although 74.9% of health care providers thought that this impacted positively, barriers to care were also identified. As we move forward, there is a need to ensure ongoing support and care for PWE to prevent a parallel pandemic of unmet health care needs.

A feasibility study to assess social stress and social support in patients enrolled in a cannabidiol (CBD) compassionate access program

Cannabidiol (CBD) trials offer an opportunity to examine social factors that shape outcomes of patients with treatment-resistant epilepsy. Prior research of patients treated with CBD for epilepsy describes financial struggles of these patients/families and the association between socioeconomic status and patient-centered outcomes. However, social determinants of health in this population are still poorly understood, mainly due to data scarcity. This study aimed to establish feasibility of assessing social stress, social support, and religious participation and their associations with outcomes (perceived health, quality of life, and mood) in patients treated with CBD for epilepsy. Data were collected during 2015-2018 through structured face-to face interviews with patients/caregivers in a CBD compassionate access/research program in the southern United States. Adult (ages 19-63; n = 65) and pediatric (ages 8-19; n = 46) patients or their caregivers were interviewed at the time of enrollment in the study. Social stress was assessed with stressful life events, perceived stress, epilepsy-related discrimination, and economic stressors; social support with the Interpersonal Support Evaluation List [ISEL]-12; and religious participation with frequency of religious attendance. The results showed economic stressors to be associated with poor overall health, but no associations were noted between stress, support, and religious participation measures and quality of life or mood. Despite a robust data collection plan, completeness of the data was mixed. We discuss lessons learned and directions for future research and identify potential refinements to social data collection in people with treatment-resistant epilepsy during clinical trials.

The intersections of stress, anxiety and epilepsy

Stress is ubiquitous in chronic medical conditions; however, the connections to psychiatric and neurologic conditions are not always clearly established. Epilepsy is a unique illness that is intimately intertwined with stress and anxiety not only as a result of the disease process but also as a cause of disease exacerbation. Anxiety and depression also involve stress management and often overlap with epilepsy. Anxiety symptoms themselves may be present as intrinsic aspects of seizure phenomena, either during the events or closely related to them. The pathways of stress and anxiety involve the hypothalamic pituitary adrenal (HPA) axis and explain at least in part how stress may lead to worsening seizure control. Ultimately, the study of stress, anxiety, and epilepsy offers insight into mind and body connections, and furthers understanding of neuropsychiatric illness.

Clinical determinants of psychopathological outcomes after epilepsy surgery

OBJECTIVES

People with refractory epilepsy submitted to surgery may improve or deteriorate their cognitive and emotional functions. The aim of this study was to determine the predictors of longitudinal changes in psychopathological symptomatology, one year after epilepsy surgery, considering clinical and demographic characteristics.

METHODS

People with refractory epilepsy referred to epilepsy surgery were included in this ambispective study. Psychiatric evaluations were made before surgery and one year after the procedure. Demographic, psychiatric, and neurological data were recorded. Linear regression was used to analyze longitudinal data regarding the Global Severity Index and 9 symptom dimensions of Symptom Checklist-90 (SCL-90).

RESULTS

Seventy-six people were included. Bilateral epileptogenic zone, lack of remission of disabling seizures, and deep brain stimulation, targeting the anterior nucleus of the thalamus (ANT-DBS), were the most important predictors of an increase in SCL-90 scores, after surgery.

CONCLUSION

Some individual factors may have an impact on the development or worsening of the previous psychopathology. This study identifies clinical aspects associated with greater psychological distress, after surgery. These patients may benefit from more frequent psychiatric routine assessments for early detection.

Serious psychological distress among adults with active epilepsy in all racial/ethnic groups and among adults with inactive epilepsy in non-Hispanic whites is significantly higher than among adults without epilepsy-U.S. National Health Interview Survey, 2010, 2013, 2015, and 2017

Serious psychological distress (SPD) includes mental health problems severe enough to cause moderate-to-serious impairment in daily activities and to require treatment. Serious psychological distress is based on answers to six survey questions from the Kessler-6 scale used internationally in public health surveillance systems to assess recent feelings of sadness, restlessness, hopelessness, nervousness, worthlessness, and the sense that everything is an effort. We combined nationally representative samples in the National Health Interview Survey (NHIS) from 2010 (N = 27,157), 2013 (N = 34,557), 2015 (N = 33,672), and 2017 (N = 26,742). We used a validated surveillance case definition to classify adults as having epilepsy if they reported a history of doctor-diagnosed epilepsy or seizure disorder (n = 2251). We further classified those with epilepsy as having active epilepsy (n = 1380) if they reported either taking epilepsy medications or having at least one seizure in the past 12 months or as having inactive epilepsy (n = 871) if they did not take epilepsy medication and had not had any seizures in the past 12 months. We used an NHIS recoded variable that classifies adults by Hispanic origin and race. Following age adjustment, among adults with active epilepsy, SPD prevalence was 13.7% among non-Hispanic white adults, 11.2% among non-Hispanic black adults, 20.7% among Hispanic adults, and 17.5% among non-Hispanic other adults. Compared with adults without epilepsy, adults with active epilepsy were 4.8 times more likely, and adults with inactive epilepsy 2.6 times more likely, to report SPD. In each racial/ethnic group, SPD among adults with active epilepsy is significantly higher than in adults without epilepsy. Among adults with active epilepsy, SPD prevalence did not differ by racial/ethnic groups. However, only among non-Hispanic white adults with inactive epilepsy did SPD prevalence significantly exceed that among non-Hispanic white adults without epilepsy. Epilepsy stakeholders can use these estimates to target culturally appropriate community-based and clinic-based interventions to reduce the high burden of psychological distress among adults with active epilepsy and inactive epilepsy.

Stress, seizures, and epilepsy: Patient narratives

In epilepsy, individual seizures can be triggered by a variety of external and internal stimuli. One of the most common trigger factors reported by patients is stress. However prevalent, stress-related triggering of episodes seems underappreciated in epilepsy for various reasons, and its misinterpretation often leads to other diagnoses, e.g., psychogenic nonepileptic seizures (PNES) or normal reactions. This article illustrates the significant role of stress as a seizure-provoking factor by referring to nine patient narratives. From this perspective, it appears that there are characteristic patterns of stress triggering, e.g., stress-induced sleep disruption, forms of acute stress, or relaxation after stress. Sometimes seizures are mistaken as symptoms of stress. Patient narratives contain interesting clues relating reports about stress and seizure histories to different epilepsy syndromes as well as nonepileptic episodes in a way that can strongly support the diagnostic process. A narrative approach is particularly valuable in this context. Therefore, accounts of stress triggering in seizures and other episodes should not be neglected, but rather taken seriously, sought and actively explored as a crucial element when taking clinical histories in patients with episodic attacks.

Effect of unaffordable medical need on distress level of family member: analyses of 1997-2013 United States National Health Interview Surveys

BACKGROUND

Reduced funding to public health care systems during economic downturns is a common phenomenon around the world. The effect of health care cost on family members of the patients has not been established. This paper aims to explore the relationship between affordability of health care and vulnerability of family members to distress levels.

METHODS

Data of a total of 262,843 participants were obtained from 17 waves (1997-2013) of the United States National Health Interview Survey. Multinomial logistic regression was used to investigate psychological distress level as a result of having family members who experienced unmet medical needs due to cost.

RESULTS

Among participants without family members who experienced unmet needs for medical care due to cost, risks of having 'moderate' (score of 5-12) or 'serious' (score of 13 or above) level of psychological distress were 1.0% and 11.5%, respectively. Risks of having 'moderate' or 'serious' level of psychological distress were 3.1% and 23.4%, respectively among participants with family members who experienced unmet needs. The adjusted relative risk ratio of 'moderate' and 'serious', as compared to 'normal' level of psychological distress, were 1.58 (95% confidence interval: 1.47-1.69) and 2.09 (95% confidence interval: 1.78-2.45) if one's family members experienced unmet medical needs.

CONCLUSIONS

Unmet medical needs due to cost increases risk of distress levels experienced by family members. Careful planning and adequate funding to public health care system could be implemented to prevent any unnecessary detrimental effect on mental health among family members of the unwell and any further increment of the prevalence of mental illnesses. This recommendation aligns with the World Health Organization Mental Health Action Plan 2013-2020.

Stress regulation in drug-resistant epilepsy

The prevalence of psychological distress, especially depressive and anxiety disorders, is higher in epilepsy than in other chronic health conditions. These comorbid conditions contribute even more than epileptic seizures themselves to impaired quality of life in patients with epilepsy (PWE). The link between these comorbidities and epilepsy appears to have a neurobiological basis, which is at least partly mediated by stress through psychological and pathophysiological pathways. The impact of stress in PWE is also particularly important because it is the most frequently reported seizure trigger. It is therefore crucial for clinicians to take stress-related conditions and psychiatric comorbidities into account when managing PWE and to propose clinical support to enhance self-control of stress. Screening tools have been specially designed and validated in PWE for depressive disorders and anxiety disorders (e.g. NDDI-E, GAD-7). Other instruments are useful for measuring stress-related variables (e.g. SRRS, PSS, SCS, MHLCS, DSR-15, ERP-R, QOLIE-31) in order to help characterize the individual "stress profile" and thus orientate patients towards the most appropriate treatment. Management includes both pharmacological treatment and nonpharmacological methods for enhancing self-management of stress (e.g. mindfulness-based therapies, yoga, cognitive-behavioral therapies, biofeedback), which may not only protect against psychiatric comorbidities but also reduce seizure frequency.

Perceived stress and its predictors in people with epilepsy

OBJECTIVE

Perceived stress in people with epilepsy (PWE) is one of the major precipitants for seizures. We investigated the degree of perceived stress in PWE and its predictors. We also aimed to reveal the interrelationships among the predictors.

METHODS

This was a case-control study. Consecutive patients visiting a tertiary care epilepsy clinic completed self-reported questionnaires including the Perceived Stress Scale (PSS), Revised Stigma Scale (RSS), Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), Generalized Anxiety Disorder - 7 (GAD-7), and short forms of the Patient-Reported Outcomes Measurement Information System - Sleep Disturbance (PROMIS-SD) and Patient-Reported Outcomes Measurement Information System - Sleep-Related Impairment (PROMIS-SRI) scales.

RESULTS

The mean score of the PSS was significantly lower in patients with well-controlled epilepsy (WCE) and higher in those with uncontrolled epilepsy compared with controls. Although several factors including demographic, socioeconomic, psychosomatic, and epilepsy-related factors were associated with the PSS score, the strongest predictor for the PSS score was the K-NDDI-E score, followed by the PROMIS-SRI score, the GAD-7 score, and seizure control. Psychosomatic factors exerted both a direct effect on the PSS score and an indirect effect on the PSS score through seizure control.

CONCLUSION

Rapid detection and appropriate management of psychiatric and sleep-related problems in PWE may lessen stress and aid in preventing further seizures.

Depression and anxiety in people with epilepsy: Why should we identify?

Introduction. People with epilepsy (PWE) have a higher risk of developing depression and anxiety than people without epilepsy. However, understanding and management of that issue remain under-recognized.

Aim. To emphesize: a) the relationship between depression, anxiety, and epilepsy, and b) to suggest practical strategies for their identification by clinicians.

Methods. The current literatures was reviewed investigating the impact of depression and anxiety in PWE and those examining the validity of simple screening tools for the detection of depression and anxiety.

Review. Approximately one quarter of PWE have been known to be suffered from depression. The frequency of depression and anxiety was closely related to poor seizure control. Depression and anxiety have been reported to have a bidirectional relationship with epilepsy. The higher degree of depression and anxiety was more likely to elicit the suicidal ideation and attempt, adverse events and poor compliance of antiepileptic drugs, poor surgical outcome, and eventually, poor quality of life. Furthermore, depression and anxiety were closely associated with perceived stigma, obsessive-compulsive symptom, aggression, fatigue, and perceived stress.

Conclusions. Clinicians who take care of PWE in a busy clinical setting should identify their psychiatric problems by brief screening tools and treat them instantly to minimize their negative impacts.

Psychological distress and comorbid physical conditions: disease or disability?

BACKGROUND

The relationship between comorbidity and psychological distress is well documented, however the mechanism of this association is unclear. We aim to assess the extent to which the association between common chronic conditions and high scores on the Kessler Psychological Distress Scale (K10) measure of psychological distress vary according to comorbid conditions, disability, and sociodemographic circumstances.

METHODS

Analysis of self-reported cross-sectional data from the New South Wales 45 and Up Study, Australia, for 236,508 participants aged 45 years and over, using logistic regression modeling.

RESULTS

Self-reported heart attack/angina, other heart disease, stroke, and diabetes were all significantly associated with higher risk of high/very high K10 scores. These associations were attenuated, but remained statistically significant, when comorbidity, disability, and sociodemographic factors were added to the model. Men reporting needing help for daily tasks were nine times as likely to report high/very high K10 scores as those without this need, and women reporting needing help were seven times more likely to have high/very high K10 scores.

CONCLUSIONS

Heart attack/angina, other heart disease, stroke, and diabetes are all significantly associated with psychological distress. However, these effects are partly explained by other comorbid conditions, limitations on physical functioning, and sociodemographic factors. These findings highlight the importance of developing public health policies that encompass psychological, physiological, and social domains, and provide crucial insights for clinicians in identifying and supporting those people at risk of psychological distress.

The role of stress as a trigger for epileptic seizures: a narrative review of evidence from human and animal studies

Stress is one of the most frequently self-identified seizure triggers in patients with epilepsy; however, most previous publications on stress and epilepsy have focused on the role of stress in the initial development of epilepsy. This narrative review explores the causal role of stress in triggering seizures in patients with existing epilepsy. Findings from human studies of psychological stress, as well as of physiologic stress responses in humans and animals, and evidence from nonpharmacologic interventions for epilepsy are considered. The evidence from human studies for stress as a trigger of epileptic seizures is inconclusive. Although retrospective self-report studies show that stress is the most common patient-perceived seizure precipitant, prospective studies have yielded mixed results and studies of life events suggest that stressful experiences only trigger seizures in certain individuals. There is limited evidence suggesting that autonomic arousal can precede seizures. Interventions designed to improve coping with stress reduce seizures in some individuals. Studies of physiologic stress using animal epilepsy models provide more convincing evidence. Exposure to exogenous and endogenous stress mediators has been found to increase epileptic activity in the brain and trigger overt seizures, especially after repeated exposure. In conclusion, stress is likely to exacerbate the susceptibility to epileptic seizures in a subgroup of individuals with epilepsy and may play a role in triggering "spontaneous" seizures. However, there is currently no strong evidence for a close link between stress and seizures in the majority of people with epilepsy, although animal research suggests that such links are likely. Further research is needed into the relationship between stress and seizures and into interventions designed to reduce perceived stress and improve quality of life with epilepsy.

Satisfaction with life domains in people with epilepsy

While commonly used quality-of-life instruments assess perceived epilepsy-associated limitations in life domains and formally document patient concerns, less is known of community-dwelling adults with epilepsy about their satisfaction with broader life domains, such as satisfaction with housing, education, neighborhood, ability to help others, and achievement of goals. The purpose of this study was to examine satisfaction with life domains in a representative sample of community-dwelling adults with self-reported epilepsy from the 2008 HealthStyles survey. Following adjustment for sex, age group, race/ethnicity, education, and income, people with epilepsy were more likely to report frustration in the domains of achievement (e.g., dissatisfaction with education and life goals), compromised social interactions (dissatisfaction with family life, friends, and social life), and compromised physical capability (dissatisfaction with health and energy level). Life satisfaction and other well-being domains can supplement health indicators to guide treatment and program services for people with epilepsy to maximize their well-being.

Depression in epilepsy: a systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence of depression in persons with epilepsy (PWE) and the strength of association between these 2 conditions.

METHODS

The MEDLINE (1948-2012), EMBASE (1980-2012), and PsycINFO (1806-2012) databases, reference lists of retrieved articles, and conference abstracts were searched. Content experts were also consulted. Two independent reviewers screened abstracts and extracted data. For inclusion, studies were population-based, original research, and reported on epilepsy and depression. Estimates of depression prevalence among PWE and of the association between epilepsy and depression (estimated with reported odds ratios [ORs]) are provided.

RESULTS

Of 7,106 abstracts screened, 23 articles reported on 14 unique data sources. Nine studies reported on 29,891 PWE who had an overall prevalence of active (current or past-year) depression of 23.1% (95% confidence interval [CI] 20.6%-28.31%). Five of the 14 studies reported on 1,217,024 participants with an overall OR of active depression of 2.77 (95% CI 2.09-3.67) in PWE. For lifetime depression, 4 studies reported on 5,454 PWE, with an overall prevalence of 13.0% (95% CI 5.1-33.1), and 3 studies reported on 4,195 participants with an overall OR of 2.20 (95% CI 1.07-4.51) for PWE.

CONCLUSIONS

Epilepsy was significantly associated with depression and depression was observed to be highly prevalent in PWE. These findings highlight the importance of proper identification and management of depression in PWE.

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

Although epilepsy is associated with substantial role impairment, it is also highly comorbid with other physical and mental disorders, making unclear the extent to which impairments associated with epilepsy are actually due to comorbidities. This issue was explored in the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 5692 US adults. Medically recognized epilepsy was ascertained with self-report, comorbid physical disorders with a chronic conditions checklist, and comorbid DSM-IV mental disorders with the Composite International Diagnostic Interview. Lifetime epilepsy prevalence was estimated at 1.8%. Epilepsy was comorbid with numerous neurological and general medical conditions and with a sporadic cluster of mental comorbidities (panic, PTSD, conduct disorder and substance use disorders). Although comorbid disorders explain part of the significant gross associations of epilepsy with impairment, epilepsy remains significantly associated with work disability, cognitive impairment and days of role impairment after controlling comorbidities. The net association of epilepsy with days of role impairment after controlling for comorbidities is equivalent to an annualized 89.4 million excess role impairment days among US adults with epilepsy, arguing that role impairment is a major component of the societal costs of epilepsy per se rather than merely due to disorders comorbid with epilepsy. This estimated burden is likely conservative as some parts of the effects of epilepsy are presumably mediated by secondary comorbid disorders.

Epilepsy care and mental health care for people with epilepsy: California Health Interview Survey, 2005

INTRODUCTION

Epilepsy, which requires complex care, can be further complicated by comorbid mental illness. Evidence indicates deficiencies exist in the care received for both epilepsy-related care and for mental health care in people with epilepsy. Evidence indicates there are deficiencies in both these areas for people with epilepsy. Our objective was to evaluate treatment gaps in epilepsy and mental health care among California adults with epilepsy and to compare the mental health services and treatment received by people with epilepsy to that of the general population.

METHODS

We conducted multivariate analyses of data from the 2005 California Health Interview Survey (N = 43,020), which included data from 604 adult participants who said they had been told they had epilepsy, to examine comparisons of interest.

RESULTS

Twenty-seven percent of California adults with epilepsy who had had at least 1 seizure in the past 3 months had not seen a neurologist or epilepsy specialist in the past year. Of respondents with psychological distress and epilepsy, 84% perceived a need for mental health care in the past year, but only 57% had seen a mental health provider during that time. Of respondents without epilepsy but with psychological distress, 77% perceived a need for mental health care in the past year, but only 32% had seen a mental health provider during that time.

CONCLUSION

California adults with epilepsy appear to have substantial unmet needs in both epilepsy care and mental health care. Adults with epilepsy and psychological distress appeared to have received more mental health treatment than psychologically distressed adults without epilepsy. Efforts should be made to improve access to quality epilepsy care that includes assessment and treatment of mental health disorders.

Future directions for epidemiology in epilepsy

Epidemiology continues to be an important research tool in the study of epilepsy and related disorders, providing a better understanding of the frequency, causes and natural history of the disorder. But, beyond risk factors and seizure prognosis, epidemiological studies advance knowledge of many other aspects of epilepsy. Epidemiological studies are being conducted in a new environment in which high quality neuroimaging and fast through-put genomic technologies have become routine tools in clinical diagnosis and therapeutics. Epilepsy is currently understood, not as a single, homogeneous disorder, but a multitude of different clinical syndromes and disease, each with its own cause(s), natural history, and treatment implications. That is why; the comorbidites of epilepsy represent an important area, amenable to study, as they may ultimately have a greater impact on quality of life than epilepsy itself. In this document we share our thoughts on what we think are the future directions for epidemiology in epilepsy.

Association of serious psychological distress with health services expenditures and utilization in a national sample of US adults

OBJECTIVE

The Kessler six-item scale has been shown to be a valid and reliable measure of serious psychological distress (SPD) in community samples. We examined the effect of SPD on health service expenditures and utilization for seven categories in a national probability sample of community dwelling adults in the United States.

METHODS

We used the two-step sample selection model to examine the association between SPD and total, office-based, outpatient, emergency department (ED), inpatient, dental, home health and prescription expenditures and utilization in 18,330 US adults who participated in the 2007 Medical Expenditure Panel Survey (MEPS).

RESULTS

SPD was significantly associated with $1735 ( 95% CI: $702-2769) higher total expenditures, $285 higher office expenditures ( 95% CI: $30-539), $183 higher ED expenditures (95% CI: $64-303), $282 (95% CI: $62-503) higher home health expenditures, $614 (95% CI: $403-825) higher prescription expenditures and $41 (95% CI: -$103 to $22) lower dental expenditures. SPD was associated with 3.09 (95% CI: 2.09-4.08) more office visits, 0.27 (95% CI: 0.17-0.36) more ED visits, 0.84 (95% CI: 0.36-1.32) more inpatient visits, 2.93 (95% CI: 0.13-5.70) more home health visits, 8.13 (95% CI: 6.08-10.18) more prescriptions and 0.18 (95% CI: -0.30 to -0.07) less dental visits.

CONCLUSIONS

Among US adults, SPD is associated with significant increases in total expenditures and most other categories of expenditure and utilization. Targeted interventions to mitigate the adverse effects of SPD are needed.

The impact of marriage and social support on persons with active epilepsy

Persons with epilepsy (PWE) are more likely to report never being married than those without epilepsy. Social support, especially from marriage, may buffer the negative impact of stressful events and chronic health conditions. In 2005, sixteen U.S. states asked about epilepsy and social support in the Behavioral Risk Factor Surveillance System. A set of survey weight-adjusted logistic regression analyses were conducted to examine the impact of marriage and social support on self-rated health status and life satisfaction in persons with active epilepsy. PWE who were married with poor social support were less likely to report excellent/very good self-rated health status (OR=0.34) and better life satisfaction (OR=0.20), compared with those who were married with good support (reference group) after controlling for demographics and comorbid conditions. Once poor mental health status was controlled for, these differences were no longer significant. In contrast, persons with active epilepsy who were not married with poor support were significantly less likely to report better life satisfaction (OR=0.22) after controlling for demographics, comorbid conditions, and poor mental health status. Epilepsy practitioners need to address poor mental health through appropriate treatment and/or referral. Practitioners should also encourage PWE to improve their social support contacts.

Suicidality and divalproex sodium: analysis of controlled studies in multiple indications

BACKGROUND

Recent analyses of antiepileptic drugs have indicated an increase in the risk of suicidality. The objective of this report was to provide clinical information and an independent meta-analysis of divalproex sodium and suicidality events by analyzing data from 13 placebo-controlled studies and 1 low-dose controlled study.

METHODS

Adverse events considered to be possibly suicide related were identified using the Columbia Classification Algorithm of Suicide Assessment (C-CASA) methodology. Indications included epilepsy, bipolar disorder, migraine prophylaxis, impulsive aggression, and dementia. Narratives were produced for every event, and suicidality event ratings were performed by a third party blinded to treatment assignment. Statistical analyses were conducted using methodology similar to that reported by the US Food and Drug Administration (FDA).

RESULTS

Suicidality events were identified in 5 of the 13 placebo-controlled studies. Of the 1,327 (0.83%) subjects taking divalproex sodium, 11 had suicidality events: 2 suicide attempts and 9 suicidal ideation. Of 992 (0.91%) subjects taking placebo, 9 had suicidality events: 1 preparatory act toward suicide, 2 suicide attempts, and 6 suicidal ideation. Across placebo-controlled studies, the overall estimated odds ratio (OR) of suicidal behavior or ideation was 0.72 (95% CI 0.29 to 1.84). The OR for suicidal behavior was 0.37 (95% CI 0.04 to 2.58), and the OR for suicidal ideation was 0.90 (95% CI 0.31 to 2.79).

CONCLUSIONS

In this meta-analysis, divalproex sodium does not appear to increase the risk of suicide-related adverse events relative to placebo in the populations studied. Clinicians should nonetheless remain vigilant in assessing suicidality, not only in patients treated for mental disorders with inherently high suicide risk, but also in patients taking antiepileptic medications.

The impact of social support on health related quality of life in persons with epilepsy

Previous studies have found that psychosocial factors have the greatest impact on health-related quality of life (HRQOL). Social support can buffer the negative impact of stressful events and chronic health conditions. To date, no population studies have examined the association between social support and epilepsy. In the 2003 California Health Interview Survey (CHIS), four questions were used to assess social support. A set of survey weight-adjusted logistic regression analyses were conducted with self-rated health status as the outcome. In those regression models, we examined the effect of epilepsy status, social support, and their interactions, after controlling for demographics. Analyses examining the interaction between epilepsy and social support showed a significant interaction between epilepsy and "availability of someone to love you and make you feel wanted." Once demographics were controlled for, persons without epilepsy and poor affectionate support reported fair/poor self-rated health status (odds ratio=1.7). Persons with epilepsy and good affectionate support also reported fair/poor self-rated health status (odds ratio=3.3). Persons with epilepsy and poor affectionate support were the most likely to report fair/poor self-rated health status (odds ratio=9.1). Persons with epilepsy need encouragement to actively seek and sustain supportive personal relationships that may help improve their quality of life.