Health, wealth, and culture as predominant factors in psychosocial morbidity

https://doi.org/10.1016/j.yebeh.2009.03.006Get rights and content

Abstract

Depression is the most common psychological morbidity in epilepsy, yet this comorbidity is not well understood. Possible explanations for this comorbidity include recurrence of premorbid depression, increased risk for severe epilepsy due to a history of depression, shared risk factors for depression and epilepsy, AED-induced depression in vulnerable individuals, and coping styles in the face of stressors linked to epilepsy. Preexisting vulnerability to depression may contribute to each of these explanations. Vulnerability may arise from the influence of common risk factors, family history of depression, a history of depression before initiation of relevant AEDs, or coping styles and may reflect allostatic load. These exposures may precede the occurrence of epilepsy or follow the onset of epilepsy, in both cases increasing the risk for depression in prevalent epilepsy. Their careful evaluation is vital to identifying people at greatest risk for depression in epilepsy and for informing interventions to prevent the occurrence of this disabling epilepsy comorbidity.

Introduction

Depression is the most common psychosocial morbidity in epilepsy. In cross-sectional studies of people with prevalent epilepsy, 10–24% have a moderate to severe number of symptoms of depression (see, for example, [1], [2], [3], [4], [5], [6], [7]). The prevalence of depressive symptoms has been shown to increase with increasing seizure frequency in two community surveys from the British general practice system [2], [3]. In these studies, a moderate to severe number of depressive symptoms occurred in 4–20% of cases in remission, 10–39% of those with less than one seizure per month, and 21–55% of those with one or more seizures per month. In a cross-sectional study of less severe epilepsy [6], in which 60% of patients had generalized seizures and 63% were without seizures for 12 months or more, depression in epilepsy was compared to depression in blood donors. This study found that people with epilepsy were 11.3-fold more likely to have moderate to severe depression compared to blood donors with no difference by seizure type. Thus, associations between prevalent epilepsy and depression are not necessarily confined to individuals with frequent seizures.

It is possible that epilepsy or its correlates may cause depression. This could operate in several ways. Epilepsy could increase the risk for a first episode of depression, accounting for findings from cross-sectional studies. However, no studies have been conducted in an incident epilepsy cohort without prior depression to determine the risk for a first episode of depression. A second possibility is that in prevalent epilepsy, depression represents a recurrence of premorbid depression, either independent of or dependent upon factors associated with epilepsy that could influence vulnerability to both recurrent depression and continued seizures. Still another possibility is that risk factors for epilepsy, such as low socioeconomic status and depression, index increased allostatic load that also increases the risk for epilepsy, or that epilepsy itself causes an increase in allostatic load that, in turn, increases the risk for comorbidity. Understanding the reasons for the occurrence of depression in prevalent epilepsy could guide treatment and prevention of this psychosocial morbidity in epilepsy.

Section snippets

Depression can precede epilepsy

Several studies show that a history of major depression is associated with an increased risk for developing unprovoked seizures, suggesting a common underlying susceptibility that may be genetic. In the earliest population-based case–control study to examine this, Forsgren and Nystrom [8] found that a history of “depression” was associated with an increased risk for developing epilepsy, particularly for “localized-onset” seizures. Since then, two additional studies demonstrated that a history

Depression and epilepsy share risk factors

Several risk factors for epilepsy are also risk factors for developing depression (Table 1). These include low socioeconomic status [18], [19], [20], [21], stroke [22], [23], [24], dementia [25], [26], [27], [28], traumatic brain injury [29], [30], [31], [32], and migraine [33], [34], [35], [36], [37]. Except for socioeconomic status, each risk factor has a bidirectional relationship with depression [32], [38], [39], [40], [41], [42]. Attention deficit hyperactivity disorder [43], [44] and use

Psychosocial health

Psychosocial health is a composite of health and well-being involving physical, mental, emotional, social, and spiritual realms. It describes a person’s well-being in different settings, including the social, community, family, and individual contexts in which life occurs. Several factors have been shown to adversely affect psychosocial health, including disease burden, low socioeconomic status (SES), race, and ethnicity. Disease burden, indexed by comorbidity, is associated with restricted

The contribution of other facets to the psychosocial impact of epilepsy

Allostatic load may explain why stressors associated with the psychosocial impact of having epilepsy may lead to depression in vulnerable individuals [59]. These stressors include stigma [60], [61], employability, and the ability to hold a driver’s license. The degree to which such stressors may adversely impact a person with epilepsy and lead to depression seems to be determined by coping strategies, which mediate how life stressors are perceived. Different coping strategies have been shown to

The contribution of antiepileptic drug (AED)-induced depression

AED-induced depression [66], [67], [68], [69], [70] may account for some of the depression observed in cross-sectional studies of epilepsy. Such depression appears to occur 3.2-fold more often in association with AEDs that enhance γ-aminobutyric acid (GABA) neurotransmission (Fisher’s exact p = 0.14) and 5.1-fold more often with drugs that potentiate GABA-mediated neurotransmission (Fisher’s exact p = 0.15). Risk factors for AED-induced depression include a previous psychiatric history [70], often

Conclusions

Several explanations have been outlined to account for the frequency of depression in prevalent epilepsy. These include recurrence of premorbid depression, increased risk for severe epilepsy in association with a history of depression, shared risk factors for depression and for epilepsy, AED-induced depression in vulnerable individuals, and coping styles in the face of stressors linked to epilepsy. For each of these possible explanations, preexisting vulnerability to depression has been

Moderator discussion

The wider “health” implications of epilepsy in determining overall psychosocial well-being and quality of life are amply illustrated above through the example of depression. However, if, as is highlighted, epilepsy and depression share common risk factors, they also share common mediating ones, including those of “wealth” and “culture.” The link between health and wealth is well understood, with many, many studies across a wide range of health issues highlighting that those of lower

General discussion

  • •

    There is a considerable amount of evidence for a strong relationship between epilepsy and depression. For example, a serotonin deficit has been found in rats with epilepsy, explaining their possible predisposition to depression, and similar sleep patterns and thyroid defects have been found in both depression and epilepsy models.

  • •

    Glutamate has recently been found to have an important role, not only in epilepsy but also in mood disorders.

  • •

    Further exploration of the role of neurotransmitters will

Conflict of Interest Statement

All authors declare no conflict of interest.

References (75)

  • A.G. Fischer et al.

    The role of comorbid major depressive disorder in the clinical presentation of adult ADHD

    J Psychiatric Res

    (2007)
  • L.A. Simmons et al.

    Comorbid substance and mental disorders among rural Americans: results from the National Comorbidity Survey

    J Affect Disord

    (2007)
  • J.W. Lynch et al.

    Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic life course

    Soc Sci Med

    (1997)
  • B.S. McEwen

    The neurobiology of stress: from serendipity to clinical relevance

    Brain Res

    (2000)
  • P.L. Sample et al.

    Experiences of persons with epilepsy and their families as they look for medical and community care: a focus group from South Carolina

    Epilepsy Behav

    (2006)
  • G.A. Baker et al.

    Impact of epilepsy in adolescence. a UK controlled study

    Epilepsy Behav

    (2005)
  • B.P. Hermann et al.

    Psychosocial predictors of interictal depression

    J Epilepsy

    (1989)
  • H. Livneh et al.

    Psychosocial adaption to epilepsy: the role of coping strategies

    Epilepsy Behav

    (2001)
  • L.H. Goldstein et al.

    Illness representations, coping styles and mood in adults with epilepsy

    Epilepsy Res

    (2005)
  • M. Mula et al.

    The role of hippocampal sclerosis in antiepileptic drug-related depression in patients with epilepsy: a study on levetiracetam

    Seizure

    (2006)
  • A.M. Paschal et al.

    Stigma and safe havens: a medical sociological perspective on African-American female epilepsy patients

    Epilepsy Behav

    (2005)
  • A. Jacoby et al.

    Meanings of epilepsy in its sociocultural context and implications for stigma: findings from ethnographic studies in local communities in China and Vietnam

    Epilepsy Behav

    (2008)
  • M.F. O’Donoghue et al.

    Assessing the psychosocial consequences of epilepsy: a community-based study

    Br J Gen Pract

    (1999)
  • A. Jacoby et al.

    The clinical course of epilepsy and its psychosocial findings from a U.K. community study

    Epilepsia

    (1996)
  • M.A. Dominian et al.

    A follow-up study of late-onset epilepsy. II. Psychiatric and social findings

    Br Med J

    (1963)
  • L.S. Boylan et al.

    Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy

    Neurology

    (2004)
  • J.F. Tellez-Zenteno et al.

    Psychiatric comorbidity in epilepsy: a population-based analysis

    Epilepsia

    (2007)
  • D.C. Hesdorffer et al.

    Major depression is a risk factor for seizures in older adults

    Ann Neurol

    (2000)
  • D.C. Hesdorffer et al.

    Depression and attempted suicide as risk factors for incident unprovoked seizures and epilepsy

    Ann Neurol

    (2006)
  • M. Olfson et al.

    Bipolar depression in a low-income primary care clinic

    Am J Psychiatry

    (2005)
  • R.C. Kessler et al.

    Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey

    Am J Psychiatry

    (1999)
  • S. Anhoury et al.

    Psychiatric outcome after temporal lobectomy: a predictive study

    Epilepsia

    (2000)
  • D.C. Hesdorffer et al.

    Socioeconomic status is a risk factor for epilepsy in Icelandic adults but not in children

    Epilepsia

    (2005)
  • D.C. Heaney et al.

    Socioeconomic variation in incidence of epilepsy: prospective community based study in south east England

    BMJ

    (2002)
  • B.P. Dohrenwend et al.

    Socioeconomic status and psychiatric disorders: the causation–selection issue

    Science

    (1992)
  • J.G. Johnson et al.

    A longitudinal investigation of social causation and social selection processes involved in the association between socioeconomic status and psychiatric disorders

    J Abnormal Psychol

    (1999)
  • P. De Carolis et al.

    Late seizures in patients with internal carotid and middle cerebral artery occlusive disease following ischemic events

    J Neurol Neurosurg Psychiatry

    (1984)

    • Cited by (21)

    • Psychosocial factors associated with anxiety and depression in adolescents with epilepsy: A systematic review

      2023, Epilepsy and Behavior

    • Evaluation of eight psychoactive drugs used in Chinese cities by wastewater-based epidemiology

      2023, Science of the Total Environment
      Citation Excerpt :

      A Canadian study reported that major depression was the most common mental disorder among people with epilepsy (Fuller-Thomson and Brennenstuhl, 2009). Thirteen percent of people with epilepsy are depressed compared with 7 % of people without epilepsy (Hesdorffer and Lee, 2009), and a significantly higher prevalence (Fuller-Thomson and Brennenstuhl, 2009). The prevalence of depression is also higher in women, ethnic minorities, and the elderly (Ettinger et al., 2004).

    • Troubles psychiatriques et facteurs associés chez une population de patients épileptiques à Fès, Maroc Psychiatric disorders and associated factors in patients with epilepsy in Fez, Morocco

      2015, Encephale

    • Self-reported anxiety and sleep problems in people with epilepsy and their association with quality of life

      2015, Epilepsy and Behavior

    • Neurocognitive and psychological profiles of adult patients with epilepsy in Hong Kong

      2013, Epilepsy and Behavior
      Citation Excerpt :

      Results revealed particular vulnerabilities among patients with drug-resistant epilepsy; they were, thus, more in need of neuropsychological attention. Increasing evidence indicates that elevated stress and disturbed psychological states could precede and might aggravate seizures [19,50–54]; the role of psychobehavioral interventions in epilepsy care has received the attention that it deserves in recent decades. Some were shown to be efficacious in reducing psychological distress [55–57] or even improving seizure manifestations [58,59].

    • Psychosocial predictors of depression and anxiety in patients with epilepsy: A systematic review

      2012, Journal of Affective Disorders
      Citation Excerpt :

      In the context of other, null findings (Asadi-Pooya et al., 2007; Hermann and Whitman, 1989), Endermann's results therefore do not provide compelling support for the role of attributional theory constructs. Stigma has been described as the largest burden faced by PWE (McCagh et al., 2009) and it has been suggested in multiple reviews as a likely risk factor for the development of psychopathology (Antonak and Livneh, 1992; Baker, 2002; Barry, 2003; Beyenburg et al., 2005; Hesdorffer and Lee, 2009; Lambert and Robertson, 1999; Marsh and Rao, 2002). However, increased levels of stigma predicted depression in only 1/3 studies and it was found to be associated with very small proportion of the variance in anxiety in the one study to assess this.

    View all citing articles on Scopus
    View full text
    Copyright © 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.