Health, wealth, and culture as predominant factors in psychosocial morbidity
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
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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.
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Glutamate has recently been found to have an important role, not only in epilepsy but also in mood disorders.
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Further exploration of the role of neurotransmitters will
Conflict of Interest Statement
All authors declare no conflict of interest.
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Evaluation of eight psychoactive drugs used in Chinese cities by wastewater-based epidemiology
2023, Science of the Total EnvironmentCitation 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).
Self-reported anxiety and sleep problems in people with epilepsy and their association with quality of life
2015, Epilepsy and BehaviorNeurocognitive and psychological profiles of adult patients with epilepsy in Hong Kong
2013, Epilepsy and BehaviorCitation 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 DisordersCitation 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.