Background: Epilepsy is associated with significant psychiatric morbidities. However, little is known about epilepsy and emotional distress in northern Nigeria. Aim: To assess the prevalence and determinants of emotional distress among people with epilepsy (PWE) in Kaduna, northern Nigeria. Settings and Design: This cross-sectional study was conducted between January, 2011 and June, 2011. Materials and Methods: We administered the Hospital Anxiety and Depression Scale as well as the Oslo 3-Items Social Support Scale to 209 consecutive PWE of at least 1 year duration attending the outpatient clinic of Federal Neuropsychiatric Hospital, Kaduna in order to measure their levels of anxiety and depression, and social support. The socio-demographic and clinical characteristics of the subjects were also recorded. Results: The 209 subjects consisted of 123 (58.7%) males and 86 (41.3%) females with mean age of 28.7 (SD, 12.1) years. Majority have strong social support (56.3%) and less than 6 months seizure-free periods (82.3%). The prevalence of anxiety and depressive symptoms were 20.2% and 15.4% respectively. Older age, being a female, poor social support and short seizure-free periods were significantly associated with emotional distress (P value < 0.05) while female sex (OR = 2.201, P value = 0.024, 95% CI = 1.108 – 4.373) and poor support (OR = 0.361, P value = 0.024, 95% CI = 0.149 – 0.875) predicted anxiety and depressive symptoms respectively. Conclusion: Emotional distress is quite common among PWE and should be taken into consideration in the management of patients with this disorder. Keywords: Emotional distress, epilepsy, northern Nigeria
Epilepsy is a disorder of the brain characterized by recurrent seizures, which are physical reactions to sudden, usually brief, too much electrical discharges in a group of brain cells. [1] Epilepsy affects people in every country of the world. According to a World Health Organization survey, about 50 million people worldwide suffer from epilepsy and almost 90% of them are found in the developing countries. [2] The point prevalence of epilepsy varies from 5.3 to 37 per 1000 in Nigeria. [3] Although some patients with epilepsy lead normal lives, devoid of cognitive or emotional problems, a significant number of them experience psychiatric disturbances including mood disorders and anxiety disorders. [4] Sixty-seven percent of the PWE reported living with high level of psychological distress [1] which impact negatively on their family, social interaction, leisure opportunities and occupation. There is also higher level of psychiatric co-morbidity and poor self-esteem compared with people without the condition. [5] The unpredictability of the seizures results in embarrassment as well as disruption of the normal activity of daily living with consequent emotional distress. Depression and anxiety are the most common psychological disorders in PWE [6] which are frequently unrecognized and untreated. [7],[8] The presence of emotional distress badly affects the disease and treatment outcome and also exerts a profound negative effect on the health-related quality of life in PWE. [1],[4],[9] The prevalence of depression among PWE ranges from 3-55%. [10] Ogunrin and Obiabo [11] obtained a prevalence of 42% and 45% for depression in PWE using the Hamilton rating scale for depression and the Beck depression inventory respectively. History of depression in PWE is a predictor of a more severe form of epilepsy, likelihood of resistance to antiepileptic medications, and recurrence of epilepsy after surgical removal of focus. [12] Depression is an independent predictor of poor quality of life [13],[14],[15] and can increase suicidality in these patients. [6] Antiepileptic medications such as Vigabatrin, Phenobarbitone, and Topiramate may also predispose patients to depression. [6],[16] Anxiety is often a dominant symptom of the adjustment disorders, which most people go through when first diagnosed with epilepsy. States of heightened anxiety can become self-reinforcing with an increase in seizure frequency. [6] In addition, PWE live constantly with the stress of a highly stigmatizing chronic illness. [17] The predictors of emotional distress in PWE include gender, duration of the disease, uncontrolled seizures, poly-pharmacy, felt stigma, [4],[11],[18],[19] lack of social support, unemployment, and the attendant worrying. [20] The previous studies of epilepsy and emotional distress in Nigeria were conducted in the Southern part of the country. This study, thus, aimed at assessing the prevalence and determinants of emotional distress among PWE in a Northern Nigerian cosmopolitan city.
This cross-sectional study was conducted at the outpatient clinic of Federal Neuropsychiatric Hospital (FNPH) Kaduna in the North-western part of Nigeria. The hospital is a tertiary health institution with 5 inpatient admission wards – male, female, emergency, child and adolescent, and drug rehabilitation wards with a total of about 120 beds. It also has the outpatient clinic, which runs 4 days in a week with total attendees of about 15,000 in a year. It receives referral, mostly psychiatric but also neurological, from virtually all the northern states of the country and the Federal Capital Territory, Abuja. We interviewed all consecutive outpatients with a diagnosis of epilepsy of at least one year duration and who were 10 years and above between January 2011 and June, 2011. We excluded patients who had a co-morbid major mental disorder (such as schizophrenia and bipolar affective disorder), cognitive disorder (such as dementia or mental retardation), substance use disorder, and serious physical illness (that made it impossible for patient to be interviewed). We arbitrarily chose 10 years because younger subjects may not understand some of the questionnaire items. Epilepsy was diagnosed clinically based on information from eye-witness account of 2 or more unprovoked generalized seizure episodes. Some subjects were diagnosed based on the clinical history and abnormalities found on electro-encephalography (EEG). EEG is a useful tool in diagnosing epilepsy, but some patients with epilepsy do not manifest EEG abnormalities while some normal subjects show non-specific EEG findings. [21] We recorded the subjects’ socio-demographic details using a data collection sheet while information on their clinical characteristics such as onset of seizure, type of seizure, and seizure-free periods was obtained from the case files. The Hospital Anxiety and Depression Scale (HADS) was used to assess the emotional distress of the subjects. HADS consists of 7 items each for anxiety and depression, which are selected to distinguish the effects of physical illness from mood disorders. Thus, physical symptoms like headache and dizziness were not included. The HADS has been validated and used in Nigeria. [22],[23] We used the Oslo 3-items social support scale to measure the level of social support. There are 3 questions, which ask about the ease of getting help from neighbors, the number of people that subjects can count on when there are serious problems, and the level of concern people show in what the subject is doing. The instrument has been validated for use in Nigeria. [24] A sum index can be obtained by adding the raw scores of the 3 items. The range is 3-14. The scores are interpreted as follows; 3-8 (poor social support), 9-11 (moderate support), and 12-14 (strong support). Using the process of back-translation, we obtained the Hausa version of the instruments, which was applied to all subjects who could not understand English language. This study was approved by the Ethics and Research Committee of FNPH, Kaduna while informed consent was obtained from all subjects who are older than 18 years of age and caregivers/parents of the children and adolescents recruited for the study. Statistical analysis The 15th edition of the Statistical Package for Social Sciences (SPSS-15) was used to analyze the data collected. Descriptive statistics were calculated for the variables, which included frequencies and percentages. We also calculated the means and standard deviation. Cross tabulations were generated using Chi-square (X 2 ) test to investigate association between emotional distress and socio-demographic/clinical variables while multiple regression analysis was used to identify the predictors of emotional distress among PWE at a P value < 0.05.
Out of 209 subjects interviewed, 123 (58.7%) are males while 86 (41.3%) are females. The mean age of the subjects was 28.7 ± 12.1 (95% CI 27.06 – 30.34) years. Forty-three (20.2%) subjects had anxiety symptoms (95% CI 0.1476 – 0.2564) while 33 (15.4%) subjects had depressive symptoms (95% CI 0.1516 – 0.2029). [Table 1] shows the socio-demographic and clinical characteristics of the subjects as well as prevalence of anxiety and depressive symptoms.
The association between emotional distress and socio-demographic/clinical characteristics of the subjects is shown in [Table 2].
Multiple logistic regression analysis shows that female sex predicts anxiety symptoms (OR = 2.201, P value = 0.024, 95% CI = 1.108 – 4.373) while poor social support predicts depressive symptoms (OR = 0.361, P value = 0.024, 95% CI = 0.149 – 0.875).
The mean age of our subjects was 28.7 years (SD 12.1) and majority of them (53.9%) were within the age group of 20-40 years. Epilepsy is known to have a bimodal peak, highest in childhood, plateaus at 15-65 years and then rises again among the elderly. [25] The reverse observed in this study may be attributable to the fact that only subjects 10 years and above were studied. Subjects below 10 years may not be able to comprehend the significance of the questions asked or adequately express their feelings. Ogunniyi et al [26] reported a mean age of 21 years amongst adult Nigerians with epilepsy. This is similar to the finding in this study. Male preponderance of 58.7% in this study was in keeping with previous studies in Nigeria. [27] Indeed, males are more likely to be exposed to epileptogenic insults such cranial trauma and excessive alcohol consumption. In this study, 15.4% of the subjects had depressive symptoms and 20.2% had anxiety symptoms. Depression and anxiety may be a reaction to recurrent ill-health and unpredictability of the attack. Either of them could also result from fear of possible death from the attacks. The impairment/disruption of activities and work in addition to the inability to perform other roles as expected may be contributory factors. Furthermore, previous studies have attributed the high prevalence of anxiety in PWE to the possibility of seizure-induced alterations of neuronal circuits in the amygdale region via a kindling-like mechanism. [28],[29] Both hospital-based and community studies [5],[6] have found the prevalence of an inter-ictal anxiety disorder to be between 10-25% and, in the majority, this is a generalized anxiety disorder. [6] A common pathogenic transmitter mechanism involving decreased serotonergic, noradrenergic, dopaminergic and gabaergic activity is also being proposed for depression and epilepsy. [7] Some recent studies have suggested the existence of a bi-directional relationship between epilepsy and depression. PWE have a higher risk than the general population of suffering depression, not just after but also before the onset of epilepsy. [30],[31] The prevalence of depressive and anxiety symptoms of 25% each in this study is similar to findings by Allgower et al.[32] Inability to find (or loss of) job as a result of epilepsy [17] and the attendant failure to meet role obligations expected of an adult may be contributory factors to the development of emotional distress in our subjects. Although there are more males among our subjects, the females had higher percentages of depressive and anxiety symptoms. While 18 males (14.8%) had depressive symptoms and 15 males (12.3%) had anxiety symptoms, 24 females (27.6%) had depressive symptoms and 18 females (20.7) had anxiety symptoms. Similar observation has been made by some previous researchers. [4],[11] This may not be unexpected in view of the fact that female gender is a recognized risk factor for depression even in non-epileptic populations. [10] With regards to anxiety, other researchers have also reported that female patients tend to be more anxious than the males. [5],[33] This most likely reflects a tendency observed in the general population although gender is generally considered to have a subtle effect on anxiety in PWE. [29],[34] Some studies, however, found a higher prevalence of emotional symptoms in males with epilepsy, [1],[18] which was ascribed to male’s being the bread winner in the family. About 85% of our subjects had moderate to good social support. This is not surprising because the traditional way of extended living is still very strong in Northern Nigeria. The whole family supports any individual with a problem and troops to the hospital in the same manner to visit relatives on admission. Nine (26.4%) of the 34 subjects with poor social support had anxiety symptoms and 10 (30.3%) of them had depressive symptoms compared to 18.8% (anxiety) and 13.1% (depression) among those with moderate to good support. Lack, and lower perceived adequacy, of social support have been linked to poorer mental and physical health while high social support has been found to act as a mediating factor for disease severity. Social support plays a very important role in the life of patients. Amir et al [37] concluded that it is possible to improve the quality of life among PWE by improving social support. In this study, there is a numerical difference in the prevalence of anxiety and depressive symptoms in terms of the duration of illness. However, this was not statistically significant (P value > 0.05). It has been reported that PWE with longer duration of illness have higher depression scores. [38] This may indicate that as the burden of epilepsy increases, so does the severity of mood symptoms. Majority of our subjects (82.3%) had seizure free-period of less than 6 months. This finding suggests poor seizure control. Emotional distress was higher in the patients with poor seizure control. This is in keeping with findings from previous studies. [31],[38] Ogunrin and Obiabo [27] found that poor seizure control was the most potent predictor of depression in their study. This seems paradoxical as one of the most effective treatments for depression is electroconvulsive therapy, which is entirely based on the tenet of the antidepressant effects of convulsions. Smith et al [40] found that 33% of PWE with poor seizure control were clinically anxious while Jacoby et al [5] reported a rate of 25% for anxiety among PWE in a large community-based study. Frequent seizures may have direct damaging effects on the brain and may disrupt academic, occupational, and recreational activities. Patients with frequent seizures are also more likely to be stigmatized. [17] It is also possible that frequent seizure would be interpreted as a sign of impending death. One or more of these factors may explain higher prevalence of emotional symptoms in PWE, which is particularly significant for depression. However, in interpreting the results of this study, we must consider its limitations. This is a cross-sectional study conducted among hospital-based patients, and its generalization to the community may, therefore, be difficult. In addition, emotional symptoms rather than specific psychiatric diagnosis were assessed
Despite the above limitations, the results of this study have confirmed that emotional distress is quite common among PWE. Older age, being a female, poor social support, and short seizure-free periods are associated with emotional distress. However, female sex and poor social support are the only predictors of anxiety and depressive symptoms, respectively. Physicians, Neurologists, and Psychiatrists managing PWE should have high index of suspicion in order to recognize and manage depression and anxiety that may co-exist with epilepsy.
Source of Support: None, Conflict of Interest: None DOI: 10.4103/1755-6783.115179
[Table 1], [Table 2] |
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