Epilepsy & Behavior 53 (2015) 37–42

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Psychiatric disorders among 165 patients with juvenile myoclonic epilepsy in India and association with clinical and sociodemographic variables Shanmuki Somayajula, Sudhindra Vooturi, Sita Jayalakshmi ⁎ Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India

a r t i c l e

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Article history: Received 11 July 2015 Revised 11 September 2015 Accepted 19 September 2015 Available online 28 October 2015 Keywords: Juvenile myoclonic epilepsy Psychiatric disorders Depressive disorders Anxiety disorders Marital status

a b s t r a c t Objective: The current study evaluated the association between clinical variables and psychiatric disorders (PDs) in patients with juvenile myoclonic epilepsy (JME). Methods: Consecutive patients with JME who had at least two years of regular follow-up from May 2011 to April 2014 formed the study population. The association between clinical and sociodemographic data with psychiatric evaluation on structured clinical interview and quality of life in epilepsy — 31 (QOLIE-31) was evaluated using logistic regression analysis. Results: Out of 165 patients in the current study, 77 (46.6%) patients were diagnosed with PDs; while 50 were categorized to having anxiety disorders, 27 patients had depressive disorders. The mean age of the study population was 25.35 ± 7.6 years with 37.52% women. Patients with PDs had lower overall QOLIE score (55.84 ± 13.07 vs 68.70 ± 11.23, p b 0.001) and lower social function score (80.95 ± 19.22 vs 91.09 ± 14.74, p b 0.001). Being married was the strongest predictor of depressive disorders (β = 8.59; 95% CI, 1.44–51.28; p = 0.018); whereas, lower emotional well-being (β = 0.942; 95% CI, 0.907–0.978; p = 0.002) was the only variable associated with anxiety disorders. Patients with depressive disorders had longer duration of PDs (11.85 ± 8.68 years vs 7.75 ± 6.70 years, p = 0.039), and a majority of them were married (66.7% vs 26.0%, p = 0.001). Patients with depressive disorders scored low on emotional well-being (50.81 ± 14.62 vs 61.02 ± 13.05, p = 0.002), energy levels (52.78 ± 11.71 vs 62.80 ± 10.84, p b 0.001), and social function (70.96 ± 20.69 vs 86.34 ± 16.16, p = 0.001). Depressive disorders were more prevalent among married patients above 35 years of age (5.2% vs 36.8%, p = 0.042). Significance: Nearly half of the patients with JME had coexisting PDs. The psychological profile of anxiety disorders was different from depressive disorders in patients with JME. Depressive disorders were more prevalent among older patients with JME, and marriage was strongly associated with depressive disorders. © 2015 Elsevier Inc. All rights reserved.

1. Introduction Juvenile myoclonic epilepsy (JME) is an age-related, clinically welldefined idiopathic generalized epilepsy syndrome characterized by myoclonic jerks (MJ), generalized tonic–clonic seizures (GTCS) especially on awakening, and absence seizures in about one-third of the patients [1]. An abnormal behavioral profile in patients with JME was reported as early as 1957 [2]. The prevalence of psychiatric disorders (PDs) in nearly one-third of patients with JME is similar to that reported in patients with temporal lobe epilepsy where psychiatric aspects have been more commonly studied [3]. A high prevalence of PDs has been reported in patients with early onset of seizures (age b 11 years) in ⁎ Corresponding author at: Department of Neurology, Krishna Institute of Medical Sciences, 1-8-31/1, Ministers Road, Secunderabad, Telangana, India. Tel.: +91 9848019036; fax: +91 40 27814499. E-mail address: [email protected] (S. Jayalakshmi).

http://dx.doi.org/10.1016/j.yebeh.2015.09.024 1525-5050/© 2015 Elsevier Inc. All rights reserved.

comparison with those with a later onset [4]. Patients with JME perform more poorly than those with frontal lobe epilepsy on tests requiring psychomotor speed, abstract reasoning, and concept formation [5]. Personality traits like psychasthenia and instability due to PDs characterize social consequences in patients with JME [6]. In fact, Lund et al. [7] reported “character neurosis” defined as emotional instability, lack of perseverance, and fearful inhibition in a subgroup of patients with JME associated with a feeling of being discriminated, lower income, and need for social assurance. Furthermore, studies have also reported that coexisting PDs make management of patients with JME difficult [8] with reports associating PDs with drug resistance [9,10], higher seizure frequency [11], and worst seizure control [12]. Special attention is, therefore, needed with regard to PDs in the comprehensive management of JME [3]. In recent times, assessment with structured diagnostic instruments like SCID-I and SCID-II allow more accurate classification and quantification of PDs, particularly anxiety and personality disorders [13]. A comprehensive neuropsychological assessment of patients with JME

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revealed executive dysfunction attributable to attention deficits [14]. This improved quantification is helpful in evaluating the association between psychiatric aspects of JME with clinical factors like duration of epilepsy and age of onset of epilepsy. However, there is insufficient research on the influence of clinical factors on PDs, chronological behavior of PDs, and their influence of socioprofessional integration in patients with JME [3]. The current study evaluated the association between clinical variables and PDs with implications on psychosocial integration in patients with JME. 2. Material and methods The study was part of a larger epilepsy registry, where consecutive patients with JME aged 16 years and above, who had at least two years of regular follow-up at an outpatient department of the epilepsy clinic at the Krishna Institute of Medical Sciences, a tertiary referral center in South India, from May 2011 to April 2014, formed the study population. The diagnosis of JME was based on the International Classification of Epilepsies [1]. Patients with chronic illnesses besides JME and patients with evidence of neurological (or) intellectual deficit secondary to brain hypoxia, metabolic disease, and degenerative diseases were excluded. The study was approved by the institutional ethics committee. The sociodemographic data collected included details about age, gender, schooling, family income, education, family history of neurological or psychiatric illness, marital status, employment, smoking, and alcohol use. The clinical variables collected were semiology, type of seizures, time of occurrence of GTCS and MJ, duration of epilepsy, age of onset of epilepsy, precipitating factors, family history of epilepsy, and antiepileptic drug (AED) history. The seizure frequency score was assessed at every visit using the Department of Veteran Affairs (VA) seizure type and frequency rating for GTCS [15]. 2.1. Psychiatric evaluation All subjects were evaluated by a clinical psychologist, using International Classification of Psychiatric Disorders (ICD-10), by the structured clinical interview method in which each patient can have more than one psychiatric diagnosis in each axis. For analysis, patients were classified into two major groups (i.e., anxiety disorders or depressive disorders). Patients with anxiety disorders mixed with depressive disorders were grouped under anxiety disorders, and those with schizophrenia were categorized into depressive disorders. The QOLIE-31 questionnaire was used to assess health-related quality of life in the study patients [16]. The QOLIE-31 contains seven subscales which quantify the patient's seizure worry, overall quality of life, emotional well-being, energy/fatigue, cognitive functioning, medication effects, and social functioning on a scale of 0–100 where higher scores reflect a better quality of life. An overall score is obtained by using a weighted average of the subscale scores. Seizure severity and its psychometrics were analyzed using the Liverpool seizure severity scale (LSSS), a 16-point scale, containing 2 subscales: perception of control and ictal/postictal effects [17]. 2.2. Statistical analysis After confirming the homogeneity of the data, the study population was divided into groups based on the presence of PDs, type of PDs, and marital status. While the differences between groups for categorical variables were analyzed using chi-square test, unpaired student t-test was used for continuous variables. All the factors that were significantly different between the groups were tested for association with the type of PD using binary logistic regression analysis. All the statistical analysis was performed using Statistical Package for Social Sciences software version 17.0, IBM Computers, New York, USA. A p b 0.05 was considered significant.

3. Results A total of 165 patients with JME were enrolled in the current study. All the patients had myoclonic jerks, 142 (86%) had GTCS, and absence seizures were reported in 46 (27.9%) patients. Febrile seizures were reported in 27 (16.3%) patients. The optimum AED dose (maximum tolerated dose according to body weight) was administered in all the patients. Valproic acid was taken by 132 patients while 22 received lamotrigine and 10 were given levetiracetam. The other AEDs used were topiramate in six, and clobazam in 28 patients as the seizure control was not optimum in spite of one AED. Seizures were well-controlled in 127 (76.9%) patients who were seizure-free for at least two or more years. Seventy-seven (46.6%) patients were diagnosed with PDs in the entire cohort of 165 patients. Among the 77 patients with JME with PDs, 50 were categorized to having anxiety disorders which included six patients with mixed anxiety and depressive disorders; 27 patients with JME had depressive disorders which included one patient with schizophrenia. The mean age of the study population was 25.35 ± 7.6 (range 16 to 54) years. While 62 (37.52%) were women, an equal number were married at enrolment into the study. 3.1. Patient characteristics and PDs There were no significant differences between the patients with or without PDs for mean age (25.88 ± 7.51 years vs 24.83 ± 7.70 years, p = 0.377), female gender (36.4% vs 38.6%, p = 0.872), and fraction of patients with graduate education (40.0% vs 40.9%, p = 1.000). Both groups were similar for duration of epilepsy (9.19 ± 7.65 years vs 8.74 ± 6.98 years, p = 0.692), seizure scores (4.45 ± 2.44 vs 4.33 ± 2.13, p = 0.726), and percentage of those who were married (40.3% vs 35.2%, p = 0.523). However, patients with PDs had lower overall QOLIE score (55.84 ± 13.07 vs 68.70 ± 11.23, p b 0.001), lower emotional well-being (57.44 ± 14.38 vs 76.43 ± 10.93, p b 0.001), and lower social function score (80.95 ± 19.22 vs 91.09 ± 14.74, p b 0.001). The differences between patients with PDs and those without PDs are summarized in Table 1. 3.2. Patient characteristics and depressive disorders Upon comparison of patients with depressive disorders (n = 27) with those who had no PDs (n = 88), patients with depressive disorders were older (30.11 ± 9.37 years vs 24.83 7.70 years, p = 0.004) and had longer duration of epilepsy (11.85 ± 8.68 years vs 8.74 ± 6.97 years, p = 0.055), and a majority of them were married (66.7% vs 35.2%, p = 0.007). On the psychological assessment, patients with depressive disorders scored low on emotional well-being (50.81 ± 14.62 vs 76.43 ± 10.93, p b 0.001), cognitive function (60.96 ± 24.89 vs 82.00 ± 18.90, p b 0.001), energy levels (52.78 ± 11.71 vs 67.98 ± 15.33, p b 0.001), lack of seizure worry (60.18 ± 21.11 vs 79.89 ± 19.03, p = 0.004), and social function (70.96 ± 20.69 vs 91.09 ± 14.74, p b 0.001). The differences between groups based on depressive disorders are summarized in Table 2. On further analysis on factors associated with depressive disorders, being married was the strongest predictor of depressive disorders (β = 8.59; 95% CI, 1.44–51.28; p = 0.018) with contributions from lower QOLIE score (β = 0.906; 95% CI, 0.843–0.973; p = 0.007), lower emotional well-being (β = 0.920; 95% CI, 0.866–0.978; p = 0.008), and lower social function (β = 0.938; 95% CI, 0.901–0.977; p = 0.002). 3.3. Patient characteristics and anxiety disorders Upon comparison of patients with anxiety disorders (n = 50) with those who had no PDs (n = 88), there were no differences between the groups for mean age (23.60 ± 5.07 years vs 24.83 7.70 years, p = 0.314), duration of epilepsy (7.75 ± 6.70 years vs 8.74 ± 6.97 years,

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Table 1 Differences for study variables for patients with psychiatric disorders (n = 77) and those without psychiatric disorders (n = 88). S. NO

Variable

Patients without psychiatric disorders (n = 88)

Patients with psychiatric disorders (n = 77)

p-Value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female (%) Married (%) Graduate (%) Unemployed (%) Family history of psychiatric disorders (%) More than two antiepileptic drugs (%) Age (years) Duration of epilepsy (years) Seizure score Liverpool seizure severity score Overall QOLIE score Seizure worry Emotional well-being score Energy score Cognitive function score Medical side effects score Social function score

34 (38.6%) 31 (35.2%) 36 (40.9%) 10 (11.4%) 41 (46.6%) 20 (22.7%) 24.83 ± 7.70 8.74 ± 6.98 4.33 ± 2.13 11.90 ± 18.68 68.70 ± 11.23 79.89 ± 19.03 76.43 ± 10.93 67.98 ± 15.33 82.00 ± 18.90 95.74 ± 10.14 91.09 ± 14.74

28 (36.4%) 31 (40.3%) 31 (40.0%) 1 (1.3%) 29 (37.7%) 21 (27.3%) 25.88 ± 7.51 9.19 ± 7.65 4.45 ± 2.44 15.65 ± 21.24 55.84 ± 13.07 66.33 ± 20.61 57.44 ± 14.38 59.29 ± 12.07 67.50 ± 22.81 89.74 ± 13.86 80.95 ± 19.22

0.872 0.523 1.000 0.010 0.272 0.589 0.377 0.692 0.726 0.230 b0.001 b0.001 b0.001 b0.001 b0.001 0.002 b0.001

p = 0.420), and marital status (26.0% vs 35.2%, p = 0.342). On the psychological assessment, patients with anxiety disorders scored low on emotional well-being (61.02 ± 13.05 vs 76.43 ± 10.93, p b 0.001), cognitive function (71.03 ± 21.02 vs 82.00 ± 18.90, p b 0.001), and energy levels (62.80 ± 10.84 vs 67.98 ± 15.33, p = 0.022) but not on social function (86.34 ± 16.16 vs 91.09 ± 14.74, p b 0.090). The differences between groups based on anxiety disorders are summarized in Table 3. On further analysis of factors associated with anxiety disorders, lower emotional well-being (β = 0.942; 95% CI, 0.907–0.978; p = 0.002) was associated with anxiety disorders. 3.4. Anxiety disorders versus depressive disorders On comparison of patients with depressive (n = 27) versus anxiety disorders (n = 50), patients with depressive disorders were older (30.11 ± 9.37 years vs 23.60 ± 5.07 years, p = 0.002). The percentage of patients with JME with anxiety disorders was higher than those with depressive disorders among patients between 15–20 (27.8 vs 9.2%, p = 0.024) and 21–25 years (41.2% vs 5.9%, p b 0.001) years of age. The distribution was equal for the age group 26–30 years (39.1% vs 39.1%, p = 1.000). However, among those aged above 35 years, depressive disorders were more prevalent than anxiety disorders (5.0% vs 35.0%, p = 0.043), summarized in Fig. 1. Patients with depressive disorders had longer duration of epilepsy (11.85 ± 8.68 years vs 7.75 ± 6.70 years, p = 0.039), and a majority of them were married (66.7% vs 26.0%, p = 0.001). On the psychological assessment, patients with depressive

disorders scored low on emotional well-being (50.81 ± 14.62 vs 61.02 ± 13.05, p = 0.002), energy levels (52.78 ± 11.71 vs 62.80 ± 10.84, p b 0.001), lack of seizure worry (60.18 ± 21.11 vs 69.65 ± 21.11, p = 0.004), social function (70.96 ± 20.69 vs 86.34 ± 16.16, p = 0.001), and overall QOLIE (47.32 ± 12.12 vs 60.45 ± 11.21, p b 0.001). The differences between groups of PDs are summarized in Table 4. 3.5. Patient characteristics and marital status An analysis of study population divided based on marital status revealed that patients who were married were older (21.35 ± 4.03 years vs 31.92 ± 7.59 years, p b 0.001) and had longer duration of epilepsy (6.83 ± 5.12 years vs 12.47 ± 8.88 years, p b 0.001) than their unmarried counterparts. Importantly, while depressive disorders were more prevalent among the married group (8.7% vs 29.0%, p b 0.001), anxiety disorders were common among the unmarried (35.9% vs 21.0%, p = 0.054). Moreover, average scores on psychiatric assessment were lower for married patients than the unmarried. The differences between study populations based on marital status are summarized in Table 5. On further analysis of distribution of PDs among patients who were married across the age groups, we found none of the married patients under 20 years of age had PDs. In the age group of 21–25 years, anxiety disorders were observed in 40% and depressive disorders in 10% of the married patients (p = 0.303). Similarly, there was no significant difference for distribution of anxiety disorders and

Table 2 Differences for study variables for patients with depressive disorders (n = 27) and those without psychiatric disorders (n = 88). S. NO

Variable

Patients without psychiatric disorders (n = 88)

Patients with depressive disorders (n = 27)

p-Value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female (%) Married (%) Graduate and above studies (%) Professional employment (%) Family history of psychiatric disorders (%) More than two antiepileptic drugs (%) Age (years) Duration of epilepsy (years) Seizure score Liverpool seizure severity score Overall QOLIE score Seizure worry Emotional well-being score Energy score Cognitive function score Medical side effects score Social function score

34 (38.6%) 31 (35.2%) 45 (55.1%) 12 (13.6%) 41 (46.6%) 20 (22.7%) 24.83 ± 7.70 8.74 ± 6.97 4.33 ± 2.32 11.90 ± 18.68 68.70 ± 11.23 79.89 ± 19.03 76.43 ± 10.93 67.98 ± 15.33 82.00 ± 18.90 95.74 ± 10.14 91.09 ± 14.74

10 (37.0%) 18 (66.7%) 11 (40.7%) 6 (22.2%) 9 (33.3%) 8 (29.6%) 30.11 ± 9.37 11.85 ± 8.68 4.85 ± 2.50 16. 39 ± 22.97 47.32 ± 12.12 60.18 ± 18.49 50.81 ± 14.62 52.78 ± 11.71 60.96 ± 24.89 88.38 ± 12.06 70.96 ± 20.69

1.000 0.007 0.385 0.363 0.271 0.454 0.004 0.058 0.288 0.304 b0.001 b0.001 b0.001 b0.001 b0.001 0.007 b0.001

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Table 3 Differences for study variables for patients with anxiety disorders (n = 50) and those without psychiatric disorders (n = 88). S. NO

Variable

Patients without psychiatric disorders (n = 88)

Patients with anxiety disorders (n = 50)

p-Value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female (%) Married (%) Graduate and above studies (%) Professional employment (%) Family history of psychiatric disorders (%) More than two antiepileptic drugs (%) Age (years) Duration of epilepsy (years) Seizure score Liverpool seizure severity score Overall QOLIE score Seizure worry Emotional well-being score Energy score Cognitive function score Medical side effects score Social function score

34 (38.6%) 31 (35.2%) 45 (55.1%) 12 (13.6%) 41 (46.6%) 20 (22.7%) 24.83 ± 7.70 8.74 ± 6.97 4.33 ± 2.32 11.90 ± 18.68 68.70 ± 11.23 79.89 ± 19.03 76.43 ± 10.93 67.98 ± 15.33 82.00 ± 18.90 95.74 ± 10.14 91.09 ± 14.74

18 (36.0%) 13 (26.0%) 29 (58.0%) 7 (14.0%) 20 (40.0%) 13 (26.0%) 23.60 ± 5.07 7.75 ± 6.70 4.24 ± 2.40 15.25 ± 20.48 60.45 ± 11.21 69.65 ± 21.11 61.02 ± 13.05 62.80 ± 10.84 71.03 ± 21.02 90.47 ± 14.81 86.34 ± 16.16

0.855 0.342 0.481 1.000 0.481 0.682 0.314 0.420 0.821 0.331 b0.001 0.004 b0.001 0.022 0.002 0.015 0.090

distribution (26.6% vs 53.3%, p = 0.263) in married patients between 26–30 years of age and 31–35 years of age (28.5% vs 14.2%, p = 0.648). However, depressive disorders were more prevalent among married patients above 35 years of age (5.2% vs 36.8%, p = 0.042). The distribution of percentage of patients who are married across the age groups is summarized in Fig. 1.

4. Discussion In this prospective single center study, we report that nearly half of patients with JME had coexisting PDs. Psychosocial characteristics of patients with JME with depressive disorders differed from those with anxiety disorders. Not only were patients with JME with depressive disorders older than those with anxiety disorders; they also had longer duration of epilepsy. Marital status was the strongest predictor of depressive disorders in the entire study group. Estimates of psychiatric comorbidity in patients with JME are heterogeneous with variations attributed to methodological issues, severity and chronicity of epilepsy, population setting, and psychometric assessment used [18,19]. The prevalence of PDs at 46.6% and depressive disorders at 16.3% in the current study is similar to the 49% and 17% reported by De Araujo et al. in a review of psychiatric comorbidity in patients with JME [3]. However, the same review disclosed prevalence of anxiety disorders at 23.0%; slightly lower than 30.3% reported in our study. This variation may be due to the different psychiatric assessment scales being used; while ICD was implemented in our study, De Araujo et al. utilized SCID-I. Therefore, our results are in line with existing literature supporting an increased comorbidity of PDs in patients with JME [7,9,20].

We report that the two major PDs (i.e., anxiety disorders and depressive disorders) in patients with JME differed from each other, where the average age was younger in those with anxiety disorders than in those with depressive disorders. Furthermore, the average duration of epilepsy was longer in patients with depressive disorders. When observed for chronology for anxiety disorders, the incidence of anxiety disorders was higher in patients between 15 and 25 years of age which subsequently plateaued until 30 years of age and then was reduced. This age-related variance in anxiety disorders is similar to that reported by Weissman et al. [21] in a cross-national epidemiological study. In contrast, incidence of depressive disorders was lower in younger patients and higher in the age group above 35 years in the present study. The association between mental health and social relationships has been a topic of evaluation for a long time. It has been shown that social relationships may influence mental health through health-related behaviors, social functioning, and access to resources [22]. In the current study, we did not find differences between patients with JME with or without PDs for level of education and socioeconomic status, suggesting that the presence of JME, especially a longer duration of epilepsy, might have been the major factor. However, our observation that patients with JME with depressive disorders have lower social functioning scores may explain depressive disorders in these patients. We also report that being married is a predictor of depressive disorders in our study population. We have previously reported in patients with JME from India that lack of family support is associated with increased incidence of PDs [10]. Therefore, perceived marital dissatisfaction and negative marital quality, both risk factors for depressive disorders as shown by prospective community studies [23,24], may have contributed to a higher prevalence of depressive disorders in married patients with JME.

Fig. 1. Distribution of psychiatric disorders and marital status across the age groups. Anxiety disorders were more prevalent among the younger age group while depressive disorders were more prevalent among the older age group.

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Table 4 Differences for study variables for patients with depressive disorders (n = 27) and anxiety disorders (n = 50). S. NO

Variable

Depressive disorders (n = 27)

Anxiety disorders (n = 50)

p-Value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female (%) Married (%) Graduate (%) Unemployed (%) Family history of psychiatric disorders (%) More than two antiepileptic drugs (%) Age (years) Duration of epilepsy (years) Seizure score Liverpool seizure severity score Overall QOLIE score Seizure worry Emotional well-being score Energy score Cognitive function score Medical side effects score Social function score

10 (37.0%) 18 (66.7%) 8 (29.6%) 0 (0.0%) 9 (33.3%) 8 (29.6%) 30.11 ± 9.37 11.85 ± 8.68 4.85 ± 2.50 16. 39 ± 22.97 47.32 ± 12.12 60.18 ± 18.49 50.81 ± 14.62 52.78 ± 11.71 60.96 ± 24.89 88.38 ± 12.06 70.96 ± 20.69

18 (36.0%) 13 (26.0%) 23 (46.9%) 1 (2.0%) 20 (40.0%) 13 (26.0%) 23.60 ± 5.07 7.75 ± 6.70 4.24 ± 2.40 15.25 ± 20.48 60.45 ± 11.21 69.65 ± 21.11 61.02 ± 13.05 62.80 ± 10.84 71.03 ± 21.02 90.47 ± 14.81 86.34 ± 16.16

1.000 0.001 0.224 1.000 0.628 0.792 0.002 0.039 0.297 0.824 b0.001 0.046 0.002 b0.001 0.064 0.532 0.001

Age of marriage, socioeconomic status, and education have previously been reported as factors associated with depression [25]. Thomas and Nair [26] have previously reported that in a country like India, where the majority of marriages remain arranged, families of people with epilepsy may confront stigma when they try to arrange marriages [26]. This stigma may lead to concealing the disease from their spouse before marriage. In fact, a majority of patients with epilepsy who get divorced did not reveal the disease to their spouse before marriage [27]. Psychological disturbance associated with epilepsy should be a priority for intervention. Di Matteo et al. [28], in a quantitative review of patients in hospitals, reported that depressed patients were three times as likely as nondepressed patients to be noncompliant to medical therapy. The reasons the authors attributed for the noncompliance were: Firstly, depression often involves an appreciable degree of hopelessness, and compliance might be difficult or impossible for a patient who holds little optimism that any action will be worthwhile. This may be true for the current study population as patients with JME with depressive disorders have higher medical side effect scores than those without PDs. Secondly, considerable research [29] suggests the importance of support from the family and social network in a patient's attempts to be compliant with medical treatments. Lack of family support as a reason for lack of response to treatment in patients with JME from India has been previously reported by us [10]. Therefore, these observations

hold more significance in patients with JME; hence, further evaluation of the influence of the social network is warranted. Depression is often accompanied by considerable social isolation and withdrawal from the very individuals who would be essential in providing emotional support and assistance [28]. Similarly, we report low social functioning scores, emotional well-being, energy score, and overall QOLIE scores in patients with JME with depressive disorders when compared with those in patients with JME without PDs. Thirdly, depressive disorders may be associated with reductions in the cognitive functioning essential to remembering and following through with treatment recommendations (e.g., taking medication). In line with this, we we showed a lower score for cognitive function in depressed patients with JME. The quantitative review also reported that in contrast to depression, anxiety has an unclear relationship with adherence [28]. The reviewers went on to add that anxiety itself can be heterogeneous and range from panic, which might have no direct effect on compliance, to obsessive–compulsive disorder and generalized anxiety about health, which might actually improve compliance activities. Seizure avoidance or abortion by the use of cue-controlled relaxation (or arousal) or the use of countermeasures was suggested to be effective for focal seizures with a well-defined aura [30,31]. Similarly, cognitive behavioral strategies may be helpful in patients with mood-related seizure triggers [32,33]. Psychological techniques may improve psychological adjustment and seizure control perspectives in patients with JME, and such treatment is worth investigating further.

Table 5 Differences for study variables for marital status. S. NO

Variable

Unmarried (n = 103)

Married (n = 62)

p-Value

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Female (%) Graduate (%) Professionals (%) Family history of psychiatric disorders (%) More than two antiepileptic drugs (%) Age (years) Duration of epilepsy (years) Seizure score Liverpool seizure severity score Overall QOLIE score Seizure worry Emotional well-being score Energy score Cognitive function score Medical side effects score Social function score Depressive disorders Anxiety disorders

35 (34.0%) 58 (56.3%) 12 (11.7%) 46 (44.7%) 26 (25.2%) 21.35 ± 4.03 6.83 ± 5.12 4.59 ± 2.32 10.17 ± 15.11 65.14 ± 12.37 74.97 ± 20.45 69.25 ± 15.11 65.95 ± 13.45 76.11 ± 21.06 93.61 ± 12.31 86.11 ± 18.30 9 (8.7%) 37 (35.9%)

27 (43.5%) 27 (43.5%) 13 (21.0%) 24 (38.7%) 15 (24.2%) 31.92 ± 7.59 12.47 ± 8.88 4.05 ± 2.16 19.44 ± 25.17 58.64 ± 14.48 71.22 ± 21.48 64.66 ± 16.61 60.55 ± 15.71 73.77 ± 23.55 91.82 ± 12.45 86.77 ± 16.70 18 (29.0%) 13 (21.0%)

0.247 0.148 0.120 0.517 1.000 b0.001 b0.001 0.138 0.004 0.003 0.265 0.072 0.020 0.510 0.370 0.815 b0.001 0.054

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Limitations of this study that deserve to be mentioned are: confounding by unmeasured variables is a threat in any study, perhaps even more so in studies like ours that examine social determinants of health. Psychiatric disorders were broadly divided into only two major groups (anxiety disorders or depressive disorders); data regarding specific subgroups of anxiety disorders or depressive disorders and other coexisting PDs were not collected. Therefore, the findings of our study must be interpreted with caution. Though this study was longitudinal, it does not contain time points for analysis. As a consequence, it is possible that in the long interim interval, participants' quality of social relationships varied. However, negative social interactions, at least in older adults, are considered to be stable over years. Our analyses were not powered to distinguish between incident and recurrent PDs; it is likely that many cases were recurrent. Therefore, we are unable to report whether social relationship quality is more or less of a predictor for first-episode or recurrent depressive disorders. Finally, several measures relied on participants' recall of the prior year, which is a lengthy period of time. 5. Conclusion In the current study, we showed that nearly half of the patients with JME have coexisting PDs. The psychological profile of anxiety disorders was different from depressive disorders in patients with JME. While anxiety disorders were more common among young patients, depressive disorders were more prevalent among the older patients with JME. Marriage was strongly associated with depressive disorders in these patients. Author contributions Dr. Shanmukhi Somayajula: data collection and manuscript writing; Dr. Sudhindra Vooturi: data analysis and statistical methods; Dr. Sita Jayalakshmi: data collection, data analysis, and critical review of the manuscript. Declaration We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Acknowledgment None. Disclosure of conflict of interest None of the authors has any conflict of interest to disclose. References [1] Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1989;30:389–99. [2] Janz DCW. Impulsiv-petit mal. Dtsch Z Nervenheilkd 1957;3:346–86. [3] de Araujo Filho GM, Yacubian EM. Juvenile myoclonic epilepsy: psychiatric comorbidity and impact on outcome. Epilepsy Behav 2013;28(Suppl. 1):S74–80.

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Psychiatric disorders among 165 patients with juvenile myoclonic epilepsy in India and association with clinical and sociodemographic variables.

The current study evaluated the association between clinical variables and psychiatric disorders (PDs) in patients with juvenile myoclonic epilepsy (J...
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