Factors Associated With Anxiety and Depression in Persons With Epilepsy (PWE)

Introduction: Epilepsy is a common neurological disease that is associated with increased morbidity and mortality globally. Persons with epilepsy (PWE) experience a heavy emotional burden mainly due to social stigmatization and limited opportunities in life. The purpose of this study was to explore factors associated with anxiety and depression in PWE. Material and methods: In the present cross-sectional study, we enrolled 100 PWE who visited outpatient settings in a public hospital for scheduled follow-up. Data collection was carried out by the completion of the Hospital Anxiety and Depression Scale (HADS), which included participants’ characteristics. The statistical significance level was p < 0.05. Results: Of the 100 participants, the majority were women (65%), below 50 years old (62%), and single (40%). In terms of mental comorbidity, 58% and 48% experienced anxiety and depression, respectively. A statistically significant association was observed between anxiety and age (p = 0.002). Furthermore, a statistically significant association was observed between depression and gender (p = 0.044), age (p = 0.001), marital status (p = 0.036), educational level (p = 0.003), job (p = 0.025), residency (p = 0.041), and whether they went out at night (p = 0.009). Conclusion: Identifying factors associated with anxiety and depression is essential for PWE to receive appropriate support.


Introduction
Epilepsy is a major neurological disorder that affects approximately 65 million people globally [1] and over 3 million adults in the United States [2].In mainland China, the number of persons with epilepsy (PWE) from 2.30 million in 1990 increased to 9.84 million in 2015 [1].In Arab countries, the median lifetime prevalence of epilepsy is 6.9 per 1000 and the median incidence is 89.5 per 100,000 [3].In Europe, there are approximately 6 million PWE, with the prevalence of epilepsy at 8.23 per 1000 individuals across 53 countries [4].Epilepsy constitutes a major determinant of the global burden of neuropsychiatric disease [5].
According to estimates, up to 50-60% of PWE experience at least one mood disorder, including depression and anxiety [6].Anxiety disorders among PWE is approximately 22.8% and may reach 50% in specialized clinical settings [5].The rate of depression in PWE is higher compared to patients with other chronic diseases, such as diabetes mellitus and asthma [7], as well as two to three times more common than in the general population [8].However, there is observed variability in the prevalence of these mental disorders among PWE across the world [9].For example, a high prevalence of depression and anxiety was reported in the United Arab Emirates (26.9% and 25.8%),China (52.6% and 33.4%), Brazil (24.4% and 39.4%), Thailand (20% and 39%), Iran (9.5% and 24.5%), USA (26.9% and 25.8%), and Canada (17.4% and 22.8%) [10].
PWE experience various difficulties that may trigger emotional burdens, such as loss of control in life due to unexpected seizures, diminished disease adaptation, and limited quality of life [10,11].
Raising awareness among health professionals regarding factors associated with anxiety and depression in this population is a challenge.Furthermore, the government and medical institutions should consider offering a multidisciplinary management program to improve psychological status among PWE [12].
The aim of this cross-sectional study was to explore factors associated with anxiety and depression among

Statistical analysis
Categorical data are presented with absolute and relative (%) frequencies, while continuous ones with mean, standard deviation, median, and interquartile range, according to the normality of the data (checked with Kolmogorov-Smirnov normality test and graphically with histograms).The X2 test of independence (with Fisher's exact adjustment wherever applicable) was used to assess the association between anxiety/depression levels and patient characteristics, as well as the non-parametric Mann-Whitney test.In addition, multiple logistic regression was performed to assess the impact of patient's characteristics (independent factors) on their anxiety/depression.Results are presented as odds ratio (OR) and 95% confidence interval (95% CI).The observed significance level of 5% was considered statistically significant.All statistical analyses were performed using SPSS version 25 statistical program (IBM Corp., Armonk, NY).

Sample description
Table 1 shows the demographic characteristics of the sample.In particular, 35% of the sample were men, 62% were under 50 years old, 40% were single, 46% had a university education, 55% were employees, 83% were living in Attica, and 58% did not have children.

Factors associated with anxiety/depression
Tables 4, 5 present associated factors with anxiety/depression.A statistically significant association was observed between anxiety and age (p = 0.002) (Table 4).More specifically, participants over 40 had a higher rate of anxiety (65.8%) than younger patients (53.2%).There was no statistically significant association with other variables.A statistically significant association was observed between depression and gender (p = 0.044), age (p = 0.001), marital status (p = 0.036), educational level (p = 0.003), job (p = 0.025), residency (p = 0.041), and whether they went out at night (p = 0.009) (Table 5).More specifically, female participants had a higher rate of depression (55.4%) than men (34.3%).Participants over the age of 40 had a higher rate of depression (68.4%) than younger patients (35.5%), as well as the divorced/widowed patients had a higher rate of depression (76.5%) than single and married ones (42.5% and 41.9%, respectively).Participants with primary education had a higher rate of depression (90%) than those with secondary and university education (57.6% and 35.1%, respectively).Unemployed had a higher rate of depression (68%) than pensioners and employees (55% and 36.4%,respectively).Participants living in a country area had a higher rate of depression (70.6%) than those living in Attica (43.4%).Similarly, those who did not go out at night had higher rates of depression (66.7%).

Impact of participants' characteristics on their anxiety/depression
Multiple logistic regression was performed to estimate the effect of potential confounders (characteristics) on participants' anxiety and depression.

Discussion
The results showed that PWE over the age of 40 years experienced anxiety and depression.A possible interpretation is that individuals of this age perceiving they are unable to perform prior functional roles or activities experience anxiety and depression.According to Acharya et al. [16], an additional reason is underdiagnosis in this age group and the absence of specialized physicians in the diagnostic process.Contrariwise, Escoffery et al. [17] argue that treatment is less effective in PWE under 30 years of age compared to older ones, which is possibly attributed to deficits in self-management and necessary skills.
Also, results revealed depression in women.Indeed, epilepsy hinders women's ability to care for family, imposes role changes, frequent hospitalizations, and financial burdens that trigger or reinforce depression.Hajszan et al. [18] stated that depression in women with epilepsy may reflect a state of hormonal deficiency and disorders in reproductive function.According to Gopinath et al. [19], comorbidities, lower employment rates, and higher anxiety occur more frequently in females.Compared to men, women face more difficulties in finding life partners and an increased risk of divorce, even when the clinical profiles of epilepsy are similar [19].
In the present study, divorced PWE experienced depression, which is explained by the lack of companionship and communication with their partner.Indeed, lack of support has negative consequences for physical and mental health [20][21][22].Tedrus et al. [23] demonstrated that psychiatric comorbidity and epilepsy duration were positively associated with divorce.Marriage is less common in PWE compared to patients with other chronic diseases or the general population [23].A study by Motamedi et al. [24] showed that 39% of PWE living alone perceived epilepsy as an obstacle to marrying the ideal partner (n = 179).On the other side of the coin, caregiver depression is a significant contributor to depression in PWE [25].
Regarding educational background, PWE with primary education experienced depression.Possibly, they are less likely to access healthcare services, face difficulties in understanding the provided information by health professionals, fail to communicate effectively with them, and confront barriers in learning self-care skills.Additionally, PWE with a low educational level may have poor coping strategies, which in turn lead to social isolation and reduced psychosocial adjustment.PWE who are unable to read and write are over four times more likely to develop depression compared to those of higher school graduates.Having lower educational status, early onset of illness, poor social support, high perceived stress, high seizure frequency, and polytherapy were factors associated with depression [8].
As for employment status, the unemployed PWE experienced depression.Interestingly, there are strong associations between epilepsy and low education and income due to difficulties in completing school or experiencing seizures and the side effects of medication.All these parameters subsequently consist of an obstacle to independent living [2].However, many factors are held to be affecting the employability of PWE, such as clinical (uncontrolled seizure), psychological (perceived social stigma), socioeconomic (low education level), and political (driving restriction) factors [26].
PWE living in a country had a higher rate of depression than those living in Attica.It is widely accepted that the area of residence and work either protects health or creates risks.Factors more common in rural society such as economic stagnation, poverty, and low insurance rates undermine the provision of health care.
Although the importance of screening and treating anxiety and depression in PWE is increasingly recognized both in contemporary literature and guideline recommendations, in clinical practice, they remain underdiagnosed and undertreated [9,10].It is not rare that health professionals often ignore, overlook, or are unable to recognize mental burden, they tend to focus on the biological dimension of the disease and act only when the patient complains.Nurses are called to screen and understand the comorbidity of anxiety/depression and confront possible obstacles, such as lack of proper training, skills, and available time [27,28].

Limitations of the study
In this cross-sectional study, there was no evidence of a causal relationship between anxiety/depression and characteristics of patients.The method of convenience sampling in a single-center study in Attica is not representative of all PWE living in Greece, thus limiting the generalizability of the results.Moreover, there was no next measurement in time that would allow the evaluation of possible changes in all dimensions under assessment.Although many significant associations were observed, the sample size might be a small one.In addition, the presence of anxiety and depression was only explored through questionnaires and not by psychiatric evaluation.
The HADS is a widely used research tool that permits comparison with other research studies on a global scale.

Conclusions
According to the present results, an association was observed between depression and gender, age, marital status, educational level, job, residency, and whether they went out at night.In terms of anxiety, results revealed an association between anxiety and age.Interestingly, in-depth knowledge of factors associated with the frequently encountered dyad of anxiety/depression and epilepsy is supposed to help guide clinical decision-making.Nurses as health professionals should adopt an approach model based on scientific information, guidance, and patient support combined with evidence-based knowledge as well as to strengthen the expression of questions regarding the disease and its treatment.Moreover, they need to ensure that PWE receive comprehensive care, including access to health promotion resources and counseling for risk behaviors.

Table 2
presents the distribution of other characteristics.More specifically, the majority of patients had very good relations with nursing and medical staff (76% and 78%, respectively) and 27% maintained relations with other PWE.In addition, 50% avoided situations in which a crisis could be dangerous, 29% were keeping a medical note describing their illness, 77% were smokers, 25% were drinking alcohol, 48% were driving, and 28% went out at night.
n (%)Relations with the nursing staff