|Year : 2017 | Volume
| Issue : 2 | Page : 97-101
A study on interictal depressive symptoms and laterality in temporal lobe and generalized epilepsies
Neena S Sawant1, Biswarup M Ghosh2
1 Department of Psychiatry, Seth GSMC and KEM Hospital, Acharya Dhonde Marg, Mumbai, Maharashtra, India
2 Department of Psychiatry, University at Buffalo, The State University of New York, New York, USA
|Date of Web Publication||8-Dec-2017|
Neena S Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Acharya Dhonde Marg, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Mood disorders like inter-ictal depressive symptoms and inter-ictal major depressive episodes are the most frequent psychiatric co-morbidity seen in temporal lobe epilepsies with left hippocampal sclerosis than generalized epilepsies. Despite the clinical significance of depression, it often goes unrecognized and hence untreated in this population. These patients may tend to minimize their complaints to avoid further stigmatization of their illness. This study was undertaken to the prevalence and severity of depressive symptoms in patients with complex partial and generalized seizures, association of depression with the duration of illness and correlation of depression with right or left sided focus in complex partial seizures. Methods: 30 patients each of complex partial and generalized seizure disorder were enrolled to study depressive symptoms with the help of the Beck's Depression inventory a 21 item measure of depressive symptoms. A proforma was prepared to study the various demographic variables, details of seizure disorder &MRI findings. Results: As per the Beck's Depression inventory 26% of complex partial seizure patients and 40% of generalized seizure disorder patients had depressive symptoms which was not statistically significant. 20% and 63% of complex partial seizure patients and 30% and 40% of generalized seizure patients had moderate and mild severity of depression respectively. No significant association between left sided temporal lobe scleroses for depressive symptoms was seen. No correlation was seen of duration of illness with depressive symptoms in both the groups. Conclusions: A high prevalence of depressive symptoms in the generalized seizure group as compared to complex partial seizure group patients emphasizes the fact that the psychiatric morbidity is multi-factorial involving neurobiological as well as psychosocial issues which need to be addressed.
Keywords: Complex partial seizures, depressive symptoms, generalized seizures, laterality of seizures, mesial temporal sclerosis, temporal lobe seizures
|How to cite this article:|
Sawant NS, Ghosh BM. A study on interictal depressive symptoms and laterality in temporal lobe and generalized epilepsies. Ann Indian Psychiatry 2017;1:97-101
|How to cite this URL:|
Sawant NS, Ghosh BM. A study on interictal depressive symptoms and laterality in temporal lobe and generalized epilepsies. Ann Indian Psychiatry [serial online] 2017 [cited 2019 Jul 19];1:97-101. Available from: http://www.anip.co.in/text.asp?2017/1/2/97/220242
| Introduction|| |
Mood disorders are the most frequent psychiatric comorbidity seen in patients with epilepsy (PWE),, especially temporal lobe epilepsy (TLE), particularly in those with left TLE , and possibly hippocampal sclerosis. In fact, interictal depressive symptoms, and interictal major depressive episodes, though common in epilepsy, are particularly linked to TLE, than generalized epilepsies.
Kanner in his review reported the prevalence of depression by several researchers to be between 20% and 55% in patients with recurrent seizures and 3% and 9% in patients with controlled epilepsy. The clinical presentations of depressive disorders in epilepsy were found to be identical to those in nonepileptic patients and include major depression, bipolar and dysthymic disorders, and minor depression. Kanner also suggested that the relationship between epilepsy and depression is “bidirectional” with the presence of a common pathogenic process facilitating the occurrence of one disease in the presence of the other. PWE express a certain constellation of symptoms, including an explosive or irritable mood, somatic pains, anxiety and fear, and periods of brief euphoria with depressive disorders being the most common type of psychiatric comorbidity in PWE.
Furthermore, PWE with depression often report a poorer quality of life on global assessments. They are also at an increased risk of suicide at least five times higher and up to 25 times higher in patients with partial seizures of temporal lobe origin than expected in the overall population., Despite the clinical significance of depression, it often goes unrecognized and hence untreated in this population. These patients may tend to minimize their complaints to avoid further stigmatization of their illness. They often present with atypical features of depression.
In general terms, it is reasonable to hypothesize that PWE can experience forms of mood disorders identical to those of patients without epilepsy. Nevertheless, it is equally reasonable to assume that the underlying brain pathology can influence the expression of psychiatric symptoms, making some aspects less evident or emphasizing others.
The physician may fear that antidepressant medication may lower the seizure threshold and worsen seizure control. Robertson et al. suggested that depression in PWE represents the outcome of multiple factors in individuals genetically predisposed to a primary or idiopathic affective disorder. Mendez et al. proposed a specific epileptic psychosyndrome producing an atypical, endogenous depression, due to a left limbic dysfunction. This link between these two disorders has been a source of great interest to both neurologists and psychiatrists for many years and has generated an expansion of knowledge in both fields to understand the relationship of mood, cognition, and temporo-limbic function in epilepsy.
Interictal depression in PWE most commonly presents as a chronic depression that more often than not tends to mimic a dysthymic disorder with endogenous features and has an intermittent course.
Therefore, in this study, we sought to investigate the prevalence and severity of depressive symptoms in patients with complex partial seizures (CPS) and generalized seizures, association of depression with the duration of illness, and correlation of depression with right- or left-sided focus in CPS.
| Methods|| |
The study was conducted in the outpatient department (OPD) of psychiatry and neurology of a general hospital after obtaining Institutional Ethics Committee approval in accordance with the Declaration of Helsinki and a valid written informed consent. Patients attending the specialized epilepsy OPD of neurology and diagnosed by a neurologist as having CPS or generalized seizures based on the International League Against Epilepsy classification of seizure disorders  and having a brain magnetic resonance imaging (MRI) were considered for the study. Among these, patients fulfilling inclusion and exclusion criteria were enrolled in the study. The inclusion criteria were: (1) Patients of either sex and above 18 years suffering from only CPS or generalized seizure disorder diagnosed by a neurologist, (2) No history of any prior psychiatric illness. Patients having any other seizure semiology or those already on psychiatric medication were excluded from the study.
Eighty-six patients were screened and sixty patients who satisfied the inclusion and exclusion criteria were enrolled in the two groups of the study.
- Group A: Patients having CPSs (n = 30)
- Group B: Patients having generalized seizures (n = 30).
A semi-structured proforma recorded the demographic variables, and details of seizure disorder, MRI findings, and the depressive symptoms were assessed with the help of a clinical interview and the following scales.
Beck's Depression Inventory
This scale was devised by Beck in 1961. It contains 21 sentence groups aimed at assessing the level of depression. Observed depression signs are evaluated objectively. The 21 signs of depression included in the scale are sensibility, pessimism, sense of failure, sense of guilt, self-dissatisfaction, self-accusation, desire to commit suicide, hysterical weeping, seizures, nervous breakdown, social retreat, indecisiveness, conflicting self-image, sleep disturbances, tiredness, loss of appetite, loss of weight, psychological complaints, and lack of sexual desire. All the questions were developed based on signs normally seen in depressed individuals. Each category receives a score of 0–3 points. If a patient scores 0–16 points, there is no depression, 17–20 points indicate mild depression, 21–30 moderate depression, and >31 points reveal severe depression. Studies using the scale indicate that the Beck's Depression Inventory (BDI) is an appropriate method for assessing the signs and levels of depression in a given individual.,
BDI translation and validation in Hindi and Marathi were done by an expert committee comprising a local language translator, a professor of psychiatry, and a professor of community medicine. However, these results were not published.
All analyses were done with SPSS statistical version 17 at 5% significance.
Group differences were analyzed using frequency distribution, Chi-square test, and t-test wherever applicable. Chi-square test was used to find the association between depressive symptoms and duration of illness in both the groups as well as lateralization in patients with CPS. Two-tailed “P” values were obtained for all analyses. P < 0.05 was considered statistically significant indicating 95% confidence limits.
| Results|| |
Demographic and illness variables
The mean age for patients with CPS was found to be 32 ± 7.9 and 32.9 ± 11.8 years for generalized seizure disorder. A male preponderance was seen in both the groups with the male:female ratio being 5:1 in CPS group with 83% (n = 25) being males and 16% (n = 5) females and 3:2 in the generalized seizure group with 60% (n = 18) of males and 40% (n = 12) of females. The mean duration of illness was found to be 22.8 ± 5.6 years in CPS and 9.9 ± 7.5 years in generalized seizure disorder group which was highly significant with P < 0.0001. The mean age of onset of seizures was 16.70 ± 4.82 years in CPS and 19.66 ± 2.67 years in generalized seizure disorder group which was highly statistically significant with P < 0.0046. About 90% of patients in both the groups were Hindus and belonged to lower economic strata.
Prevalence and severity of depressive symptoms as per Beck's Depression Inventory
When both the groups were assessed for the prevalence of depressive symptoms as per the BDI, 26% of patients having CPS and 40% of patients having generalized seizure disorder had depressive symptoms. This difference was not statistically significant when comparing patients of both the groups [Table 1a] and [Table 1b].
|Table 1a: Prevalence of depression on Beck's Depression Inventory (n=30)|
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|Table 1b: Comparison of depression as per Beck's Depression Inventory in both groups (n=30)|
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Severity of symptoms as per the scores on BDI revealed 20% of CPS patients and 30% of generalized seizure patients to have moderate severity of depression. Severe depression was seen in only one patient of the CPS group. Surprisingly, extreme depression was not at all seen in both the groups. It was also seen that, though nearly 63% of CPS patients and 40% of generalized seizure patients experienced mild mood disturbances, it did not qualify for a diagnosis of depression. Borderline clinical depression was seen in one and three patients of both the groups, respectively [Table 1c].
|Table 1c: Severity of depression as per Beck's Depression Inventory (n=30)|
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Depressive symptoms and lateralization in complex partial seizures group
All the patients were reviewed for their MRI findings. In the CPS group, 11 patients had MRI findings of right mesial temporal sclerosis (MTS), 17 patients had left MTS, and 2 patients had normal MRI scans, whereas in the generalized seizure group, MRI findings were normal in 28 patients except for 2 patients of which 1 had encephalomalacia and the other had mild generalized cortical atrophy. Though 12 patients (40%) of the generalized seizure group had depression, their MRI scans were normal.
While comparing the CPS group having right and left-sided lesions for differences in depressive symptoms, no significant differences on the total BDI scores were seen [Table 2].
|Table 2: Comparison of depressive symptoms with magnetic resonance imaging findings in complex partial seizure group (n=28)|
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Correlation of depressive symptoms with duration of epilepsy
When both the groups were compared for correlation of duration of illness with depressive symptoms as per the total BDI scores, no significant association between the two were seen in both the groups [Table 3].
|Table 3: Pearson's correlation of depressive symptoms with duration of epilepsy (n=30)|
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| Discussion|| |
Demographic and illness variables
The onset of seizures in both the groups was in their childhood or adolescence, which is keeping in with the general epidemiological findings of seizure disorders. Researchers have found a longer duration of illness in focal refractory epilepsies, especially temporal lobe seizures which was also seen in our patients., Poor reporting, cultural factors, stigma, and myths could be responsible for the longer duration of illness where medical help seeking is done late in much of rural India. We found a male predominance in both the groups which is in keeping with other studies from India.
Prevalence and severity of depressive symptoms as per Beck's Depression Inventory
In our sample of PWE, we did not find any statistical significance in the prevalence or severity of depression. However, in the generalized seizure group, the prevalence of depressive symptoms was higher than the CPS group with more patients having moderate symptoms of depression. On the contrary, many patients in the CPS group experienced mood symptoms which, however, did not qualify for diagnosis of clinical depression. Though we had not used any diagnostic criteria for the type and severity of depression, we found the prevalence of depression as per total BDI score to be 26% for CPS and 40% for generalized seizure. Our results for the CPS group happen to be slightly lower as compared to other studies where researchers have found the prevalence of mood disorders in refractory TLE to be in the range of 32.6% and 30%, respectively. Ertekin et al. found depressive disorders in nine patients of CPS and seven patients of generalized seizures though there were no significant differences between the groups with respect to BDI scores, although depressive disorders as per the Diagnostic and Statistical Manual–IV (DSMIV) (Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified) were slightly more frequent in patients with TLE than in patients with idiopathic generalized epilepsy which is contrary to our findings.
Hermann et al. in their review of published data using DSM-IV and International Classification of Disease nosology for rates of mood disorders in PWE found that the lifetime prevalence of mood disorders ranged from 44% to 63% of patients with the lifetime prevalence of major depressive disorder being 8%–48% with a mean of 29% and a median of 32%. Wiegartz et al. evaluated 76 epilepsy patients with partial seizure disorders using the Mood Disorder section of the Structured Clinical Interview for DSM-IV (SCID-IV) and found that about 30% of their patients met criteria for a current or lifetime-to-date major depressive disorder, with 25% reporting symptoms associated with an adjustment disorder with depressed mood, dysthymic disorders, or depressive disorder not otherwise specified. Kanner had reported dysthymia to be the most common disorder in comorbidity with epilepsy  and that the clinical presentation of depressive disorders in epilepsy was identical to that of patients without epilepsy; interictal depression being the most common type of recognized mood disorder, which could present as major depression, minor depression, dysthymic disorder, and bipolar disorder. Quiske et al. in their study using BDI found significant differences in mean BDI scores for patients with MTS and temporal neocortical lesion, with MTS patients being more prone to depression.
Hence, though researchers have found a high prevalence of depression in epilepsy, it is difficult to say which is the cause or effect. Some hypotheses have been put forth for understanding the operant pathogenic mechanisms. The pathogenic mechanisms of depression are due to the decreased serotonergic, noradrenergic functions which have been the bases for antidepressant pharmacologic treatments. By the same way, a decreased activity of these same neurotransmitters has been shown to facilitate the kindling process of seizure foci, to exacerbate seizure severity, and to intensify seizure predisposition in some animal models of epilepsy. Hence, parallel changes of serotonin (5-HT) and noradrenaline (NE) might be responsible for the pathophysiology of depressive disorders and epilepsy.
Depressive symptoms and lateralization in complex partial seizures
We did not find any association of laterality with the depressive symptoms in our patients with CPSs. Several researchers have given different findings. Kanner  and Sawant and Wankhede  did not find any relation between focus laterality and depression development, whereas Schmitz , reported that depression in epilepsy occurred more frequently in patients with left temporal foci. Flor-Henry  was the first who showed the more frequent occurrence of depressive disorder in the right focus. Kalinin and Polyanskiy  in their study found that organic affective disorder was observed more frequently in patients with right-sided foci, while diagnosis of organic anxiety disorder was seen in patients with left-sided foci.
Correlation of depressive symptoms with duration of epilepsy
We did not find any correlation of depressive symptoms with the duration of epilepsy in both the groups keeping in with the findings of Indaco et al. However, Swinkels et al. concluded that the chronicity of epilepsy was important in the predisposition to psychiatric comorbidity, but brain dysfunction due to the involvement of the limbic system was an additional risk. Ertekin et al. also postulated that the lack of a significant association with age at onset of epilepsy and duration of epilepsy suggests that the biological theories of anatomical connections were probably more important than the chronicity of epilepsy.
| Conclusions|| |
We found a high prevalence of depressive symptoms in the generalized seizure group as compared to CPS group patients which has not been reported earlier. This emphasizes the fact that the psychiatric morbidity is multifactorial involving neurobiological as well as psychosocial issues which need to be addressed.
Our study has several limitations. The sample size was small and reflected a selection bias of the patient group seen at a tertiary care hospital. Though the patients were assessed by psychiatrists, we did not use diagnostic criteria for the detection of depression in the patients. Studies using SCI to establish psychiatric diagnoses and structured detailed evaluation of cases of epilepsy will definitely help in understanding the associations of epilepsy with psychiatric comorbid disorders.
We would like to acknowledge Dr. Sangeeta Ravat, Professor and Head, Department of Neurology, Seth GSMC and KEMH, Mumbai, for giving us the guidance, support, and permission to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mendez MF, Cummings JL, Benson DF. Depression in epilepsy. Significance and phenomenology. Arch Neurol 1986;43:766-70.
Robertson MM, Trimble MR, Townsend HR. Phenomenology of depression in epilepsy. Epilepsia 1987;28:364-72.
Jones JE, Hermann BP, Barry JJ, Gilliam F, Kanner AM, Meador KJ, et al.
Clinical assessment of Axis I psychiatric morbidity in chronic epilepsy: A multicenter investigation. J Neuropsychiatry Clin Neurosci 2005;17:172-9.
Altshuler LL, Devinsky O, Post RM, Theodore W. Depression, anxiety, and temporal lobe epilepsy. Laterality of focus and symptoms. Arch Neurol 1990;47:284-8.
Quiske A, Helmstaedter C, Lux S, Elger CE. Depression in patients with temporal lobe epilepsy is related to mesial temporal sclerosis. Epilepsy Res 2000;39:121-5.
Kondziella D, Alvestad S, Vaaler A, Sonnewald U. Which clinical and experimental data link temporal lobe epilepsy with depression? J Neurochem 2007;103:2136-52.
Harden CL. The co-morbidity of depression and epilepsy: Epidemiology, etiology, and treatment. Neurology 2002;59:S48-55.
Kanner AM. Depression in epilepsy: Prevalence, clinical semiology, pathogenic mechanisms, and treatment. Biol Psychiatry 2003;54:388-98.
Kanner AM. Depression in epilepsy: A frequently neglected multifaceted disorder. Epilepsy Behav 2003;4 Suppl 4:11-9.
Kanner AM. Is major depression a neurologic disorder with psychiatric symptoms? Epilepsy Behav 2004;5:636-44.
Johnson EK, Jones JE, Seidenberg M, Hermann BP. The relative impact of anxiety, depression, and clinical seizure features on health-related quality of life in epilepsy. Epilepsia 2004;45:544-50.
Gilliam F, Kuzniecky R, Faught E, Black L, Carpenter G, Schrodt R, et al.
Patient-validated content of epilepsy-specific quality-of-life measurement. Epilepsia 1997;38:233-6.
Barraclough B. Suicide and epilepsy. In: Reynolds EH, Trimble MR, editors. Epilepsy and Psychiatry. Edinburgh: Churchill Livingstone; 1981. p. 72-6.
Robertson MM. Suicide, parasuicide, and epilepsy. In: Engel J, Pedley TA, editors. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven; 1997. p. 2141-52.
Mula M, Jauch R, Cavanna A, Gaus V, Kretz R, Collimedaglia L, et al.
Interictal dysphoric disorder and periictal dysphoric symptoms in patients with epilepsy. Epilepsia 2010;51:1139-45.
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.
Beck AT, Steer RA, Brown GK. BDI–II, Beck Depression Inventory: Manual. 2nd
ed. Boston: Harcourt Brace; 1996.
Beck AT, Steer RA, Garbin MG. Psychometric properties of the beck depression inventory: Twenty five years of evaluation. Clin Psychol Rev 1988;8:77.
Sander JW, Hart YM, Johnson AL, Shorvon SD. National general practice study of epilepsy: Newly diagnosed epileptic seizures in a general population. Lancet 1990;336:1267-71.
Andermann F. Temporal pole and mesiotemporal epilepsy: Introductory remarks. Epileptic Disord 2002;4 Suppl 1:S7-8.
Wieser HG, ILAE Commission on Neurosurgery of Epilepsy. ILAE commission report. Mesial temporal lobe epilepsy with hippocampal sclerosis. Epilepsia 2004;45:695-714.
Banerjee TK, Ray BK, Das SK, Hazra A, Ghosal MK, Chaudhuri A, et al.
longitudinal study of epilepsy in Kolkata, India. Epilepsia 2010;51:2384-91.
Adams SJ, O'Brien TJ, Lloyd J, Kilpatrick CJ, Salzberg MR, Velakoulis D, et al.
Neuropsychiatric morbidity in focal epilepsy. Br J Psychiatry 2008;192:464-9.
Araújo FG, Rosa VP, Caboclo LO, Sakamoto AC, Yacoubian EM. Prevalence of psychiatric disorders in patients with mesial temporal sclerosis. J Epilepsy Clin Neurophysiol 2007;13:13-6.
Ertekin BA, Kulaksizoǧlu IB, Ertekin E, Gürses C, Bebek N, Gökyiǧit A, et al.
comparative study of obsessive-compulsive disorder and other psychiatric comorbidities in patients with temporal lobe epilepsy and idiopathic generalized epilepsy. Epilepsy Behav 2009;14:634-9.
Hermann BP, Seidenberg M, Bell B. Psychiatric comorbidity in chronic epilepsy: Identification, consequences, and treatment of major depression. Epilepsia 2000;41 Suppl 2:S31-41.
Wiegartz P, Seidenberg M, Woodard A, Gidal B, Hermann B. Co-morbid psychiatric disorder in chronic epilepsy: Recognition and etiology of depression. Neurology 1999;53:S3-8.
Schildkraut JJ. The catecholamine hypothesis of affective disorders: A review of supporting evidence. Am J Psychiatry 1965;122:509-22.
Jobe PC, Dailey JW, Wernicke JF. A noradrenergic and serotonergic hypothesis of the linkage between epilepsy and affective disorders. Crit Rev Neurobiol 1999;13:317-56.
Kanner A. Depression in Neurological Disorders. Lundbeck Institute, Cambridge Medical Communication Ltd.; 2005. p. 161.
Sawant NS, Wankhede SS. Psychiatric morbidity in refractory mesial temporal lobe epilepsy before and after epilepsy surgery. Neurol Asia 2015;20:129-38.
Schmitz B. Depressive disorders in epilepsy. In: Trimble M, Schmitz B, editors. Seizures, Affective Disorders and Anticonvulsant Drugs. Guildford: Clarius Press Ltd; 2002. p. 19-34.
Schmitz B. Depression and mania in patients with epilepsy. Epilepsia 2005;46 Suppl 4:45-9.
Flor-Henry P. Psychosis and temporal lobe epilepsy. A controlled investigation. Epilepsia 1969;10:363-95.
Kalinin VV, Polyanskiy DA. Focus laterality and interictal psychiatric disorder in temporal lobe epilepsy. Seizure 2009;18:176-9.
Indaco A, Carrieri PB, Nappi C, Gentile S, Striano S. Interictal depression in epilepsy. Epilepsy Res 1992;12:45-50.
Swinkels WA, Kuyk J, van Dyck R, Spinhoven P. Psychiatric comorbidity in epilepsy. Epilepsy Behav 2005;7:37-50.
[Table 1a], [Table 1b], [Table 1c], [Table 2], [Table 3]