Systematic Literature Review of Psychiatric Comorbidities in Adults with Epilepsy

Abstract

Background and purpose: Mental illness is disproportionately common in people with epilepsy (PWE). This systematic literature review identified original research articles that reported the prevalence of psychiatric comorbidities based upon clinical assessments in a sample of PWE and assessed the clinical features of the populations found in studies included in our review of mental health comorbidity.

Methods: The included articles were written in English and published from 2008 to 2018, and focused on adults aged ≥18 years who had psychiatric diagnoses determined in clinical assessments, such as those found in medical records, clinician psychiatric evaluations, structured diagnostic interviews, and mental health screening questionnaires specific for a psychiatric disorder. The primary outcome was the prevalence of psychiatric comorbidities as a percentage of the total sample of PWE. Additional data included the overall sample size, mean age, epilepsy type, study design, and method of diagnosis. A modified Newcastle Ottawa Scale was used to assess the quality of the studies. All 23 articles that were consistent with the inclusion criteria were related to observational studies.

Results: Mood disorders and anxiety disorders were the most common psychiatric comorbidities, with prevalence rates of 35.0% and 25.6%, respectively. Major depressive disorder was the most common mood disorder, with a prevalence of 24.2%. Post-traumatic stress disorder (PTSD) had the highest reported prevalence among anxiety disorders, at 14.2%, followed by general anxiety disorder at 11.1%. Other comorbidities included psychosis (5.7%), obsessivecompulsive disorder (3.8%), schizophrenia (1.7%), bipolar disorder (6.2%), and substance abuse (7.9%). The pooled prevalence of suicidality, as reported for two studies, was 9.3%. Temporal lobe epilepsy (TLE) was associated with higher levels of psychiatric comorbidity. Two (8.7%) of the 23 studies compared psychiatric comorbidities in TLE with that of extratemporal lobe epilepsy (ETLE), and one of these two studies found that depression was more common in TLE (53.8%) than in ETLE (25%). Regarding seizure types, partial seizures were associated with a higher prevalence of depression vs generalized seizures.

Conclusions: This systematic literature review of recent original research found a relatively high prevalence of mental health comorbidities in PWE. Mood and anxiety disorders are the most common comorbidities, while psychotic spectrum conditions such as schizophrenia and bipolar disorder are much rarer. The prevalence of comorbidity may vary with the epilepsy type and treatment responsiveness. These findings suggest that screening tools for depression and anxiety should be included as part of the training for epilepsy care, while resources for other relatively common conditions such as PTSD and substance abuse disorders should be readily available to neurology specialists who treat PWE.

Keywords: comorbidity; epilepsy; mental health; psychiatric disorder; seizures.

Fig. 1. Consort diagram of the systematic literature review process.

Fig. 2. Geographical distribution of the included studies: Brazil (n=4, 17.4%), USA (n=3, 13.0%), India (n=3, 13.0%), Turkey (n=2, 8.7%), Italy (n=1, 4.3%), Australia (n=2, 8.7%), Finland (n=1, 4.3%), South Korea (n=1, 4.3%), Poland (n=1, 4.3%), Norway (n=1, 4.3%), Montenegro (n=1, 4.3%), UK (n=1, 4.3%), France (n=1, 4.3%), and Germany (n=1, 4.3%).

Fig. 3. Comparisons of pooled prevalence rates with those from the NCS-R. GAD: generalized anxiety disorder, MDD: major depressive disorder, NCS-R: National Comorbidity Survey Replication, OCD: obsessive-compulsive disorder, PTSD: post-traumatic stress disorder.