O R I G I N A L A R T I C L E

Quality of life of patients with epilepsy in MalaysiaSalina Mohamed1 MMed (Psych) MD, Jesjeet Singh Gill2 MMed (Psych) MD & Chong Tin Tan2 FRCP MD

1 University of Technology MARA, Selangor, Malaysia

2 University of Malaya, Kuala Lumpur, Malaysia

Keywordsdepression, epilepsy, quality of life

CorrespondenceSalina Mohamed MMed (Psych) MD, University

of Technology MARA, Faculty of Medicine,

Selayang Campus, Jalan Prima Selayang 7,

68100 Batu Caves, Selangor, Malaysia.

Fax: +0361264888

Tel: +0361264107

Email: salina_mohamed@hotmail.com

Received 29 December 2010

Accepted 23 March 2011

DOI:10.1111/j.1758-5872.2012.00192.x

AbstractIntroduction: To determine the quality of life of patients with epilepsy andits relationship with depression, and the clinical and sociodemographicvariables.Methods: This was a cross-sectional study in which a total of 120 epilepsypatients were recruited from a neurology outpatient clinic. Sociodemo-graphic and clinical variables were recorded. Hospital Anxiety and Depres-sion Scale (HADS) and Mini International Neuropsychiatric Interview(M.I.N.I.) were used to screen and diagnose for depression, respectively.Quality of Life Inventory of Epilepsy (QOLIE-31) was used to assessquality of life.Results: Patients with epilepsy with major depression had poorer qualitylife (36.4 � 1.8) compared to those without depression (41.7 � 3.8,P < 0.001). Depression, having one seizure or more per month and havingseizures within one month of interview were correlated with poorerquality of life, P < 0.001. Multivariate linear regression analyses showedthat depression and recent seizures predicted having poorer quality of lifein patients with epilepsy.Discussion: Depression and poor seizure control were predictors for poorquality of life in patients with epilepsy. Therefore, epilepsy patients shouldbe regularly screened for depression and treatment for epilepsy must beoptimized to minimize the negative impact of having epilepsy for thesepatients.

Introduction

Like any chronic medical illnesses, epilepsy has a pro-found effect on the sufferer. Several studies havefound that epilepsy impacts the patient’s cognition,behavior and social functioning, and is associated withsignificant psychiatric illness. Mood disorders are themost common psychiatric comorbidity in patientswith epilepsy (Silberman et al., 1994; Victoroff, 1994;Altshuler et al., 1999) with major depression being themost prevalent ranging from 8% to 48% compared tothe general population (Koch-Weser et al., 1988; Sil-berman et al., 1994; Seshadri et al., 2009) The etiologyof depression in patients with epilepsy is multifacto-rial, including clinical factors (seizure frequency,seizure type or foci, epilepsy duration, age at onset)and psychosocial factors (quality of life, life stressors,

employment, marital status) (Smith et al., 1991; Rothet al., 1994; Jacoby et al., 1996).

Recent research suggests a bidirectional relation-ship between epilepsy and depression: poor socialfunctioning as a result of epilepsy can lead to depres-sion, and depression itself can lead to poor social andoccupational functioning. Many studies have reporteddeterioration in quality of life in patients with epilepsy(Reisinger and Dilorio, 2009; Tebartz van Elst et al.,2009), which may adversely affect mood (Kanner,2009). Conversely, recent studies have also shownthat depression, regardless of its severity, and evensubsyndromal symptoms, can affect quality of life inpeople with epilepsy (Barry, 1999; Cramer et al., 2003)thus creating a potential vicious cycle.

Depression has been shown to be a strong deter-minant for poor quality of life in patients with epilepsy

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(Boylan et al., 2004; Tracy et al., 2007). Studies con-ducted in Asian countries such as Thailand and Indiafound that 22% and 60% of epilepsy patients withdepression, respectively, had significantly poorerquality of life than their non-depressed counterparts(Phabphal et al., 2009; Seshadri et al., 2009). Further-more, depression in patients with epilepsy has signifi-cant impact in their perception of epilepsy, complianceto medication regimens and quality of life.

Apart from depression, several other factors havebeen found to be associated with poorer quality of lifein patients with epilepsy; recent seizure, poor adjust-ment to seizures, seizure severity and days disableddue to seizures were significantly correlated withpoorer health-related quality of life (HRQOL) (Crameret al., 2003).

Depression is not routinely assessed in neurologyclinics and most affected patients are subsequently nottreated; therefore, substantial opportunity exists toimprove the quality of care for many people withepilepsy. This awareness and understanding of depres-sion in patients with epilepsy is vital in decreasing itsnegative impact.

In view of this, the present study was carried outto determine the quality of life of patients with epi-lepsy and the associated factors that can predictquality of life in patients with epilepsy.

Methods

Design

This was a cross-sectional study in which 120 patientswith epilepsy were recruited from a neurology outpa-tient clinic at the University Malaya Medical Centre,Malaysia, from June 2008 to August 2009. Ethicalapproval was obtained by the university’s ethical com-mittee. Universal sampling was used in the study.

The inclusion criteria were patients aged 18–65years, with a diagnosis of idiopathic epilepsy for morethan one year. Patients with a progressive clinical dis-order, documented brain lesion or mental retardationwere excluded from the study.

Data collection

Data were collected both by clinical interview andfrom patients’ medical records. Demographic variables(age, race, sex, education level, marital status andoccupation) and patients’ seizure characteristics (ageat onset of epilepsy, duration of illness, type of epilep-tic seizure, time from last seizure, frequency of seizure

and type of antiepileptic drugs) were recorded. Type ofepilepsy was determined based on the combination ofclinical and electroencephalography (EEG) findings,and classified into partial and generalized seizures.EEG findings were confirmed by a neurologist.

The patients were given Hospital Anxiety andDepression Scale (HADS) and Quality of Life inEpilepsy-31 (QOLIE-31). The diagnosis of depressionwas confirmed using Mini International Neuropsychi-atric Interview (M.I.N.I.).

Assessment tools

Quality of Life in Epilepsy-31 (QOLIE-31)(Cramer et al., 1998)

QOLIE-31 is a self-reported questionnaire of health-related quality of life for adults (18 years and older)with epilepsy where lower scores indicate poor qualityof life. The questionnaire consists of items empiricallyselected from QOLIE-89. It has 8 multi-scales selectedfrom the original 17 multi-scales in QOLIE-89 tomeasure health concepts. It has good reliability andvalidity and has been used in at least 10 differentcultural settings. The Malay version was translatedand validated locally (Lua et al., 2008).

Mini International NeuropsychiatricInterview (M.I.N.I.)

M.I.N.I. is a short structured diagnostic interviewdesigned to diagnose Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition (DSM-IV) andInternational Classification of Diseases, Tenth Revision(ICD-10) psychiatric disorders (lifetime and current).It is a relatively brief instrument that is divided intomodules corresponding to different psychiatric diag-nostic categories. It possesses good validity and reli-ability and has been translated into many differentlanguages (Sheehan et al., 1998).

Hospital Anxiety and Depression Scale (HADS)

Self-rated HADS was used to screen for depressivesymptoms. M.I.N.I. was then used to diagnose depres-sion in patients who scored �8 in the HADS depres-sion subscale. The Malay version of HADS has beenused in various studies in Malaysia and has been vali-dated locally (Lim and Ramli, 1996; Hatta et al., 1997).This Malay version has a sensitivity of 92.3% andspecificity of 90.8% for depression at 8/9 cut-off pointsof HADS.

Quality of life of patients with epilepsy S. Mohamed et al.

2 Copyright © 2012 Blackwell Publishing Asia Pty Ltd

Statistical analyses

Statistical analyses were performed using SPSSversion 13.0 (SPSS Inc., Chicago, IL, USA). All of thestatistical tests were interpreted at the 5% significancelevel. For univariate analyses, independent t-test andANOVA was used and for multivariate analyses, linearregression was used.

Results

All of the patients who were approached completedthe questionnaires (100% response rate). Demo-graphic and clinical data of the study patients are listedin Table 1.

The number of possible cases of depression inpatients with epilepsy detected using the depressionsubscale of HADS (with a cut-off point of 8 or more)was 12% (n = 14). Of these, 9% (n = 11) had majordepressive disorder (MDD) diagnosed using M.I.N.I.

The quality of life of patients with epilepsy wasassessed using the QOLIE-31 inventory, where higherscores reflect better quality of life. Calculation of thetotal score was performed according to the scoringmanual for QOLIE-31 version 1.0 (Vickrey et al.,1993). The overall mean scores for QOLIE-31 score inthis sample was 41.23 � 4.0.

Depressed patients with epilepsy had significantlylower quality of life than non-depressed patients(P < 0.001). On further analyses of the subcategoriesin QOLIE-31, with the exception of medicationeffects, there were significant differences between thedepressed and non-depressed groups in all of the sub-categories (Table 2).

None of the demographic data were associatedwith quality of life. Among the clinical variables,depression, having one or more seizures per monthand having a seizure in the past one month wereassociated with poorer quality of life (P < 0.001)(Table 3). Post hoc analyses showed that patients whohad seizures in the last one month and between oneand six months had poorer quality of life than thosewho had seizures more than six months prior to inter-view. The same post hoc analyses showed that patientswho had one or more seizures in a month also hadpoorer quality of life. On multivariate linear regressionthe variables found to be significant in Table 3, depres-sion and having seizures in the last one month pre-dicted poorer quality of life in patients with epilepsy,accounting for 40% of the variance in the regressionmodel (Table 4).

Discussion

The present study found that the total mean score forQOLIE-31 for patients with epilepsy was 41.23 � 4.0.This is in keeping with previous studies in which thetotal QOLIE-31 score in epilepsy patients varied from40 to 60 points (Cramer et al., 2000).

Patients with epilepsy who were depressed hadsignificantly poorer quality of life than patients whowere not depressed (P < 0.001). Patients reportedhigh seizure worry, poorer overall quality of life,poorer emotional well being, lower energy or higherfatigue levels, and poorer cognitive and social func-tioning, all which were significantly associated withdepression.

Table 1. Characteristics of study patients (n = 120)

Variable n (%)

Age, mean (years) � SD (range) 34.1 � 12.1 (18–65)

Race

Malay 34 (28)

Chinese 46 (38)

Indian 40 (33)

Sex

Male 67 (56)

Female 53 (44)

Marital status

Married 50 (42)

Unmarried 70 (58)

Education level

Primary 11 (9)

Higher education 109 (91)

Employment status

Employed 79 (66)

Unemployed 41 (34)

Age of onset

Young onset 69 (58)

Older onset 51 (42)

Duration of illness

<5 years 24 (20)

>5 years 96 (80)

Type of seizures

Partial 63 (53)

Generalized 57 (47)

Time from last seizure

Within 1 month 45 (37)

Between 1 and 6 months 25 (21)

Between 6 and 12 months 14 (12)

More than 12 months 36 (30)

Frequency of seizures

No seizure in the last 1 year 43 (36)

Less than 1 seizure/month 43 (36)

1 or more seizure/month 34 (28)

Medication

Monotherapy 84 (70)

Polytherapy 36 (30)

S. Mohamed et al. Quality of life of patients with epilepsy

3Copyright © 2012 Blackwell Publishing Asia Pty Ltd

These findings are similar to other studies thatfound depression was a powerful predictor of poorquality of life for patients with epilepsy, whereasseizure-related factors had little or no predictive value(Boylan et al., 2004; Tlusta et al., 2009). This wasfurther emphasized by studies conducted recently inIndia and Thailand (Phabphal et al., 2009; Seshadriet al., 2009).

Besides affecting quality of life, depression alsoimpacts on the patients’ perception to illness, compli-ance to medication and use of healthcare services. Ithas been well documented that comorbid depressionimpacts the frequency of visits for medical care(Kanner, 2005). Patients with clinical symptoms ofdepression used more health resources, with the

greatest use by people with more severe symptomsof depression. The level of healthcare utilization wasaffected only by depression status, not by seizure type.

We also found that having seizures in the last onemonth predicted poor quality of life for patients withepilepsy, similar to other findings (Cramer et al., 2004;Tlusta et al., 2009). The effect of recent seizures ondepression could be through a direct neurobiologicalchange (Thapar et al., 2009); however, it may also arisefrom the negative impact that seizures have on thepatients in terms of stigma and life disruptions (Crameret al., 2004). In Malaysia, epilepsy is still a highly mis-understood illness and patients are frequently shunnedby the public. Most Malaysians still attribute epilepsy tomythic causes, such as demonic possession. The morefrequent a person’s seizures are, the more likely he orshe will be exposed to ridicule and shamed.

In conclusion, both depression and recent seizurespredicted a poorer quality of life in our study popula-tion. Therefore, we suggest that patients with epilepsyshould be screened routinely for depression andadequately treated. Furthermore, their seizures

Table 2. Comparison of quality of life of depressed patients with epilepsy versus non-depressed

QOLIE-31 subcategories

Depressed (n = 11)

(mean � SD)

Non-depressed (n = 109)

(mean � SD) P-value

Seizure worry 3.0 � 0.7 3.6 � 0.7 0.019*

Overall quality of life 5.6 � 0.9 6.7 � 1.1 0.003*

Emotional wellbeing 5.8 � 0.9 7.5 � 0.9 <0.001*

Energy/Fatigue 5.4 � 0.3 5.9 � 0.6 0.006*

Cognitive functioning 10.9 � 1.8 13.6 � 2.5 <0.001*

Medication effects 1.6 � 0.2 1.7 � 0.2 0.221

Social functioning 8.5 � 1.5 10.5 � 1.9 0.001*

Total score for quality of life 36.4 � 1.8 41.7 � 3.8 <0.001*

*P < 0.05.

QOLIE-31, Quality of Life in Epilepsy-31.

Table 3. Univariate analyses

Variable Mean (SD) QOLIE-31 score P-value 95% CI

M.I.N.I.

Depressed 36.4(� 1.8) <0.001* -5.35 (-7.68–3.03)

Non-depressed 41.7(� 3.8)

Frequency of seizure

1 or more seizure/month 39.0(� 3.5) <0.001* 37.7–40.2

Less than 1 seizure/month 41.5(� 3.8) 40.4–42.7

No seizure in the last 1 year 42.7(� 3.8) 41.5–44.0

Time from last seizure

Within 1 month 39.3(� 3.6) <0.001* 38.2–40.3

Between 1 and 6 months 41.2(� 4.0) 39.6–42.8

Between 6 and 12 months 42.4(� 3.6) 40.3–44.4

More than 12 months 43.3(� 3.7) 42.0–44.5

*P < 0.05.

M.I.N.I., Mini International Neuropsychiatric Interview; QOLIE-31, Quality of Life in Epilepsy-31.

Table 4. Multivariate linear regression analyses

Variable R2 B Sig

Depression 0.401 0.209 0.01*

Time from last fit 0.288 0.034*

*P < 0.05.

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should be well controlled. All these are aimed to mini-mize the negative impact on quality of life and toavoid unnecessary suffering.

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