Depression in people with epilepsy: How much do Asian colleagues acknowledge it?

Open ArchivePublished:March 12, 2018DOI:https://doi.org/10.1016/j.seizure.2018.03.012

      Highlights

      • Depression is highly prevalent in PWE in different countries in Asia.
      • Prevalence rates are consistent with rates reported in the literature: 25% of PWE suffer from depression.
      • In Asian countries, depression is often under-recognized and improperly managed in PWE.
      • High quality data is scarce and validated screening tools are still lacking in many languages.

      Abstract

      Purpose

      The purpose of this review was to investigate the prevalence of depression in people with epilepsy (PWE) in different countries in Asia.

      Methods

      We searched the electronic database PubMed on June 13, 2017 for articles in English that included the following search terms: “epilepsy” AND “depression” AND “country name” for all Asian countries since 1947. Relevant original studies from Asia were included if they reported the prevalence of depression in PWE. Papers studying special populations (e.g., elderly, veterans, etc.) were not included. In addition, experts in epilepsy field were invited from some Asian countries for an in-depth assessment.

      Results

      Six hundred eighty-seven papers were reviewed and 26 related studies were included in this study. Depression is highly prevalent in PWE in different countries in Asia and the prevalence rates are consistent with rates reported in the literature from other countries: overall, about 25% of PWE suffer from depression.

      Conclusion

      In Asian countries, as elsewhere, depression is common in PWE. High quality data is scarce in many countries and validated screening tools [e.g., Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)] to appropriately investigate the prevalence of depression in PWE are still lacking in many languages. Considering the high prevalence of depression among PWE, routine and periodic screening of all PWE for early detection and appropriate management of depression would be a reasonable approach.

      Keywords

      1. Introduction

      Depression has been observed to be highly prevalent in people with epilepsy (PWE). A systematic review and meta-analysis of its prevalence, revealed a 23.1% (95% confidence interval [CI] 20.6%–28.31%) [
      • Fiest K.M.
      • Dykeman J.
      • Patten S.B.
      • Wiebe S.
      • Kaplan G.G.
      • Maxwell C.J.
      • et al.
      Depression in epilepsy: a systematic review and meta-analysis.
      ] prevalence of active depression which is much higher than that in the general population. In a population-based study [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ], the average lifetime and 12-month prevalence estimates of major depressive episodes were 14.6% and 5.5%, respectively in the 10 highest-income countries, and 11.1% and 5.9% in the eight countries with low- to middle-income. However, depression is often under-recognized and improperly treated in PWE, which is associated with work absenteeism, increased utilization of health care services and direct medical costs [
      • Kobau R.
      • Gilliam F.
      • Thurman D.J.
      Prevalence of self-reported epilepsy or seizure disorder and its associations with self-reported depression and anxiety: results from the 2004 Healthstyles Survey.
      ,
      • Cramer J.
      • Blum D.
      • Fanning K.
      • Reed M.
      • Epilepsy Impact Project Group
      The impact of comorbid depression on health resource utilization in a community sample of people with epilepsy.
      ]. Asia is the most populated continent in the world and is very diverse with respect to culture, ethnicity, religion, and other socio-demographic characteristics of the residents compared with the people in other continents. Studies about epilepsy and its comorbidities, including depression, are lacking from many Asian countries. The purpose of this review was to investigate the prevalence of depression in PWE in different countries in Asia. We also investigated how depression and depressive symptoms were evaluated in different studies in distinct Asian countries.

      2. Methods

      We searched the electronic database PubMed on June 13, 2017 for articles in English that included the following search terms: “epilepsy” AND “depression” AND “country name” for all Asian countries since 1947. If the initial search resulted in a high number of papers (>40 papers), we limited the search to the title and abstract for all countries and searches. Relevant original studies from Asia were included if they reported the prevalence of depression in PWE. Papers studying special populations (e.g., elderly, veterans, etc.) were not included.
      In addition, experts in epilepsy field were invited from some Asian countries (Japan, China, Korea, Thailand, Taiwan, and Iran). Each expert was asked to review the prevalence of depression in their country based on the previously published literature for an in-depth assessment.

      3. Results

      Six hundred eighty-seven papers were reviewed and 26 related studies were included in this study. Table 1 shows the number of published papers, the prevalence of depression and the scales applied by researchers to screen for depression in these patients in each Asian country.
      Table 1Number of published papers, the prevalence of depression in people with epilepsy (PWE), and the scales applied by researchers to identify depression in these patients in each Asian country.
      CountryInitial Papers with the Keywords of Depression and EpilepsyRelevant Papers on Depression in EpilepsyRange of Depression in PWEScale used:

      % depression in PWE
      Afghanistan10
      Armenia10
      Azerbaijan00
      Bahrain10
      Bangladesh2120%DAWBA [
      • Rabin F.
      • Mullick S.I.
      • Nahar J.S.
      • Bhuiyan S.I.
      • Haque M.A.
      • Khan M.H.
      • et al.
      Emotional and behavioral disorders in children with epilepsy.
      ]
      Bhutan00
      Brunei00
      Cambodia00
      China126716.5%–43.4%C-MINI: 16.5% [
      • Guo Y.
      • Chen Z.M.
      • Zhang Y.X.
      • Ge Y.B.
      • Shen C.H.
      • Ding Y.
      • et al.
      Reliability and validity of the Chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E).
      ]
      BDI: 19.6% [
      • Guo Y.
      • Ding X.Y.
      • Lu R.Y.
      • Shen C.H.
      • Ding Y.
      • Wang S.
      • et al.
      Depression and anxiety are associated with reduced antiepileptic drug adherence in Chinese patients.
      ]
      HAMD: 19.8% [
      • Peng W.F.
      • Ding J.
      • Li X.
      • Mao L.Y.
      • Wang X.
      Clinical risk factors for depressive symptoms in patients with epilepsy.
      ]
      C-NDDI-E: 26.7% [
      • Tong X.
      • An D.
      • Lan L.
      • Zhou X.
      • Zhang Q.
      • Xiao F.
      • et al.
      Validation of the chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E) in West China.
      ]
      DSM-IV-TR criteria for major depression: 30.2% [
      • Kui C.
      • Yingfu P.
      • Chenling X.
      • Wenqing W.
      • Xiuhua L.
      • Di S.
      What are the predictors of major depression in adult patients with epilepsy?.
      ]
      HADS: 33.2%–43.4% [
      • Tong X.
      • Chen J.
      • Park S.P.
      • Wang X.
      • Wang C.
      • Su M.
      • et al.
      Social support for people with epilepsy in China.
      ,
      • Chen J.
      • Zhang Y.
      • Hong Z.
      • Sander J.W.
      • Zhou D.
      Marital adjustment for patients with epilepsy in China.
      ]
      India126123.8%Patient Health Questionnaire −09 (based on DSM-IV criteria) [
      • Verma M.
      • Arora A.
      • Malviya S.
      • Nehra A.
      • Sagar R.
      • Tripathi M.
      Do expressed emotions result in stigma? A potentially modifiable factor in persons with epilepsy in India.
      ]
      Indonesia10
      Iran43210.7%–35%SADS: 10.7% [
      • Mohammadi M.R.
      • Ghanizadeh A.
      • Davidian H.
      • Mohammadi M.
      • Norouzian M.
      Prevalence of epilepsy and comorbidity of psychiatric disorders in Iran.
      ]
      BDI: 35% [
      • Foroughipour M.
      • Mokhber N.
      • Azarpajooh M.R.
      • Taghavi M.
      • Modarres Gharavi M.
      • Akbarzadeh F.
      • et al.
      Coping mechanisms: depression and suicidal risk among patients suffering from idiopathic epilepsy.
      ]
      Iraq20
      Israel510
      Japan143118.6%J-NDDI-E [
      • Azuma H.
      • Akechi T.
      Effects of psychosocial functioning, depression, seizure frequency, and employment on quality of life in patients with epilepsy.
      ]
      Jordan9222.8%–42%DSM-IV criteria: 22.8% [
      • Alwash R.H.
      • Hussein M.J.
      • Matloub F.F.
      Symptoms of anxiety and depression among adolescents with seizures in Irbid: northern Jordan.
      ]
      NPI: 42% [
      • Bahou Y.G.
      • Jaber M.S.
      • Kasasbeh A.S.
      Quality of life in epilepsy at Jordan University Hospital.
      ]
      Kazakhstan10
      Kuwait10
      Kyrgyzstan00
      Laos00
      Lebanon250
      Malaysia8112%HADS [
      • Mohamed S.
      • Gill J.S.
      • Tan C.T.
      Quality of life of patients with epilepsy in Malaysia.
      ]
      Maldives10
      Mongolia00
      Myanmar00
      Nepal10
      North Korea00
      Oman2127%HADS [
      • Al-Asmi A.
      • Dorvlo A.S.
      • Burke D.T.
      • Al-Adawi S.
      • Al-Zaabi A.
      • Al-Zadjali H.A.
      • et al.
      The detection of mood and anxiety in people with epilepsy using two-phase designs: experiences from a tertiary care centre in Oman.
      ]
      Pakistan10160%Semi structured interview based on ICD-10 [
      • Yousafzai A.U.
      • Yousafzai A.W.
      • Taj R.
      Frequency of depression in epilepsy: a hospital based study.
      ]
      Philippines00
      Qatar10
      Saudi Arabia1016.6%HADS [
      • Alamri Y.
      • Al-Busaidi I.S.
      Anxiety and depression in Saudi patients with epilepsy.
      ]
      Singapore90
      South Korea51321.5%−27.8%K-MINI: 21.9% [
      • Seo J.G.
      • Lee J.J.
      • Cho Y.W.
      • Lee S.J.
      • Kim J.E.
      • Moon H.J.
      • et al.
      Suicidality and its risk factors in Korean people with epilepsy: a MEPSY study.
      ]
      BDI: 27.8% [
      • Kwon O.Y.
      • Park S.P.
      Frequency of affective symptoms and their psychosocial impact in Korean people with epilepsy: a survey at two tertiary care hospitals.
      ]
      K-NDDI-E: 21.5% [
      • Ko P.W.
      • Hwang J.
      • Lim H.W.
      • Park S.P.
      Reliability and validity of the Korean version of the neurological disorders depression inventory for epilepsy (K-NDDI-E).
      ]
      Sri Lanka00
      Syria10
      Taiwan4218.5%HADS [
      • Chen H.F.
      • Tsai Y.F.
      • Hsi M.S.
      • Chen J.C.
      Factors affecting quality of life in adults with epilepsy in Taiwan: a cross-sectional, correlational study.
      ]
      Tajikistan00
      Thailand10220%–38.3%HADS: 20% [
      • Phabphal K.
      • Sattawatcharawanich S.
      • Sathirapunya P.
      • Limapichart K.
      Anxiety and depression in thai epileptic patients.
      ]
      TGDS: 38.3% [
      • Nidhinandana S.
      • Chinvarun Y.
      • Sithinamsuwan P.
      • Udommongkol C.
      • Suwantamee J.
      • Wongmek W.
      • et al.
      Prevalence of depression among epileptic patients at Phramongkutklao Hospital.
      ]
      Timor-Leste00
      Turkmenistan00
      United Arab Emirates6226.9%–28.7%Patient Health Questionnaire nine-item depression scale (PHQ-9) [
      • Alsaadi T.
      • El Hammasi K.
      • Shahrour T.M.
      • Shakra M.
      • Turkawi L.
      • Nasreddine W.
      • et al.
      Depression and anxiety among patients with epilepsy and multiple sclerosis: UAE comparative study.
      ,
      • Alsaadi T.
      • El Hammasi K.
      • Shahrour T.M.
      • Shakra M.
      • Turkawi L.
      • Almaskari B.
      • et al.
      Prevalence of depression and anxiety among patients with epilepsy attending the epilepsy clinic at Sheikh Khalifa Medical City, UAE: a cross-sectional study.
      ]
      Uzbekistan00
      Vietnam10
      Yemen10
      PWE: people with epilepsy; DAWBA: Development And Well-Being Assessment; HADS: Hospital Anxiety and Depression Scale; BDI: Beck Depression Inventory; C-NDDI-E: Chinese version of the Neurological Disorders Depression Inventory for Epilepsy; HAMD: Hamilton Depression Rating Scale; C-MINI: The Chinese version of the Mini International Neuropsychiatric Interview; SADS: Schedule for Affective Disorders and Schizophrenia; J-NDDI-E: Japanese version of the Neurological Disorders Depression Inventory for Epilepsy; K-MINI: Korean version of the Mini International Neuropsychiatric Interview; K-NDDI-E: Korean version of the Neurological Disorders Depression Inventory for Epilepsy, TGDS: Thai Geriatric Depressive Scale; NPI: Neuropsychiatric Inventory.
      The following paragraphs are the results of the expert review of the prevalence of depression in PWE in some Asian countries for an in-depth assessment. It was desirable to have consistent description of the findings related to each country. But, such results were not available consistently. That is why studies of risk factors for depression, suicidality and other variables are included in some countries, but not in others.

       Depression in PWE in Japan

      Prevalence of major depression (2.9%) was reported to be lower in Japan compared to that in the Western countries [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ,
      • Kawakami N.
      • Takeshima T.
      • Ono Y.
      • Uda H.
      • Hata Y.
      • Nakane Y.
      • et al.
      Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: preliminary findings from the World Mental Health Japan Survey 2002–2003.
      ]. The Japanese version of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was developed in 2012 [
      • Tadokoro Y.
      • Oshima T.
      • Fukuchi T.
      • Kanner A.M.
      • Kanemoto K.
      Screening for major depressive episodes in Japanese patients with epilepsy: validation and translation of the Japanese version of Neurological Disorders Depressive Inventory for Epilepsy (NDDI-E).
      ]. The prevalence of depression in PWE was 18.6% in one study [
      • Azuma H.
      • Akechi T.
      Effects of psychosocial functioning, depression, seizure frequency, and employment on quality of life in patients with epilepsy.
      ], which is very similar to the reports from other countries [
      • Fiest K.M.
      • Dykeman J.
      • Patten S.B.
      • Wiebe S.
      • Kaplan G.G.
      • Maxwell C.J.
      • et al.
      Depression in epilepsy: a systematic review and meta-analysis.
      ]. In another study [
      • Kanemoto K.
      • Tadokoro Y.
      • Sheldrick A.J.
      • Oshima T.
      Lack of data on depression-like status and antidepressant pharmacotherapy in patients with epilepsy: randomised control trials are badly needed.
      ], authors compared the symptoms of depression in PWE and those with primary depression, using three screening instruments: the Beck Depression Inventory II (BDI-II) [Ref], the Center for Epidemiologic Studies Depression Scale (CES-D) [Ref] and the Buss-Perry Aggression Questionnaire (BAQ) [Ref]. They observed that the anger item was significantly more frequent in PWE [
      • Kanemoto K.
      • Tadokoro Y.
      • Sheldrick A.J.
      • Oshima T.
      Lack of data on depression-like status and antidepressant pharmacotherapy in patients with epilepsy: randomised control trials are badly needed.
      ].

       Depression in PWE in South Korea

      Depression is the 3rd most common psychiatric disorder in Korea; however, the life-time prevalence of major depressive disorder (MDD) in Korea (3.3%-5.6%) was reported to be lower compared with that in the Western countries [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ,
      • Park J.H.
      • Kim K.W.
      A review of the epidemiology of depression in Korea.
      ]. In Korean PWE, the prevalence of MDD was reported to be ranged from 21.5% to 27.8% [
      • Seo J.G.
      • Lee J.J.
      • Cho Y.W.
      • Lee S.J.
      • Kim J.E.
      • Moon H.J.
      • et al.
      Suicidality and its risk factors in Korean people with epilepsy: a MEPSY study.
      ,
      • Kwon O.Y.
      • Park S.P.
      Frequency of affective symptoms and their psychosocial impact in Korean people with epilepsy: a survey at two tertiary care hospitals.
      ,
      • Ko P.W.
      • Hwang J.
      • Lim H.W.
      • Park S.P.
      Reliability and validity of the Korean version of the neurological disorders depression inventory for epilepsy (K-NDDI-E).
      ]; a very similar finding to that of the reports from other countries [
      • Fiest K.M.
      • Dykeman J.
      • Patten S.B.
      • Wiebe S.
      • Kaplan G.G.
      • Maxwell C.J.
      • et al.
      Depression in epilepsy: a systematic review and meta-analysis.
      ]. In a Korean multicenter study, PWE with MDD were 15.6 times at higher risk of developing suicidality than PWE and without MDD [
      • Seo J.G.
      • Lee J.J.
      • Cho Y.W.
      • Lee S.J.
      • Kim J.E.
      • Moon H.J.
      • et al.
      Suicidality and its risk factors in Korean people with epilepsy: a MEPSY study.
      ]. Major risk factors for suicidality were MDD, generalized anxiety disorder, and adverse effects of antiepileptic drugs. Odds ratio of suicidality increased up to 45.5 compared with that in patients with no risk factors, when the three risk factors were conjoined. Despite the fact that MDD was a main risk factor of suicidality, a majority of these patients had never undergone psychiatric interventions [
      • Seo J.G.
      • Lee J.J.
      • Cho Y.W.
      • Lee S.J.
      • Kim J.E.
      • Moon H.J.
      • et al.
      Suicidality and its risk factors in Korean people with epilepsy: a MEPSY study.
      ]. That means depression in Korean PWE remains significantly under-recognized and under-treated.
      The Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E) has been developed and validated [
      • Ko P.W.
      • Hwang J.
      • Lim H.W.
      • Park S.P.
      Reliability and validity of the Korean version of the neurological disorders depression inventory for epilepsy (K-NDDI-E).
      ]. A cutoff score suggestive of MDD in K-NDDI-E is 11, which is much lower than that of the original version [
      • Ko P.W.
      • Hwang J.
      • Lim H.W.
      • Park S.P.
      Reliability and validity of the Korean version of the neurological disorders depression inventory for epilepsy (K-NDDI-E).
      ].

       Depression in PWE in China

      The lifetime prevalence of MDD in China (3.6%) has been reported as being lower than that in Western countries [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ,
      • Lee S.
      • Tsang A.
      • Huang Y.Q.
      • He Y.L.
      • Liu Z.R.
      • Zhang M.Y.
      • et al.
      The epidemiology of depression in metropolitan China.
      ]. Studies from different regions of China have used different scales and revealed that 16.5% to 43.4% of Chinese PWE have comorbid depression [
      • Guo Y.
      • Chen Z.M.
      • Zhang Y.X.
      • Ge Y.B.
      • Shen C.H.
      • Ding Y.
      • et al.
      Reliability and validity of the Chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E).
      ,
      • Kui C.
      • Yingfu P.
      • Chenling X.
      • Wenqing W.
      • Xiuhua L.
      • Di S.
      What are the predictors of major depression in adult patients with epilepsy?.
      ,
      • Peng W.F.
      • Ding J.
      • Li X.
      • Mao L.Y.
      • Wang X.
      Clinical risk factors for depressive symptoms in patients with epilepsy.
      ,
      • Tong X.
      • An D.
      • Lan L.
      • Zhou X.
      • Zhang Q.
      • Xiao F.
      • et al.
      Validation of the chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E) in West China.
      ,
      • Guo Y.
      • Ding X.Y.
      • Lu R.Y.
      • Shen C.H.
      • Ding Y.
      • Wang S.
      • et al.
      Depression and anxiety are associated with reduced antiepileptic drug adherence in Chinese patients.
      ,
      • Tong X.
      • Chen J.
      • Park S.P.
      • Wang X.
      • Wang C.
      • Su M.
      • et al.
      Social support for people with epilepsy in China.
      ,
      • Chen J.
      • Zhang Y.
      • Hong Z.
      • Sander J.W.
      • Zhou D.
      Marital adjustment for patients with epilepsy in China.
      ]. Studies that investigated the risk factors associated with depression in Chinese PWE [
      • Kui C.
      • Yingfu P.
      • Chenling X.
      • Wenqing W.
      • Xiuhua L.
      • Di S.
      What are the predictors of major depression in adult patients with epilepsy?.
      ,
      • Peng W.F.
      • Ding J.
      • Li X.
      • Mao L.Y.
      • Wang X.
      Clinical risk factors for depressive symptoms in patients with epilepsy.
      ] identified: drug resistance, a history of chronic medical illnesses, unemployment, age >35 years, female gender, having focal epilepsy, history of status epilepticus, and using topiramate. In 2015, the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was translated and validated into a Chinese version (C-NDDI-E) in Western China. The authors found that the C-NDDI-E was a reliable screening tool, with a cut-off score >12 suggestive of a major depressive episode [
      • Tong X.
      • An D.
      • Lan L.
      • Zhou X.
      • Zhang Q.
      • Xiao F.
      • et al.
      Validation of the chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E) in West China.
      ]. They found a prevalence of possible MDE of 26.7%. In another study conducted in East China, the authors found a higher cut-off score (>13) for the C-NDDI-E [
      • Guo Y.
      • Chen Z.M.
      • Zhang Y.X.
      • Ge Y.B.
      • Shen C.H.
      • Ding Y.
      • et al.
      Reliability and validity of the Chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E).
      ].

       Depression in PWE in Thailand

      Using the Thai Geriatric Depressive Scale (TGDS), one hospital-based study [
      • Nidhinandana S.
      • Chinvarun Y.
      • Sithinamsuwan P.
      • Udommongkol C.
      • Suwantamee J.
      • Wongmek W.
      • et al.
      Prevalence of depression among epileptic patients at Phramongkutklao Hospital.
      ] suggested a prevalence of depression in PWE in Thailand to be 38.3%; 65.2% had mild depression and 34.8% had moderate depression. Using the Hospital Anxiety and Depression Scale (HADS) a hospital-based study [
      • Phabphal K.
      • Sattawatcharawanich S.
      • Sathirapunya P.
      • Limapichart K.
      Anxiety and depression in thai epileptic patients.
      ] suggested a 20% prevalence rate.

       Depression in PWE in Taiwan

      A comparison of prevalence rates of psychiatric disorders in Taiwanese adults 1990 and 2010, revealed an increment from 11.5% in 1990 to 23.8% in 2010 (time trend p < 0.001) [
      • Fu T.S.T.
      • Lee C.S.
      • Gunnell D.
      • Lee W.C.
      • Cheng A.T.A.
      Changing trends in the prevalence of common mental disorders in Taiwan: a 20-year repeated cross-sectional survey.
      ]. A population based study using the national health insurance research database showed that patients with a new diagnosis of epilepsy had higher occurrence of depression than those without epilepsy (adjusted hazard ratio: 7.16, 95% CI 4.87–10.5) [
      • Chang H.J.
      • Liao C.C.
      • Hu C.J.
      • Shen W.W.
      • Psychiatric Chen T.L.
      Disorders after epilepsy diagnosis: a population-based retrospective cohort study.
      ]. In another population based study using the national health insurance research database [
      • Chiang K.L.
      • Cheng C.Y.
      Prevalence and neuro-psychiatric comorbidities of pediatric epilepsy in Taiwan: a national population-based study.
      ], psychiatric comorbidities were present in 24.6% of children with epilepsy. However, no PWE was diagnosed with MDD [
      • Chiang K.L.
      • Cheng C.Y.
      Prevalence and neuro-psychiatric comorbidities of pediatric epilepsy in Taiwan: a national population-based study.
      ]. Using the HADS in one clinic based study of 260 PWE [
      • Chen H.F.
      • Tsai Y.F.
      • Hsi M.S.
      • Chen J.C.
      Factors affecting quality of life in adults with epilepsy in Taiwan: a cross-sectional, correlational study.
      ], 8.5% had scores suggestive of moderate to severe depression and 14.2% of mild depression.

       Depression in PWE in Iran

      In a population based study that used a validated Persian translation of the Composite International Diagnostic Interview (CIDI; version 2.1) [
      • Sharifi V.
      • Amin-Esmaeili M.
      • Hajebi A.
      • Motevalian A.
      • Radgoodarzi R.
      • Hefazi M.
      • et al.
      Twelve-month prevalence and correlates of psychiatric disorders in Iran: the Iranian Mental Health Survey, 2011.
      ], the 12-month prevalence of MDD was 12.7%, which was higher than that in many other countries [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ]. In one cross-sectional nationwide epidemiological study of the Iranian population using the Schedule for Affective Disorders and Schizophrenia (SADS) [
      • Mohammadi M.R.
      • Ghanizadeh A.
      • Davidian H.
      • Mohammadi M.
      • Norouzian M.
      Prevalence of epilepsy and comorbidity of psychiatric disorders in Iran.
      ], 10.7% of the PWE had major depression and 1.3% had minor depression; these figures were 3% and 0.3% in the general population, respectively [
      • Mohammadi M.R.
      • Ghanizadeh A.
      • Davidian H.
      • Mohammadi M.
      • Norouzian M.
      Prevalence of epilepsy and comorbidity of psychiatric disorders in Iran.
      ]. In one cross-sectional hospital based study of 74 adult PWE [
      • Foroughipour M.
      • Mokhber N.
      • Azarpajooh M.R.
      • Taghavi M.
      • Modarres Gharavi M.
      • Akbarzadeh F.
      • et al.
      Coping mechanisms: depression and suicidal risk among patients suffering from idiopathic epilepsy.
      ], 26 (35%) patients had symptoms of depression identified with the Beck Depression Inventory (BDI). In one clinic based study of children in Iran [
      • Shamsaei F.
      • Cheraghi F.
      • Zamani G.
      Comparing mental health of school-age children with and without epilepsy.
      ], the mean scores of the Child Symptom Inventory-4 (CSI-4) were significantly higher among children with epilepsy compared with those of a control group (major depression score: 10.5 ± 3.8 in the epilepsy group and 7.7 ± 1.1 in the control group, P < 0.001) [
      • Shamsaei F.
      • Cheraghi F.
      • Zamani G.
      Comparing mental health of school-age children with and without epilepsy.
      ].

      4. Conclusions

      Depression is highly prevalent in PWE in different countries in Asia and the prevalence rates are consistent with rates reported in the literature from other countries: overall, about 25% of PWE suffer from depression [
      • Micoulaud-Franchi J.A.
      • Barkate G.
      • Trébuchon-Da Fonseca A.
      • Vaugier L.
      • Gavaret M.
      • Bartolomei F.
      • et al.
      One step closer to a global tool for rapid screening of major depression in epilepsy: validation of the French NDDI-E.
      ]. Interestingly, the apparent cultural, demographic, religious, and ethnic diversity in Asia has not affected the prevalence of this comorbidity significantly. This is notably the case even in countries such as China and Japan, where depression rates in the general population are lower than those in many Western nations [
      • Bromet E.
      • Andrade L.H.
      • Hwang I.
      • Sampson N.A.
      • Alonso J.
      • de Girolamo G.
      • et al.
      Cross-national epidemiology of DSM-IV major depressive episode.
      ,
      • Kawakami N.
      • Takeshima T.
      • Ono Y.
      • Uda H.
      • Hata Y.
      • Nakane Y.
      • et al.
      Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: preliminary findings from the World Mental Health Japan Survey 2002–2003.
      ,
      • Azuma H.
      • Akechi T.
      Effects of psychosocial functioning, depression, seizure frequency, and employment on quality of life in patients with epilepsy.
      ,
      • Lee S.
      • Tsang A.
      • Huang Y.Q.
      • He Y.L.
      • Liu Z.R.
      • Zhang M.Y.
      • et al.
      The epidemiology of depression in metropolitan China.
      ,
      • Guo Y.
      • Chen Z.M.
      • Zhang Y.X.
      • Ge Y.B.
      • Shen C.H.
      • Ding Y.
      • et al.
      Reliability and validity of the Chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E).
      ]. Cultural differences in the expression of depression are important and well-recognized. While depression is a universal experience, its acceptance is highly dependent on many social and cultural aspects that interplay with each person’s emotional development over their lifetime [
      • Kirmayer L.J.
      Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment.
      ,
      • Juhasz G.
      • Eszlari N.
      • Pap D.
      • Gonda X.
      Cultural differences in the development and characteristics of depression.
      ]. For example, in some cultures open expression of grief or suffering is encouraged, while in other cultures such emotions should be concealed. The latter may lead to under-estimation of the depression rate in population and hospital-based investigations. In addition, the role of clinical care may be viewed very differently depending up on the cultural context: for some cultural backgrounds, depression may be considered more of a moral or spiritual problem than a medical one, which may result in reluctance to consulting a physician, reporting symptoms or following medical advice [
      • Kirmayer L.J.
      Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment.
      ]. Despite the growing effects of globalization, such cultural differences seem likely to persist, or even be reinforced by a desire to protect ethnic identity, and should be taken into account when studying depression across international boundaries [
      • Bhugra D.
      • Mastrogianni A.
      Globalisation and mental disorders: overview with relation to depression.
      ].
      In Asian countries, as elsewhere, depression is often under-recognized and improperly managed in PWE [
      • Seo J.G.
      • Lee J.J.
      • Cho Y.W.
      • Lee S.J.
      • Kim J.E.
      • Moon H.J.
      • et al.
      Suicidality and its risk factors in Korean people with epilepsy: a MEPSY study.
      ]. High quality data is scarce in many countries and validated screening tools [e.g., Neurological Disorders Depression Inventory for Epilepsy (NDDI-E)] to appropriately investigate the prevalence of depression in PWE are still lacking in many languages. This study was not a meta-analysis or a classical systematic review. It is possible that some manuscripts that could be relevant for this review were excluded without review. In spite of this limitation, this study provides the foundation for future systematic research in the field. In addition, since, different studies used various tools to investigate the prevalence of depression and depressive symptoms and also because the settings of the investigations were very variable, an analysis on the overall results was not scientifically valid in the current study. Questionnaires and scales, such as NDDI or BECK, address depressive symptoms, not a depressive disorder. Depression is a psychiatric diagnosis evaluated by a psychiatric interview. This distinction was not clear in most of the literature. A systematic review of the validated tools for depression screening in PWE concluded that NDDI-E was the most commonly validated screening tool, is validated in multiple languages and is easy to administer [
      • Gill S.J.
      • Lukmanji S.
      • Fiest K.M.
      • Patten S.B.
      • Wiebe S.
      • Jetté N.
      Depression screening tools in persons with epilepsy: a systematic review of validated tools.
      ]. However, varying cut-off points exist in different languages [
      • Micoulaud-Franchi J.A.
      • Barkate G.
      • Trébuchon-Da Fonseca A.
      • Vaugier L.
      • Gavaret M.
      • Bartolomei F.
      • et al.
      One step closer to a global tool for rapid screening of major depression in epilepsy: validation of the French NDDI-E.
      ]. This may result in variable outcomes when studying depression in different regions [
      • Cramer J.
      • Blum D.
      • Fanning K.
      • Reed M.
      • Epilepsy Impact Project Group
      The impact of comorbid depression on health resource utilization in a community sample of people with epilepsy.
      ,
      • Tong X.
      • An D.
      • Lan L.
      • Zhou X.
      • Zhang Q.
      • Xiao F.
      • et al.
      Validation of the chinese version of the neurological disorders depression inventory for epilepsy (C-NDDI-E) in West China.
      ]. Availability of NDDI-E in different languages will facilitate easier recognition of depression in PWE and may lead to appropriate treatment of this comorbid disorder, as well as facilitating cross-cultural studies. However, a uniform methodology (e.g., study settings and population) among different languages and cultures in validating this tool seems necessary. Considering the high prevalence of depression among PWE, routine and periodic screening of all PWE for early detection and appropriate management of depression would be a reasonable approach.

      Conflicts of interest

      Ali A. Asadi-Pooya, M.D., consultant: Cerebral Therapeutics, LLC and UCB Pharma; Honorarium: Hospital Physician Board Review Manual, Cobel Daru; Royalty: Oxford University Press (Book publication); others: no conflict of interest; Professor Kanemoto has received educational grants and speaker's fees from UCB, Otsuka Pharmaceuticals, GSK, Eisai, and Daiichi-Sankyo.

      Acknowledgment

      No funding was received for this study.

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