Depression in children with epilepsy from western China: A cross-sectional survey.

This study investigated the prevalence of depression among children with epilepsy and evaluated factors associated with depression.Participants who met the selection criteria were included in this cross-sectional study, which was conducted at the Pediatric Neurology Department of the West China Women's and Children's Hospital from January to May 2018. Depression status among children with epilepsy was evaluated by the Depression Self-Rating Scale for Children (DSRSC). Information on sociodemographic characteristics, co-morbid diseases and family conditions were collected as independent variables. Variables found in univariate analysis to affect depression were used in a multiple linear regression model on factors related to depression among children with epilepsy.A total of 124 patients participated in the study, with a response rate of 93.9% (124/132). In this sample, 60.5% (75/124) of patients were male and the mean age of patients was 11.17 ± 2.29 years. The mean score on the DSRSC was 9.65 ± 6.45 and 16.9% (21/124) of children with epilepsy were considered to have depression. According to the multiple linear regression analysis, the DSRSC scores showed a significant correlation with comorbidities (B = 0.178; standard error (SE) = 1.123; P = .043), attitude towards seizures (B = -0.180; SE = 1.171; P = .039) and adverse reaction to medications (B = 0.233; SE = 1.797; P = .008).There is relatively high prevalence of depression in children with epilepsy in western China. More health education is needed to reduce the rate of depression in children with epilepsy, particularly for those patients with comorbidities, negative attitudes towards seizures and adverse reactions to medications.

Introduction

Epilepsy is a group of chronic neurological diseases characterized by epileptic seizures, which are caused by sudden abnormal discharges of neurons in the brain related to transient brain dysfunction.[ Worldwide, the point prevalence of active epilepsy and the lifetime prevalence of epilepsy are 6.38% and 7.60%. In children, these rates are 6.35% and 1% in children, respectively.[ In China, reported estimates of the prevalence of active epilepsy vary from 0.48% to 8.51%, while the estimated incidence rate is between 0.22% to 0.29%.[

Epilepsy can have a number of negative impacts in patients’ lives. Patients with epilepsy can have sudden seizures at any time, and in certain environments, these seizures may cause falls, burns, drowning, and traffic accidents. In addition, patients with epilepsy often suffer discrimination in school, social interactions, employment, and marriage, which can have negative impacts on mental health.

Children with epilepsy often have negative emotions such as depression. Depression in children manifests as mood swings, impulsivity, poor self-esteem, self-harm and suicide, and abdominal pain, which can have undesirable consequences to both the patient and the family. Caplan et al found that the prevalence of depression in children with epilepsy is 7% to 29% and the chance of having depression in children with epilepsy is 5 times greater than in children without epilepsy.[ There are many factors that may cause depression in children with epilepsy, those most consistently found to be related include sex, frequent seizures, comorbidities, seizure onset, and types of antiepileptic drugs.[

Previous studies have reported on depression among children with epilepsy in China. In a sample from northern China, Liang et al reported that 23.8% of children with epilepsy have depression according to the Depression Self-rating Scale for Children (DSRSC) compared with 5.9% of children without epilepsy.[ This study found that the course of disease, type of seizures, and frequency of seizures could affect depression in children, but the authors did not conduct multiple linear regression analysis to explore independent predictors of depression.

Studies on the prevalence of depression in children with epilepsy from western China are lacking and limited studies have investigated the factors influencing depression among people with epilepsy in China. Therefore, this study assessed the depression status of children with epilepsy and factors associated with depression to provide evidence-based information to improve the management of epilepsy in this population.

Method

Study design

This is a cross-sectional study on the prevalence and associated factors of depression among children with epilepsy. Participants were 8 to 18 year-old children diagnosed with epilepsy who visited the Pediatric Neurology Department of the West China Women's and Children's Hospital from January to May 2018. The West China Women's and Children's Hospital is located in Chengdu, Sichuan, and is one of the largest pediatric treatment centers in western China.

Subject

The inclusion criteria for subjects of this study were:

clinical diagnosis of epilepsy according to the International League Against Epilepsy Classification 2018;

aged over 8 and under 18 years; and

ability to give informed consent.

The exclusion criteria were:

comorbidities that were likely to affect emotion, including congenital heart disease and diabetes;

patients and their caregivers who were unable to understand or fill out the questionnaire; and

mental disorders prior to the first attack of epilepsy or family history of mental disorders.

Data collection

We extracted demographic information (name, sex, age, place of residence) from patients’ medical card records. Medical information (recency of diagnosis, seizure type, epilepsy type, family history of epilepsy, comorbidity, seizure frequency, children's attitude towards seizures, frequency of clinical examination), also extracted from medical records, was collected by neurologists or clinical pharmacists with at least 3 years of clinical experience. Information about caregivers was collected using questionnaires. Questions included, among others, caregiver age, education status, marital status, working status, total household income, confidence in treatment, and acceptance of epilepsy. Medication information (quantity of medication, adverse reactions, time for medication use, medication adherence) was also self-reported by both the patient and the caregivers in questionnaires. The DSRSC scale was used to evaluate the severity of depression and was completed by the patients.

Instruments

The DSRSC was developed by Birleson in 1981 based on the diagnostic criteria for adult depression. The DSRSC assesses the depression status in the preceding week in children and adolescents aged between 8 and 18 years. This tool is widely used in clinical practice of children with mental disorders in China. The Chinese version has been found to have good psychometric characteristics for the Chinese population[ The retest reliability of the DSRSC scale after 3 months was r = 0.53, the half-reliability of the scale was 0.74, and Cronbach α was 0.73. The sensitivity for the diagnosis of depression was 86% and the specificity was 82%.[ The scale contains 18 items scored on 3 levels. The maximum score is 36, and depression is defined as a score ≥15. Higher scores indicate more severe depression.

Data analysis

Quantitative variables were expressed as mean ± SD. Normally distributed data were tested by variance analysis and the non-normally distributed data were tested by the Mann–Whitney U test to compare quantitative variables between groups. To identify the independent variables that contribute to depression, we created multiple linear regression models using the univariate factors with P value equal to or less than .10. The limit of statistical significance was set at P value less than .05. Statistical analyses were performed using SPSS 22.0.

Ethical issues

The study protocol was conformed to the Helsinki Declaration and it was approved by the Office of Research Ethics Committees of West China Women's and Children's Hospital. All participants voluntarily took part in the study and all patients and caregivers provided informed consent.

Results

Demographic characteristics of the patients

A total of 132 patients were recruited for this study and 124 participants completed the study, for a response rate of 93.9% (124/132). Among study completers, 60.5% (75/124) were male and 39.5% (49/124) were female. The mean of age of participants was 11.17 ± 2.29 years (range from 8–17.8 years). In the study sample, 2.4% (3/124) of patients were newly diagnosed, 46.0% (57/124) of patients had comorbidities and 7.3% (9/124) of patients had a family history of epilepsy. There were 50.4% (67/124) patients with systemic epilepsy and 46.0% (57/124) patients with focal/partial epilepsy.

Prevalence of depression

The mean score on the DSRSC was 9.65 ± 6.45. Using a cut-off of 15 on the DSRSC to indicate depression, we found that 16.9% (21/124) of the children in the sample were depressed.

Factors affecting DSRSC scores

We assessed demographic information, disease status, medical status, and family conditions of children with epilepsy. In univariate analysis, there were 4 variables with statistically significant associations with DSRSC scores. These were comorbidities (P = .005), fear of seizures (P = .008), adverse reaction to medications (P = .002), and seizure frequency (P = .021) (Table 1 ). Univariate factors with P≤ .10 were included in the multiple linear regression model.

Table 1

Characteristics of the study population.

In the multiple linear regression model, 3 factors were found to be independently associated with DSRSC scores. The factors included comorbidities (B = 0.178; standard error (SE) = 1.123; p = 0.043), attitude towards seizures (B = -0.180; SE = 1.171; P = .039) and adverse reaction to medications (B = 0.233; S = 1.797; P = .008) (Table 2).

Table 1 (Continued)

Characteristics of the study population.

Discussion

We conducted a cross-sectional study to assess the depression status of children with epilepsy and factors related to depression. In our sample of children from western China, 16.9% presented with symptoms of depression. Factors found to be associated with depressive symptoms in children with epilepsy in multivariate analyses were medical comorbidities, adverse reactions to medication and negative attitudes towards seizures.

The prevalence of depression in our study is similar to that found in other studies. Kwong et al in Hong Kong,[ which included 140 children between the ages of 10 and 18 years, reported that 22.1% of children with epilepsy had depression. This study also found that factors such as medical comorbidities, female sex, frequent seizures, and younger age of seizure onset predicted depression. In addition, Berg et al in the United States,[ which included 500 children with epilepsy aged 6 to 9 years, found that 67 (13.4%) of children with epilepsy met criteria for depression.

These results offer information that could be used to improve the management of children with epilepsy. Key points are as follows:

Patients with comorbidities are more likely to focus on and worry about their disease. Therefore, doctors and pharmacists should pay more attention to managing patients’ comorbidities in addition to their seizures.

Patients who are afraid of seizures are more likely to be depressed. For these patients, clinicians can attempt to increase understanding of the disease and reduce the level of fear.

Patients with adverse reactions to medications are more likely to experience depression. Adverse reactions to antiepileptic drugs are common in clinical practice, especially impacts the nervous system and gastrointestinal system. Medical staff should pay more attention to helping patients understand adverse reactions and manage them.

At present, guidelines and expert consensus documents[ state that more attention should be paid to the mental status of epilepsy children in clinical practice and that timely intervention should be taken. First, the treatment team should actively control seizures to reduce patients’ depression and anxiety. In addition, patients may need treatment for depression, beginning with non-pharmacological treatment including cognitive behavior therapy, psychodynamic therapy, and interpersonal relationship therapy.[ If psychotherapy is not effective, medications can be initiated to control depression. However, patients should be informed of the common adverse effects of antipsychotics because these adverse effects could increase depressive symptoms. In general, regular health education is imperative, including how to use drugs, how to recognize adverse reactions, how to understand disease-related information and how to manage seizures.

Limitations of the study included:

Patients with neuropsychiatric disorders were excluded, which makes it difficult to generalize results to patients with these comorbidities.

Participants were from hospital-based samples, which may not represent the whole population of children with epilepsy;

Because we used a cross-sectional study design, a causal relationship could not be demonstrated between predictors and depression. Further prospective studies with larger sample sizes are needed to overcome these limitations.

Conclusion

There is a relatively high prevalence of depression in children with epilepsy in western China. Medical staff should pay more attention to patients with comorbidities, patients attitudes towards seizures and patient response to adverse drug reactions, and more health education is needed for improving the depression status of children with epilepsy.

Acknowledgments

We thank Diane Civic, PhD, from Liwen Bianji, Edanz Editing China (www.liwenbianji.cn/ac) for editing the English text of a draft of this manuscript.

Author contributions

Chunsong Yang: designed the review, collected data, carried out analysis and interpretation of the data and wrote the review.

Zilong Hao: designed the review, collected data, carried out analysis and interpretation of the data and wrote the review.

Yifei Mao: designed the review, collected data, checked the data and wrote the review.

Qunfen Xu: designed the review, collected data, checked the data and wrote the review.

Li Zhao: designed the review, collected data, checked the data and wrote the review. Lingli Zhang: designed the review, commented on drafts for previous version.

Table 2

Multiple linear regression analysis of factors influencing depression of children with epilepsy.