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Transcultural Aspects of Depression in Epilepsy
Dr. Ennapadam.S. KrishnamoorthyMD., DCN, PhD (Lond), FRCP (Lond, Glas, Edin), MAMS (India)
Founder Director
TRIMED I NEUROKRISH
www.trimedtherapy.com I www.neurokrish.com
Neuropsychiatry in Epilepsy: Transcultural Perspectives- I
• Studies largely confined to the west• Limited literature from Asia, Africa & South America with the
exception of Japan• Schizophrenia like psychosis has been well described from
Africa, Japan and the Indian sub-continent• Some references to “epileptic personality” exist in the
literature from these countries, but hospital or community research data is lacking
1. Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal lobe epilepsy: a controlled study. Br J Psychiatry 1979; 135: 411-7; 1.; Asuni T, Pillutla VS. Schizophrenia-like psychoses in Nigerian epileptics. (A study made in Nigeria). Br J Psychiatry;113(505):1375-9
1. Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal lobe epilepsy: a controlled study. Br J Psychiatry 1979; 135: 411-7; 1.; Asuni T, Pillutla VS. Schizophrenia-like psychoses in Nigerian epileptics. (A study made in Nigeria). Br J Psychiatry;113(505):1375-9
Neuropsychiatry in Epilepsy: Transcultural Perspectives- II
• Post-ictal psychoses has been extensively written about in the Japanese literature, including the relative frequency, link to temporal lobe epilepsy, and lucid interval
• AED linked psychopathology has also been written about extensively in Japan, and linked to the Forced Normalization phenomenon
1. Matsuura M & Trimble MR. Psychoses in Epilepsy: A Review of Japanese Studies. Epilepsy & Behavior 2000; 1: 315-326
1. Matsuura M & Trimble MR. Psychoses in Epilepsy: A Review of Japanese Studies. Epilepsy & Behavior 2000; 1: 315-326
Depression in Epilepsy: Epidemiology
• Number of studies report a high prevalence of depression in epilepsy- up to 50% in hospital populations and between 20 and 35% in community populations surveyed
• Depression is significantly commoner in persons with recurrent seizures than in those with controlled epilepsy
• Is depression more common in epilepsy than in other neurological disorders? CONFLICTING DATA
• Vast majority of studies from UK/ Europe/ USA
Kanner AM. Biol. Psychiatry 2003; 54: 388-398; Harden CL. Neurology 2002; 59: S48-S55. Lambert & Robertson. Epilepsia 1999; 40 (suppl.10): S21-S47
Kanner AM. Biol. Psychiatry 2003; 54: 388-398; Harden CL. Neurology 2002; 59: S48-S55. Lambert & Robertson. Epilepsia 1999; 40 (suppl.10): S21-S47
Transcultural aspects of Depression in Epilepsy
• There have been many more studies of psychoses than of depression
• Studies from around the world have shown a significant component of mood and affective symptoms in epilepsy
• Many studies however end up assessing common mental disorder symptoms, than depression specifically
• Reliance on screening instruments/ diagnostic criteria!
Depressive symptoms frequent in epilepsy: Global perspectives-I
• Indian Subcontinent: • Shukla (1976)- India: 62 TLE- 70 Grand Mal: 4/5 of TLE had
emotional disturbances- neurosis• Tejpal (cited in Maheshwari- 2001)- depression in 60% of
151 subjects; ↓ in CSF serotonin metabolites in depressed pts.
• Africa:• Gureje (1991): 37% of 204 subjects had psychiatric illness:
two-thirds neurotic/affective symptoms• Matuja (1990): 60% had some psychological disturbance:
affective symptoms frequent
Depressive symptoms frequent in epilepsy: Global perspectives-II
Middle East (Alwash RF. Seizure 2000;9:412-416)
• Anxiety & depression more common in 101 patients with epilepsy (48%) than in matched controls (24%) (OR anx=3.66; p= 0.000/ dep=2.41; p=0.024)
Italy (Beghi E. Epi & Behav. 2002;3:255-261)
• Depression more common in epilepsy group when compared to diabetes and control groups (OR 7.3; CI: 1.7-35.8)
Spain (Modrego PJ. Eur Neurol 2002;48:80-86)
• Depression significantly more in 63 patients than in 40 unrelated controls (OR=7; 95% CI 2.3-21)
Is There Reason To Believe That Cross-cultural Differences Exist?
• Organic factors in developing nations may increase/alter burden of psychiatric co-morbidity
• CNS infections, head injury, nutritional factors, neurodevelopment factors may all have a role
• Neurocysticercosis: Important factor in developing nation setting; psychiatric manifestations have been described
Trimble MR & Krishnamoorthy ES. Neuropsychiatric Aspects of Epilepsy- Some Transcultural Issues, In: Transcultural Perspectives in Epilepsy. Epilepsia 2003; 44 (Supplement-1)
Trimble MR & Krishnamoorthy ES. Neuropsychiatric Aspects of Epilepsy- Some Transcultural Issues, In: Transcultural Perspectives in Epilepsy. Epilepsia 2003; 44 (Supplement-1)
Are There Cross-cultural Differences In Prevalence?
• On the face of it
- Depression is a common problem among patients with epilepsy
- That it is prevalent has been well described across cultures
• However comparative cross-cultural data is lacking!
Are There Cross-cultural Differences In Psychopathology?
• Unique manifestations of depression in non-western cultures: considerable literature outside epilepsy
• Somatisation: presenting symptom of CMD in 97% of subjects (Patel V. Psychol Med 1998;28(1):135-43)
• Somatisation and somatic attribution may be more common in non-western cultures (Duddu. Psychopathology 2003;36(2):98-103; Weiss MG. Br J Psychiatry 1995;166(3):353-9)
• Cross-cultural studies- ethnic minority populations fail to recognise psychological symptoms as psychological when compared to native Caucasian populations (Bhatt. J Psychosom Res 2002;33(6): 671-690)
• Consequent physician failure to make a diagnosis
Unique Cultural Explanations- Depression/ Mental Disorders
• Amplification of and attribution to recent somatic illness is common (Duddu. Psychopathology 2003;36(2):98-103): In refractory epilepsy the somatic illness is constant
• Attribution of symptoms to black magic, spirits; role of native and faith healers (Nambi, Nat Med J India 2002;15(6):331-5). Misattribution and myths about epilepsy are widely prevalent
• Acquisition of psychological models as they pass through the care process (Patel. Psychol Med 1998;28(1):135-43). Patients with refractory epilepsy are seldom outside this care process.
Are Epilepsy Specific Psychiatric Disorders Expressed Across Cultures?• Frequently interface with depression• Interictal Dysphoric Disorder/ Mesial Temporal Lobe
Syndrome/ Personality
- Described in Indian (Shukla, 1976), Japanese (Murai, 1998), Spanish subjects (Modrego, 2002)
• Forced Normalization or variants of the same
- Described among Japanese (Matsuura & Trimble, 2000; Indian (Shukla, 1976) & in African studies
• AED induced psychopathology: Many reports: a number from Japan (Matsuura & Trimble, 2000)
Transcultural Research at the Interface between Epilepsy &
Depression- Problems, pitfalls & solutions
1. Collaborative Expertise
• Need for interest in and knowledge of the cultures in question- Minority populations in developed countries may suffer from perceived/ real social isolation, stigma, linguistic barriers (difficult to penetrate)- Populations in developing countries: multiple barriers: pragmatic, cultural, social. May have little inclination for research; problems of the treatment gap
• Need for genuine collaborators
2. Case Definition
• Need for acceptable case definition: - Active epilepsy (well defined)- Psychiatric disorder (well defined)- Depression in epilepsy (more controversial)
• Need to measure both generic and epilepsy specific psychopathology?
• A case of what?
3. Associated Measures
• Use of acceptable criteria & classificatory system• Use of valid measures of seizure frequency,
severity, and temporality• Use of valid measures of quality of life,
disablement & life-course• Need to operationalise the quantification of these
variables across cultures• Are predominantly western norms ideal?
4. Choice of Instruments
• Screening versus diagnostic• Trait versus state versus life-course• Generic versus epilepsy specific• Rater- Self, versus carer/observer, versus
expert/observer• Reliability and validity in population that is being
measured• Low levels of literacy exist in many developing
countries
5. Novel Approaches
• Combining qualitative with quantitative approaches (method triangulation)
• Use of “clinical diagnosis of caseness” and “intention to treat” as gold-standard
• Exploring roots! Collaborating with region of origin• Twinning of developed and developing centres• Combining genetics, imaging and other biological measures
with epidemiology• Provision of care through research to eliminate treatment
gap
Bridging The Treatment Gap Through Transcultural Research
• Barriers to care in a developing nation
- Availability - Accessibility
- Affordability - Acceptability?
In a developing nation, there can be no research without service.KS Mani
In a developing nation, there can be no research without service.KS Mani
Krishnamoorthy ES, Satishchandra P & Sander JWAS. Research in Epilepsy- Development Priorities for Developing Nations. Transcultural Perspectives in Epilepsy, Epilepsia 2003; Vol. 44 (Supplement-1): 5-9.
Krishnamoorthy ES, Satishchandra P & Sander JWAS. Research in Epilepsy- Development Priorities for Developing Nations. Transcultural Perspectives in Epilepsy, Epilepsia 2003; Vol. 44 (Supplement-1): 5-9.
