Depression and associated factors among people with epilepsy at Wolaita Sodo University Hospital, South Ethiopia

doi:10.21203/rs.3.rs-4862772/v1

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Depression and associated factors among people with epilepsy at Wolaita Sodo University Hospital, South Ethiopia

https://doi.org/10.21203/rs.3.rs-4862772/v1

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Background

Epilepsy is the most common neurological disorder in the world and contributed to various psychiatric illnesses. Depression is one of the most frequent co morbid psychiatric disorders that affect the quality of life in patients with epilepsy. Despite this impact depression continues to be under-recognized and undertreated. Therefore this study amid to assess the magnitude of depression and its associated factors among patients with epilepsy at Wolaita sodo university hospital, South Ethiopia 2021.

Methods

A hospital based cross sectional study was conducted from April 2021-May 2021. A systematic random sampling technique was used to select 423 samples of patients with epilepsy and interviewer administrated structured questionnaires was employed. Patient Health Questionnaire with 9-items was used to assess depression. Logistic regression model was used to determine the association between the outcome and independent variables. A 95% CI and Odds ratio with corresponding p-value < 0.05 were used to determine the strength of association.

Result

The overall magnitude of depression among epileptic patients in this study was 49.2%. Educational status; unable to read and write (AOR = 3.43, 95%CI:1.09,10.7), being female (AOR = 2.54, 95%CI:1.43,4.52), perceived stigma (AOR = 5.96, 95%CI:2.88,12.3), poor social support (AOR = 2.88, 95%CI:1.28, 6.48), poor medication adherence (AOR = 4.60, 95%CI: 2.46,8.63), seizure frequency of 6 times per month (AOR = 5.59, 95%CI:1.72, 18.1) were independent predictors of depression among patients with epilepsy at p-value < 0.05.

Conclusion and recommendation:

In this study nearly half of the patient with epilepsy had depression. Educational status; unable to read and write, being female, perceived stigma, poor social support, poor medication adherence, seizure frequency of 6 times per month were independent predictors of depression among patients with epilepsy. Therefore screening depression in epileptic patients and appropriate management critically needed attention to reduce the effects of the problems.

Depression

Epilepsy

Wolaita Sodo

South Ethiopia

Epilepsy is the most common neurological disorders characterized by recurrent seizures and abnormal electrical activity in the brain that causes an involuntary change in body movement or function, sensation, awareness, or behavior(1). The presence of recurrent seizures may cause difficulties in physical, social, psychological and important areas of the patient’s life (2). Approximately 50 million people worldwide and the majority of whom (80–85%) live in developing countries affected by epilepsy(3, 4). In Ethiopia the prevalence rate between 45.2% and 49.3%. Which affects 5.2 per 1000 population with an estimation of 0.5% of patients with seizers in the past 1–2 years(5, 6, 7).

Depression is the most common psychiatric comorbidity in people with epilepsy and it affects 9.5 to 63% of epileptic patients (8, 9). Depression defined by depressed mood, loss of interest or pleasure, feeling of worthlessness or inappropriate guilt, disturbed sleep and appetite, feeling of tiredness, and poor concentration for a minimum of two weeks(10, 11). Globally from the total people who suffer from epilepsy, ≈ 15–60% also experienced depression, 80% of them were exist in low-income regions and are often under recognized and undertreated (12–16). Depression in people with epilepsy leads significant burdens to the patients and their families. People with epilepsy have been experienced more psychological disorders than general population (17, 18). Despite this burden and consequences, depression continues to be under-recognized and undertreated due to limited study of its impact on epileptic patients(19–25).

According to previous study factors for occurrence of depression among patients with epilepsy were female gender, low educational status (26, 27, 28, 29), uncontrolled seizure(25), presence of frequent seizures, long duration of epilepsy and poor compliance to antiepileptic drug(22), cannot read and write (20, 31, 32), poor medication adherence, frequency of seizure, having developed perceived stigma, contagious belief, heritability belief & treatability belief of the patients was associated with co-morbid depression (30, 33, 34, 35).

Moreover, the magnitude of depression among epileptic patients was rarely studied in developing countries, despite the fact that there are factors in these countries that contribute it. Therefore this study amid to assess the magnitude of depression and its associated factors among patients with epilepsy at Wolaita sodo university hospital, South Ethiopia.

Study design, setting and period

A study was conducted from April 15 to May 10 2021 at Wolaita Sodo University Hospital Psychiatry clinic, Wolaita Sodo, South Ethiopia. Wolaita sodo university teaching and referral hospital located in Wolaita Sodo town which is located at 380 km south from Addis Ababa. Wolaita Sodo University Teaching Referral Hospital (WSUTRH) is the only public teaching and referral hospital in Wolaita Zone which provides a broad range of medical services in its catchment area for about more than three million people. The hospital delivers different medical services for outpatients, emergency and inpatients for approximately 450–500 patients per day. In the hospital the psychiatry unit is giving neurological services with mental health services.

Participants

All sampled epileptic patients who attending at Wolaita sodo university hospital psychiatry clinic during the data collection period were included in the study and participants who critically ill to the extent of unable to communicate during data collection period were excluded from the study.

Sample size and Sampling procedure

Single population proportion formula was used to calculate the number of required sample for this study and the sample size was calculated by using 51.2% prevalence of depression among peoples with epilepsy attending at Selected Public Health Facilities of Bench Maji Zone, South Ethiopia, 0.512 P, 1.96 Z (standard normal distribution), 95% CI, ⍺=0.05, (31). By adding 10% non-response rate the final sampling size was 423. Systematic random sampling technique was used for the selection of study participants. The k value was calculated by dividing the total population to total sample size so, the sampling fraction is (868/423 ≈ 2). Hence, the sample interval was 2, study participants were chosen at regular K intervals up to required sample size.

Data collection Tools

Patient health question (PHQ-9) was used to assess depression. It is one of the most widely used self-report measures of depression. It is a reliable and valid measure of depression in a range of cultural groups and has been validated with psychiatric and non-psychiatric populations with Cronbach’s α range from 0.84–0.915 in most of the countries including Africa. In Ethiopia, it was validated in Amharic and Afan Oromo version with Cronbach’s α of 0.85, specificity (67%) and sensitivity (86%). PHQ-9 consists of 9 items, and each item four-point Likert scores (not at all ‘0’up to nearly every day ‘3’) to describe a specific behavioral manifestation of depression. A score ≥ 10 were considered as having depression (36, 37).

Perceived stigma was measured by using the KSSE which was developed and validated in Kilifi, Kenya with high internal consistency, Cronbach's 𝛼 of 0.91 and adopted to Ethiopia. It has three-point Likert scale which scored as "not at all" (score of 0), "sometimes" (score of 1), and "always" (score of 2). It has fifteen items and a total score was calculated by addition of all item scores. The 66th percentile was used to categorize the scores (38, 39).

Social support was assessed by Oslo 3-item social support scale, Oslo 3-item social support scale is a 3- item questionnaire commonly used to asses' social support. The scale asks about the ease of getting help from neighbors, the number of people the subjects can count on when there are serious problems, and the level of concern people show in what the subject is doing. A sum-index was obtained by adding the raw scores of the three items. The range is 3–14. The scores were interpreted as ; 3–8 (poor social support), 9–11 (moderate social support), and 12–14 (strong social support) (40, 41).

Medication non-adherence was assessed by using validated Morisky Medication Adherence Scale (MMAS) which consists of 8 items with a dichotomous response (yes/no) with questions asking the patient to respond "yes" or "no" responses to items 1–7 and a 5 point Likert response for the last item. A positive response indicates a problem with adherence. Therefore, higher scores indicate that a patient is least-adherent to medications. The total score for each patient is the summation of the scores in each item. According to MMAS good medication adherence is categorized as (MMAS < 3) and poor medication adherence (MMAS ≥ 3) (42).

For screening of substance use, modified form of ASSIST was used which is developed by World Health Organization (WHO) an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings.

Data collection procedure

A structured face-to-face interviewer-administered questionnaire was used to gather data. Data was collected by three bachelors of Science degree in psychiatry and one mental health specialist under supervision of principal investigator.

Data quality control

The questionnaire was developed in English version and translated in to Amharic then back translated to English by experts and psychiatry professionals to check consistency. To assure the quality of data, training was given for data collector prior to the data collection time. Before the actual data collection, the questionnaire was tested on 5% of the total sample size (n = 21) epileptic patients at Hawassa university referral hospital. The principal investigator was supervising and distributing all necessary items for data collection on each data collection day, checking filled questionnaire for completeness, solve forwarded problems timely during data collection.

Data processing and analysis

Data was entered into Epi data Software version 4.6.0.2 and then it was exported and analyzed by using STATA version 14. Then, the data was analyzed to generate descriptive statistics: means, frequency, percentages and standard deviations, using STATA version 14. Logistic regression analysis was used to calculate adjusted odds ratios to control for confounding variables with 95% confidence interval. Bivariate analysis was done to get variables which have association with dependent variable and then variables with p-value less than 0.25 were entered to multivariable analysis. Odds ratio with 95% CI was computed and variables having p-value less than 0.05 in multivariable models were considered as significantly associated with the dependent variable.

Socio-demographic Characteristics of the respondents

Out of 423 participants 402 were completed interview with response rate 95%. In this study male respondents were 212(52.7%), greater than half of the respondents 243 (60.45%) were protestant by their religion, about 134(33.3%) of the study subjects have attended secondary education followed by Diploma and above 102(25.4%), out of 402 participants 172(42.79%) were married and more than half of them 215(53.48%) were urban residents (Table 1).

Table 1

Distribution of participants by their socio demographic characteristics at Wolaita sodo University Hospital, south Ethiopia, 2021 (n = 402)
Variables		Frequency(n = 402)	Percentage
Sex	Male	212	52.7
	Female	190	47.3
Age (years)	18–24 24–34	115 179	28.6 44.5
	35–44 > 45	91 17	22.6 4.23
Religion	Orthodox Muslim Catholic Protestant	91 29 39 243	22.6 7.21 9.70 60.4
Educational level	Can’t read and write Read and write only Primary school	43 49 74	10.7 12.1 18.4
Marital status Occupation Residence	Secondary school Tertiary(college/university) Single Married/in union Divorced/ Separated Widowed/ widower Student Self-employee Government employee Unemployed House wife Urban Rural	134 102 159 172 32 39 96 130 120 26 30 215 187	33.3 25.3 39.5 42.8 7.96 9.70 23.8 32.3 29.8 6.47 7.46 53.4 46.5

Clinical, psychosocial and substance use characteristics of the respondents

Regarding to clinical characteristics, among respondents 283(70.4%) had seizure frequency of 2–5 times/ month and 339(84.33%) of respondents had age at onset of illness greater than 18 years, of the participants 101(25.12%) had family history of mental illness and about 169 (42%) respondents had moderate social support. From the respondents 69(17.2%) and 55(13.7%) had life time and current substance use history respectively (Table 2).

Table 2

Distribution of participants by their clinical, psychosocial and substance use characteristics at Wolaita sodo university hospital, 2021.
Variables	Categories	Frequency (n = 402)	Percentage
Family history of mental illness Seizure frequency per month Age at onset of disease in years Duration of illness in years Treatment duration in years Social support Life time substance use history Substance use in the past 3 months Perceived stigma Cause of epilepsy Contagious Heritable Treatable By what means Anti-epileptic Drug Adherence	Yes No < 2 times 2–5 times > 5 times < 11 years 11–17 years > 18 years < 5 year 5–10 years > 11 years < 5 years 5–11 years > 11 years Poor Moderate Strong Yes No Yes No Yes No I don't know Spiritual possession Evil eye Family history Others Yes No Yes No Yes No Prayer Traditional treatment Modern medicine Good Poor	101 301 78 283 41 10 53 339 258 114 30 287 92 23 144 169 89 69 333 55 347 116 286 240 60 14 81 7 105 297 146 256 376 26 9 5 388 251 151	25.1 74.9 19.4 70.4 10.2 2.49 13.2 84.3 64.2 28.4 7.46 71.4 22.9 5.72 35.8 42.0 22.1 17.2 82.8 13.7 86.3 28.9 71.1 59.7 14.9 3.48 20.2 1.74 26.1 73.9 36.3 63.7 93.5 6.47 2.24 1.24 96.5 62.4 37.6
Others indicates-Pathogens, Sinful act and Walks around garbage, walking along a river.

Magnitude of Depression among epileptic patients

In this study the magnitude of depression among people with epilepsy was found to be 49.2%. Finding of this research reviled that the prevalence of depression is higher in female than male patient living with epilepsy at Wolaita Sodo University Hospital, South Ethiopia.

Factors associated with depression among people with epilepsy

In bi-variable analysis sex, educational status, marital status, social support, seizure frequency, duration of illness, duration of treatment, contagious, heritable and treatability belief, anti-epileptic medication adherence and perceived stigma were associated with depression among people with epilepsy at p-value < 0.25. During multivariable analysis being female, being unable to read and write, having poor social support, seizure frequency, poor medication adherence and having perceived stigma were significantly associated with depression at p-value < 0.05(Table 3).

Table 3

Bivariable and multivariable analysis of factors associated with depression among people with epilepsy at Wolaita sodo university hospital, 2021.
Variables	Depression	COR (95% CI)	AOR (95% CI)
	Yes No
Sex Male Female Marital Status Single Married/in union Divorced/ Separated Widowed/ widower Educational status Can’t read and write Read and write only Primary school (1–8) Secondary school (9–12) Diploma and above Seizure Frequency < 2 per month 2–5 per month > 5 per month Contagious Belief Yes No Heritability Belief Yes No Treatable belief Yes No Duration of illness < 5 years 5–10 years > 11 years Treatment duration < 5 years 5–11 years >11 years Social Support Poor Moderate Strong Stigma Yes No AED adherence Good Poor	82 130 116 74 77 82 72 100 24 8 25 14 33 10 29 20 36 38 61 73 39 63 18 60 147 136 33 8 75 30 123 174 94 52 104 152 179 197 19 7 107 151 75 39 16 14 127 160 61 31 10 13 116 28 59 110 23 66 99 187 99 17 82 169 116 35	1.00 2.48 (1.66, 3.71) 1.30(0.84, 2.01) 1.00 4.16(1.77, 9.80) 2.48(1.20, 5.10) 5.33 (2.36, 12.0) 2.34(1.16, 4.69) 1.53(0.83, 2.80) 1.34(0.79, 2.28) 1.00 1.00 3.60(2.02, 6.40) 13.7 (5.39, 35.0) 3.53(2.18, 5.72) 1.00 2.64(1.73, 4.02) 1.00 1.00 2.98(1.22, 7.27) 1.00 2.71(1.71, 4.29) 1.61(0.75, 3.44) 1.00 2.47(1.51, 4.05) 0.96(0.41, 2.28) 11.8(6.33, 22.2) 1.53(0.87, 2.72) 1.00 11(6.22, 19.4) 1.00 1.00 6.83(4.30, 10.3)	1.00 2.54(1.43, 4.52) 1.21(0.65, 2.26) 1.00 2.09(0.56, 7.77) 2.60(0.98, 6.92) 3.43(1.09, 10.7)* 0.75(0.26, 2.10) 0.87 (0.37, 2.04) 1.26(0.62, 2.57) 1.00 1.00 2.28(1.10, 4.70) 5.59(1.72, 18.1)** 1.49(.67, 3.34) 1.00 1.19(0.59, 2.39) 1.00 1.00 0.60(0.13, 2.64) 1.00 1.74(0.54, 5.59) 3.58(0.23, 24.2) 1.00 0.83(0.23, 2.93) 0.27(0.01, 5.08) 2.88(1.28, 6.48)* 1.11(0.54, 2.28) 1.00 5.96(2.88, 12.3)** 1.00 1.00 4.60(2.46, 8.63)****
NB. :- p < 0.05 *:- p < 0.01

In this study the magnitude of depression among epileptic patient was 49.2%, which is in line with the study done in Northwest Ethiopia (45.2%) (4) and Nigeria (45%) (29). But the result of this study was higher than the study conducted in Mekelle Ethiopia(34.8%) (34), in Central Ethiopia(43.8%) (16), Thai-land (38.5%)(43) and Egypt (25.5%) (44). The observed difference might be due to difference in data collection tools, cutoff points, study areas and cultures of the study participants. For instance, in the study conducted in Egypt, from the total study participants, 100 of them were healthy individuals taken for comparison which may lower the prevalence of depression. In Thai-land, Hospital Anxiety and Depression scale was used to evaluate depression with different cutoff point compared to our study; this difference can be lead to the deference in magnitude of depression among epileptic patients.

In this study PWE who had seizure frequency of 6 and above were more than five times (AOR = 5.59, 95%= 1.72, 18.1) more likely to develop depression as compared to those patients who had seizure frequency less than 6 which is consistent with study conducted at Northwest Ethiopia(4). The possible explanation for this linkage might be the symptomatic appearance of epilepsy is overt, sudden and not easy to realize, so this difficulty of realizing where and when the seizure come may associated with socially unacceptable sign such as loss of bladder control, foaming from the mouth and tongue biting. These signs may lead the patients with epilepsy to stigma, depression, anxiety and other social and psychological problems.

Finding of this study investigated that being female was significantly associated with depression compared to male respondents which was consistent with the study carried out in Gaza(45)(33, 46). This association might be females face difficulty in performing normal activities of daily living, and they might face several risks or challenges regarding with reproductive activity and pregnancy. Furthermore, women with epilepsy can have hard time to making decision with regard to major life events such as marriage or bearing children. Thus, these consequences might increase depression among females.

Those PWE who had perceived stigma were nearly six times (AOR = 5.96, 95% CI: 2.88, 12.3) more likely to develop depression than those people with epilepsy who had no perceived stigma. This finding supported by other studies conducted in south India(47) and Addis Ababa, Ethiopia(30). The possible explanation for this association could be lack of coping strategies to different seizure effect such as perceived negative social attitude as a result of unaccepted sign of seizure, or the subjects may not develop stigma resistance ability through their life that help them to cope up with different cultural belief, social stigma and the impact of the illness that contributed to felt stigma.

The odds of developing depression among epileptic patients who had poor social support (AOR = 2.88, 95% CI = 1.28, 6.48) were nearly 3 times more likely when compared with patients who had strong social support which is evidenced by the studies from South West Ethiopia(32). This association might be due to the fact that social isolation reduces social support, which can have undesirable influence on physical and mental well-being including depression.

Finally this research reviled that those patients who cannot read and write had more than three times (AOR = 3.43, 95% CI = 1.09, 10.7) odds of developing depression as compared to those patients who had educational status of college and above. These findings were consistent with the previous studies from in India(48) and Iran (49). This linkage could be due to the fact that those patients with lower educational status may have poor insight about their illness and stress coping mechanisms to their illness which has contribution for developing depression.

Limitation of the study

This research used a small sample size, which could affect the generalizability of the results in other study settings and the data was collected through interviewer administered questionnaire, there might have social desirability, interviewer and recall bias. Lastly shortage of financial support didn’t allow reaching all chronic follow up clinic like HIV, DM and HTN.

In this study, the magnitude of depression among PWE was found to be slightly higher than similar study. Having lower educational status, poor social support, seizure frequency, having poor medication adherence and having perceived stigma were factors associated with depression in PWE. Routine screening for depression among epileptic patients, education on medication adherence, strengthening social support and educational status of PWE strongly needed to reverse the effect of the problems and enhance quality of live.

ASSIST- Alcohol, Smoking and Substance Involvement Screening Test, AOR: Adjusted Odd Ratio, CI-Confidence Interval, COR: Crude Odd Ratio, ETB- Ethiopian Birr, IRB- Institutional Review Board, ICCMH- Integrated Clinical and Community Mental Health, KSSE- Kilifi Stigma Scale for Epilepsy, MH- Mental Health, OSS- Oslo Social Support, PHQ-Patient Health Questionnaire, PWE- People with Epilepsy, STATA- Statistical Data, WSU- Wolaita Sodo University, WSUTRH- Wolaita Sodo University Teaching and Referral Hospital, WHO- World Health Organization.

Consent for publication

Not applicable.

Availability of data and materials

The data that support the findings of this study is available from the corresponding authors upon reasonable request.

Competing interests

The authors declared that they have no competing interests.

Funding institution

This research was funded by the University of Gondar. However, the University of Gondar has no role in the designing of the study and data collection, analysis, as well interpretation of data and in writing the manuscript.

Acknowledgements

The authors would like to thank University of Gondar and study participants for their commitment in giving study information.

Ethical consideration

Ethical clearance was obtained from Institutional Review Board (IRB) of University of Gondar. Detail information about the study was explained to all study participants in the information sheet. Each participant provided written informed consent; for those who can’t read and write the interviewer read the consent; and after they agreed to participate, informed consent was obtained by the use of their finger prints. Participants had the right not to participate in the study and even to withdraw in between explained in advance. The privacy and confidentiality of study participants’ information was kept at every stage of data processing by excluding any personal identifiers in the questionnaire well explained. Finally participants who had depression after screening received appropriate treatment.

Authors' contributions

TB revised and edited the final manuscript; AB conceptualized the study, wrote the proposal, participated in data collection, analyzed the data and prepared the manuscript. NY, ST and YM revised the proposal, and reviewed subsequent drafts, approved the proposal. All authors read and approved the final manuscript.

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No competing interests reported.

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Depression and associated factors among people with epilepsy at Wolaita Sodo University Hospital, South Ethiopia

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Abstract

Background

Methods

Result

Conclusion and recommendation:

Introduction

Methods and Materials

Study design, setting and period

Participants

Sample size and Sampling procedure

Data collection Tools

Data collection procedure

Data quality control

Data processing and analysis

Results

Socio-demographic Characteristics of the respondents

Clinical, psychosocial and substance use characteristics of the respondents

Magnitude of Depression among epileptic patients

Factors associated with depression among people with epilepsy

Discussion

Limitation of the study

Conclusions and Recommendation

Abbreviations

Declarations

References

Additional Declarations

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