Development and validation of the NDDI-E-Y: a screening tool for depressive symptoms in pediatric epilepsy

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1 FULL-LENGTH ORIGINAL RESEARCH Development and validation of the NDDI-E-Y: a screening tool for depressive symptoms in pediatric epilepsy * Janelle L. Wagner, Tanja Kellermann, *Martina Mueller, * Gigi Smith, Byron Brooks, **Alex Arnett, and **Avani C. Modi SUMMARY Dr. Wagner is a research associate professor who focuses on behavioral health in pediatric epilepsy. Objectives: To validate the revised 12-item revised Neurological Disorders Depression Inventory-Epilepsy for Youth (NDDI-E-Y), a self-report screening tool for depressive symptoms tailored to youth ages with epilepsy. Methods: Youth at two sites completed the NDDI-E-Y during a routine epilepsy visit. Youth at one site also completed the Children s Depression Inventory-2 (CDI-2). Seizure and demographic data were abstracted from the electronic medical record. Exploratory factor analyses were conducted. Internal consistency, area under the curve (AUC), and construct validity were assessed. Results: NDDI-E-Y questionnaires were analyzed for 143 youth. The coefficient for internal consistency for the NDDI-E-Y was Factor analyses suggested a one-factor solution with all 12 items loading on the factor. The NDDI-E-Y was positively correlated with the CDI-2 (N = 99). Sensitivity and specificity of the NDDI-E-Y were high. Significance: Reliability and construct validity were established for the revised 12-item NDDI-E-Y. The NDDI-E-Y is a brief, free measure of depressive symptoms that can be administered during a routine epilepsy visit. KEY WORDS: Depressive symptom screening, Behavioral health, Pediatric epilepsy. Using generic self-report depression surveys and current diagnostic codes, clinical and surveillance studies have revealed prevalence rates of 20 25% for depression in youth with epilepsy, with adolescents showing particular vulnerability. 1,2 Furthermore, 20% of youth with epilepsy endorse suicidal ideation, 3 and youth endorsing suicidal ideation do not necessarily have clinical symptoms of depression. 4 However, one practical and two conceptual issues potentially complicate the assessment of depressive symptoms in youth with epilepsy when using generic depression measures. First, standardized depression measures cost between Accepted May 26, 2016; Early View publication June 29, *College of Nursing; Comprehensive Epilepsy Program; Departments of Pediatrics; Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A.; Department of Psychology, East Tennessee State University, Johnson City, Tennessee, U.S.A.; and **Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children s Hospital, Cincinnati, Ohio, U.S.A. Address correspondence to Janelle Wagner, Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas St., MSC 160, Charleston, SC , U.S.A. wagnerjl@musc.edu Wiley Periodicals, Inc International League Against Epilepsy $1 and $2 per administration and often require training or certain credentials for administration and interpretation, rendering use of such measures without the presence of a behavioral health professional (psychologist, psychiatrist, social worker) not feasible during a routine epilepsy visit. Conceptually, core diagnostic symptoms of depression overlap with both the clinical presentation of neurocognitive deficits common to youth with epilepsy and the adverse effects associated with antiepileptic drugs (AEDs) (e.g., fatigue, concentration, sleep disturbance). 5 In addition, although not examined in youth with epilepsy, shared underlying brain pathology between epilepsy and depression may influence the expression of depression by emphasizing certain symptoms and minimizing others in adults with epilepsy. 5 Therefore, a brief, free measure of specific depressive symptoms in youth with epilepsy would be beneficial. The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was developed to screen adults for depressive symptoms, excluding symptoms that may overlap with epilepsy and AED side effects. The NDDI-E is a 1265

2 1266 J. L. Wagner et al. Key Points Reliability and construct validity were established for the NDDI-E-Y An NDDI-E-Y score 32 demonstrated high sensitivity and specificity in predicting clinical depressive symptoms The NDDI-E-Y is a free, brief screening tool that can be easily included in routine pediatric epilepsy care brief, well-validated, free screening measure that has been translated into many languages for use in adults with epilepsy. 6 However, there was no such tool for youth with epilepsy. Therefore, in a previous study, the NDDI-E-Y was developed and piloted with 93 youth. Support for preliminary psychometrics were established; however, small sample size limited analyses. 7 Based on preliminary findings from that study, revisions were made to the NDDI-E-Y. Consequently, the purpose of the current study was to explore the factor structure and establish internal consistency, reliability, and construct validity for the revised NDDI-E-Y. It was hypothesized that the NDDI-E-Y would have (1) high internal consistency and (2) strong associations with another well established measure of depressive symptoms. Methods Instrument development The content for the original NDDI-E-Y was developed from the adult NDDI-E, 6 with input from a panel of experts and results of cognitive interviewing with 17 youth. An 11-item NDDI-E-Y was administered to 93 youth. 1 Several revisions were made to the NDDI-E-Y based on preliminary findings. Specifically, we deleted two items due to low correlation coefficients (r values of <0.3). The original NDDI- E item I d be better off dead was also the least endorsed item by youth (8%), and responses were contradictory to the published rates of >20% suicidal ideation in youth with epilepsy. 2,4 These data suggested that the item as worded may not have adequately assessed ideation or been misunderstood. Furthermore, the NDDI-E-Y item difficulty finding pleasure was the second least endorsed item. Three new items were added. Given the prevalence of suicidal ideation in youth with epilepsy, 2,4 an item ( I think about dying ) that was dropped following cognitive interviewing due to confusion over to what the question was referring (i.e., death in general, my death) was revised to I think about dying or killing myself. I feel cranky or irritated was also added because it is a seminal symptom of depression in the general population of youth as indicated by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, 8 and irritability was not represented in the initial NDDI-E-Y. Finally, I feel alone was added to represent the domain of interpersonal difficulties or loneliness in depression 8,9 and frequent endorsement in youth with epilepsy. 10 Loneliness is not likely to be related to AED adverse effects. These revisions resulted in the 12-item measure validated in the present study. Participants Participants were youth ages diagnosed with epilepsy (International Classification of Diseases, Ninth Revision [ICD-9] codes through 345.9x) with at least low average cognitive abilities and the ability to self-report from two comprehensive epilepsy centers (South Carolina, Ohio). Cognitive abilities were confirmed via neurocognitive reports contained in the electronic medical record. If a neurocognitive report was not available, the treating epilepsy healthcare professional was approached and reviewed the electronic medical record with the research associate to determine eligibility. Exclusion criteria included developmental disability (e.g., autism, intellectual disorder) or severe psychiatric illness (e.g., psychotic disorders) that would affect the reliability of self-reporting and were ruled out by electronic medical record review. Measures At both sites youth completed the 12-item revised NDDI- E-Y (Table 2). On the NDDI-E-Y, youth are asked to mark the answer that best describes how often you have the following feelings and thoughts within the past 2 weeks, and response choices include 0 (never) to 3 (always). Raw scores are added to create a total score. At both sites, epilepsy diagnoses, age at onset, and duration as well as current medications were abstracted from the electronic medical record in accordance with guidelines for common data elements suggested by the National Institute of Neurological Disorders and Stroke (NINDS). 11 In South Carolina (SC), youth and caregivers completed additional measures. Youth completed the Children s Depression Inventory-2 (CDI-2), a 28-item gold standard self-report measure of depressive symptoms in children and adolescents. 9 Although the CDI-2 does not provide a diagnosis of depression, many of the CDI-2 items are DSMbased depressive symptoms, and the CDI-2 is well respected as a quantified index of depressive symptom severity. 9 The CDI-2 has demonstrated strong psychometric properties (i.e., internal consistency, construct validity) in pediatric epilepsy populations. 2 The total T score for the CDI-2 was used in the current study. Procedure Youth and caregivers completed self-report measures as part of a larger research protocol during a routine epilepsy clinic visit. Demographic and medical data were abstracted from the electronic medical record.

3 1267 Depressive Symptoms in Youth Standard protocol approvals, registrations, and patient consents The institutional review boards at both medical centers approved the study protocol. During a routine epilepsy visit at a comprehensive epilepsy center, all eligible youth and caregivers were approached by a research associate (someone other than the treating epilepsy professional), and informed consent from the caregiver and assent from the child were obtained in accordance with the established methods of the institutional review boards. As part of the consent process, families were informed that they would receive modest compensation for their time. Statistical analysis Data analyses were conducted using the SAS software package version Responses to the 12-item NDDI-E-Y questionnaire were examined by exploratory factor analysis (EFA) using squared multiple correlations as prior communality estimates. The principal factor method was used to extract factors, followed by promax (oblique) rotation. Selection of the number of factors was based on the eigenvalue of the factor >1, Scree test, the proportion of variance explained, and the following four interpretability criteria suggested by O Rourke & Hatcher: 13 (1) 3 items with significant loadings on each factor, (2) items that load on a given factor share conceptual meaning, (3) items that load on different factors measure different constructs, and (4) rotated factor patterns demonstrate simple structure (most items have high loadings on one factor only and low loadings on remaining factors; most factors have high loadings for some items and low loadings for remaining variables). To investigate alternative solutions and to assist in the determination of the most appropriate number of factors, EFA models were developed using the maximum likelihood (ML) method, which provides a chi-square test for the null hypothesis that a given number of factors is sufficient for a given data set. EFA models were investigated for solutions with 1, 2, 3, and 4 factors based on the preceding criteria. In interpreting the rotated factor pattern, an item was said to load on a given factor if the factor loading was 0.4 or greater for that factor and <0.4 for the others. CDI-2 total T scores were dichotomized into scores of 65 and above versus scores <65. Logistic regression was used to determine the area under the receiver-operating characteristic (ROC) curve (AUC). Sensitivity and specificity point estimates were obtained after dichotomizing the NDDI-E-Y score using a cut-off score of 32 based on several measures of test accuracy including Youden Index, Mathews correlation coefficient, and total accuracy that were maximized at 32 and total and weighted errors that were minimized at this value. Convergent validity was examined using Pearson correlation of NDDI-E-Y total scores with total T scores of CDI-2. Results Participants were 143 youth ages (mean 15.1, standard deviation [SD] 1.7). Sixty-eight percent were female, 29.4% identified as a racial/ethnic minority, and 87.4% were diagnosed with idiopathic epilepsy. The most frequent seizure type was partial seizure (37.5%). See Table 1 for demographic and clinical characteristics. Table 1. Demographics and clinical characteristics a Overall (n = 143) MUSC (n = 99) CCHMC (n = 44) Age in years (M SD) Gender (female) 68.2% (99/143) 67.7% (67/99) 70.5% (31/44) Race/ethnicity White non-hispanic 70.6% (101/143) 67.7% (67/99) 77.3% (34/44) White Hispanic 1.4% (2/143) 2.0% (2/99) 0 Black/African-American 24.5% (35/143) 26.7% (27/99) 18.2% (8/44) Other 3.5% (5/143) 3.0% (3/99) 4.6% (2/44) Age at onset in years (M SD) Time since epilepsy diagnosis in years (M SD) Number of AEDs (M SD) Epilepsy classification Idiopathic 87.4% (125/143) 87.9% (87/99) 86.4% (38/44) Symptomatic 12.6% (18/143) 12.1% (12/99) 13.6% (6/44) Seizure type Generalized convulsive 24.5% (35/143) 32.3% (32/99) 6.8% (3/44) Generalized nonconvulsive 16.8% (24/143) 11.1% (11/99) 29.6% (13/44) Partial epilepsy 35.7% (51/143) 40.4% (40/99) 25.0% (11/44) Unspecified 23.1% (33/143) 16.2% (16/99) 38.6% (17/44) CDI-2 Total T-score (M SD) NDDI-E-Y (M SD) MUSC, Medical University of South Carolina; CCHMC, Cincinnati Children s Hospital Medical Center; M, mean; SD, standard deviation; CDI-2, Children s Depression Inventory-2; NDDI-E-Y, Neurological Disorders Depression Inventory in Epilepsy-Youth. a Discrepancies due to missing data.

4 1268 J. L. Wagner et al. Table 2. Revised NDDI-E-Y factor pattern Factor Pattern Factor1 NDDIEY 1 Everything is a struggle NDDIEY 2 I have trouble finding anything that makes me happy NDDIEY 3 I feel like crying NDDIEY 4 I feel frustrated NDDIEY 5 I feel unhappy NDDIEY 6 I think about dying or killing myself NDDIEY 7 Nothing I do is ever right NDDIEY 8 I feel sorry about things NDDIEY 9 I feel sad NDDIEY 10 I feel guilty NDDIEY 11 I feel cranky or irritated NDDIEY 12 I feel alone Figure 1. Receiver-operating characteristic curve (ROC) for the NDDI-E- Y. Epilepsia ILAE Cronbach s alphas for the NDDI-E-Y and CDI-2 were strong at 0.92 and 0.86, respectively. Factor analyses revealed the following. All models resulted in two eigenvalues > 1 (13.3 and 1.2), whereas the scree plot suggested one meaningful factor. The proportion of variance among the 12 items accounted for by the first factor was approximately 91%. All four O Rourke & Hatch criteria 13 applied to the one-factor solution: all items loaded highly, with one item >0.5, five items >0.6, five items >0.7, and one item >0.8 (Table 2). For a two-factor solution, three items loading on factor 2 did not share conceptual meaning; three - and four-factor models were found to be unsatisfactory. These results indicate that a one-factor solution would be most appropriate for these data. The AUC for CDI-2 Total was 0.866, indicating good ability of the NDDI-E-Y to distinguish participants with high/low total scores on the CDI-2. Sensitivity (0.79) and specificity (0.92) were high using a score of 32 as cut-off (<32 vs. 32) (Fig. 1). Investigation of convergent validity showed that the NDDI-E-Y was strongly, positively correlated with the CDI-2 (r = 0.70, p < ). Twenty-five percent of youth (N = 25/99; 6 male) had T-scores 65 on the CDI-2, which is consistent with clinical levels of depressive symptoms. 9 Discussion Depression in youth with epilepsy is a common comorbidity, characterized by poorer psychosocial and healthrelated outcomes 2,14 and increased risk of suicide, 15 often presenting a complicated picture for clinicians. 16 However, youth are not routinely screened for depressive symptoms during epilepsy visits, likely due to time constraints during clinic visits and lack of available screening instruments and clinical resources. The purpose of this study was to develop and validate the NDDI-E-Y, a self-report screening tool for depressive symptoms tailored to youth ages with epilepsy. Based on the adult NDDI-E, the NDDI-E-Y represents symptoms of depression in youth with epilepsy and does not include symptoms that may be accounted for by AED side effects (e.g., fatigue, weight change, and somnolence). Results of the current study demonstrate that the NDDI- E-Y is a reliable and valid instrument to screen for depressive symptoms in youth with epilepsy. Psychometric properties of the NDDI-E-Y were strong, including internal consistency, sensitivity/specificity, and construct validity. The internal consistency of the NDDI-E-Y was comparable to another well-validated self-report measure of depressive symptoms (CDI-2). A cut-off score of 32 on the NDDI-E-Y demonstrated high sensitivity and specificity in predicting a clinical score on the CDI-2 (T 65). A single factor solution was most appropriate for the NDDI-E-Y with all items loading onto the factor, suggesting that all 12 items be retained. In terms of construct validity, the NDDI-E-Y was strongly positively correlated with the CDI-2. 9 These robust preliminary psychometrics for the NDDI-E- Y show promise for the utility of the instrument. The brevity (12 items compared to 28 on the CDI-2), availability (Table S1), low expense (cost of copying only), and access (can be administered by a health professional) of the NDDI- E-Y make it a viable solution for previously encountered barriers (e.g., cost, length of other instruments) to behavioral health assessment during pediatric epilepsy visits. It is notable that the NDDI-E-Y was developed specifically for

5 1269 Depressive Symptoms in Youth youth with epilepsy and depressive symptoms. A recent targeted review highlighted the evidence for why depression in children with epilepsy is not easy to diagnose, such as overlap of symptoms with epilepsy and AEDs and chronic subthreshold versus episodic severe symptoms. 16 In addition, the expression of depressive symptoms in youth with epilepsy may be different from that of the general pediatric population due to emphasis of certain symptoms and minimization of other more traditional depressive symptoms. 5 Furthermore, the CDI-2 is expensive (approximately $2 per survey), requires credentials for purchasing and administering, and may not capture the true nature of depressive symptoms in youth with epilepsy. One other measure, the Depression Scale of the NeuroQoL, was developed specifically for youth with neurologic disorders; however, this measure has limitations in the validation process (e.g., content domain, validation sample size). 17 Therefore, the NDDI-E-Y provides an alternative to existing measures, which for reasons described above may not be the most feasible or psychometrically sound screening tools. Finally, results of the current study revealed that 25% of the youth reported clinical levels of depressive symptoms. Indeed, comparable rates have been reported with other recent self-report studies, 2 as well as our surveillance data on adolescents with epilepsy. 1 Given that a one fourth of youth with epilepsy experience comorbid depression, clinicians must provide routine screening for depressive symptoms, and the NDDI-E-Y is suggested as a possible screening tool. A recent study on youth ages 7 17 with epilepsy found that those referred for brief behavioral medicine intervention showed improvements in depressive symptoms following the intervention. 2 They also found that depression was not stable over time, lending support for the importance of evaluating depressive symptoms at each visit. 2 Other studies have shown that behavioral health symptoms have a greater impact than seizures on long-term QoL, 14 demonstrating the necessity of evaluating both seizures and depressive symptoms during routine visits. Indeed, Guilfoyle and colleagues have nicely illustrated the feasibility of incorporating behavioral medicine assessment and intervention into routine epilepsy care. 18 Limitations Although the NDDI-E-Y demonstrated strong psychometrics, there are some limitations to this study. First, participants included in the factor analyses were from two sites. Of note, the sites are comparable in terms of demographics. 19 The sample was heavily represented by females. Although the sample size was modest for factor analysis, to date, this represents the largest sample of pediatric epilepsy patients evaluated for an epilepsy-specific screening tool for depressive symptoms. Socioeconomic status was not included as a potential covariate in this study. The scope and funding of this project did not allow for administration of a psychiatric interview to a determine DSM-5 diagnosis of depression. Instead, the CDI-2 does provide a quantified index of the severity of depressive symptoms. 9 It must be noted that the exact rationale for the NDDI-E-Y (e.g., specific to youth with epilepsy) makes it difficult to select a gold standard with which to compare it given that the existing measure of depressive symptoms (CDI-2) and depression (diagnostic interview) are based on DSM depression, which may not be sensitive to depressive symptoms in youth with epilepsy. 16,20 Inclusion/exclusion criteria for neurocognitive and behavioral health diagnoses were evaluated via electronic medical record review, and notably, such information could be missing from the record. Finally, only a portion of the sample (South Carolina sample N = 99) was used to demonstrate convergent validity with the CDI-2. Conclusions and Future Directions In summary, reliability and construct validity were established for the NDDI-E-Y. The NDDI-E-Y is a brief screening tool that can be easily included in routine epilepsy care, a setting in which providers are strongly encouraged to assess for behavioral health comorbidities, including depression, in youth with epilepsy, 21,22 and brevity is necessary for practical delivery. Utilizing a cut-off score of 32 on the NDDI-E-Y can assist epilepsy healthcare professionals in identifying youth with clinical levels of depressive symptoms. Furthermore, the American Academy of Neurology recently published updated epilepsy quality measures, which now include screening for psychiatric or behavioral health disorders at each epilepsy encounter. 23 It is important to note that because the NDDI-E-Y does not include depressive symptoms that overlap with AED side effects, the NDDI-E-Y may assist clinicians in assessing the complexities of depressive symptoms and improving the outcomes for youth with epilepsy. 16 Future evaluation of the NDDI- E-Y should involve validation with a representative minority population, and the relationship of AED side effects to NDDI-E-Y scores. Acknowledgments This study was funded by Willy s Fund for Childhood Epilepsy Research. Dr. Wagner, Dr. Mueller, Dr. Smith, and Mr. Brooks were supported by the Willy s Fund for Childhood Epilepsy Research. The authors would like to thank Kellie Brabham, BA (The Citadel), for her assistance with manuscript preparation and editing. The authors would also like to express their gratitude to the patients and their families who participated in this study. Disclosure All authors declared that they have no conflict of interest. We confirm that they have read the Journal s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

6 1270 J. L. Wagner et al. Additional Contributors Dr. Wagner conceptualized and designed the study, interpreted results, drafted the initial manuscript, and approved the final manuscript as submitted. Dr. Mueller conducted the analyses, interpreted results, and drafted the initial written and table results of the manuscript, and approved the final manuscript as submitted. Dr. Kellermann was involved in data collection, contributed to the introduction and discussion sections of the manuscript, and approved the final manuscript as submitted. Dr. Smith was involved in conceptualization of the study, contributed to the introduction, and discussion sections of the manuscript and approved the final manuscript as submitted. Byron Brooks was involved in data collection, contributed to all sections of the manuscript, and approved the final manuscript as submitted. Alex Arnett was involved in data collection, contributed to all sections of the manuscript, and approved the final manuscript as submitted. Dr. Modi was involved in data collection, contributed to all sections of the manuscript, and approved the final manuscript as submitted. References 1. Wagner J, Wilson D, Smith G, et al. Neurodevelopmental and mental health comorbidities in children and adolescents with epilepsy and migraine: a response to identified research gaps. Dev Med Child Neurol 2015;57: Guilfoyle S, Monahan S, Wesolowski C, et al. Depression screening in pediatric epilepsy: evidence for the benefit of a behavioral medicine service in early detection. Epilepsy Behav 2015;44: Jones J, Siddarth P, Gurbani S, et al. Screening for suicidal ideation in children with epilepsy. Epilepsy Behav 2013;29: Wagner J, Smith G, Ferguson P. Self-efficacy for seizure management and youth depressive symptoms: caregiver and youth perspectives. Seizure 2012;21: Kanner AM, Schachter S, Barry J, et al. Depression and epilepsy, pain, and psychogenic non-epileptic seizures: clinical and therapeutic perspectives. Epilepsy Behav 2012;24: Gilliam F, Barry J, Hermann B, et al. Rapid detection of major depression in epilepsy: a multicentre study. Lancet Neurol 2006;5: Wagner J, Smith G, Ferguson P, et al. Preliminary psychometrics of the NDDIE-Y: a depression screening tool for youth with epilepsy. J Child Neurol 2013;28: American Psychiatric Association. Diagnostic and statistical manual of mental disorders fifth edition (DSM-5). Washington, DC: American Psychiatric Publishing; Kovacs M. Children s depression inventory 2nd edition: technical manual. North Tonawanda, NY: MHS; Jacoby A, Austin JK. Social stigma for adults and children with epilepsy. Epilepsia 2007;48: Loring D, Lowenstein D, Barbara N, et al. Common data elements in epilepsy research: development and implementation of the NINDS epilepsy CDE project. Epilepsia 2011;52: SAS Institute Inc. SAS for Windows. 9.2 ed. Cary, NC, USA: SAS Institute Inc; O Rourke N, Hatcher L. A step-by-step approach to using SAS for factor analysis and structural equational modeling. 2nd ed. Cary, NC: SAS Institute Inc; Baca CB, Vickrey BG, Caplan R, et al. Psychiatric and medical comorbidity and quality of life outcomes in childhood-onset epilepsy. Pediatrics 2011;128:e1532 e Jones JE, Hermann BP, Barry JJ, et al. Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy. Epilepsy Behav 2003;4(Suppl. 3):S31 S Salpekar J, Mishra G, Hauptman A. Key issues in addressing the comorbidity of depression and pediatric epilepsy. Epilepsy Behav 2015;46: Lai J, Nowinski C, Zelco F, et al. Validation of the NeuroQoL measurement system in children with epilepsy. Epilepsy Behav 2015;46: Guilfoyle S, Follansbee-Junger K, Modi A. Development and preliminary implementation of a psychosocial service into standard medical care for pediatric epilepsy. Clin Pract Pediatr Psychol 2013;1: State Health Facts. Washington, DC: Kaiser Family Foundation. Available from: Accessed September 24, Hesdorffer D, Baldin E, Caplan R, et al. How do we measure psychiatric diagonses? Implications of the choice of instruments in epilepsy. Epilepsy Behav 2014;31: Kerr M, Mensah S, Besag F, et al. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy. Epilepsia 2011;52: Barry JJ, Ettinger AB, Friel P, et al. Consensus statement: the evaluation and treatment of people with epilepsy and affective disorders. Epilepsy Behav 2008;13(Suppl. 1):S1 S Fountain N, Van NEss P, Bennett A, et al. Quality improvement in neurology: epileps update quality measurement set. Neurology 2015;84: Supporting Information Additional Supporting Information may be found in the online version of this article: Table S1. NDDI-E-Y administration and scoring forms.