Symptoms of Depression and Anxiety in Pediatric Epilepsy Patients

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1 @ikpsia, 39(6):9-99, 1998 Lippincott-Raven Publishers, Philadelphia International League Against Epilepsy Symptoms of Depression and Anxiety in Pediatric Epilepsy Patients *lialan B. Ettinger, "fideborah M. Weisbrot, $ItEdith E. Nolan, $]'Kenneth D. Gadow, *'Isusan A. Vitale, #'Mary R. Andriola, *$INicholas J. Lenn, Gerald P. Novak, and #Bruce P. Hermann Departments of *Neurology, fpsychiatry Private Practice, #Psychiatry, and $Pediatrics, and the "Epilepsy Management Program, State University of New York at Stony Brook, Stony Brook; Departments of IpNeurology and #Pediatrics, Long Island Jewish Medical Center, New Hyde Park, New York; and the **Division of Neuropsychology, University of Wisconsin, Madison, Wisconsin, USA. Summary: Purpose: We assessed rates of symptoms of anxiety and depression among pediatric patients with epilepsy. Methods: We administered the Revised Child Manifest Anxiety Scale (RCMAS), and Child Depression Inventory (CDI) to 44 epilepsy patients aged -18 years (mean age.4 years). Demographic, socioeconomic, and epilepsy-related information was examined in relation to depression and anxiety scores. Results: No patients had been previously identified to have depression or anxiety. However, 26% had significantly increased depression scores and 16% met critieria for significant anxiety symptomatology. Conclusions: Symptoms of depression and anxiety are common among pediatric patients with epilepsy and appear to be overlooked by care providafs. Key Words: Anxiety- Depression-Epilepsy-Seizures-Pediatric. Many controversial studies suggest that patients with epilepsy are at high risk for psychiatric disturbances (1-3) including depression (43) and anxiety (6-8). Most such studies are based on adults; there are far fewer studies of psychiatric symptoms in children and adolescents with seizures. Although depression in childhood has been reported to occur with administration of barbiturates (9), very little is known about overall rates and determinants of depression and anxiety in pediatric patients with epilepsy. Rutter et al. (1) reported psychiatric disturbances in as many as 33% of children with epilepsy but did not specifically delineate affective disorders. Hoare (1 1) noted higher rates of behavioral difficulties in children with epilepsy than in children with diabetes mellitus, but did not determine rates of anxiety and depression. The present study was therefore designed to (a) determine the degree to which the affective disorders (depression and anxiety) had been detected and treated in previous clinical care, (b) determine the frequency of depressive and Accepted January 29, Address correspondence and reprint requests to Dr. A. B. Ettinger at Epilepsy Management Program, Department of Neurology, Health Sciences Center T-2, State University of New York at Stony Brook, Stony Brook, NY 94-81, U.S.A. anxiety-related symptoms among children and adolescents with epilepsy at present, and (c) examine the relationship between self-reported anxiety and depression symptoms with demographic and seizure-related factors. METHODS Inclusion and exclusion criteria were as follows: Study entry was offered consecutively to outpatients (aged - 18 years) with epilepsy (defined as recurrent unprovoked seizures) attending the Pediatric Neurology Department at the University at Stony Brook. Patients with mental retardation were excluded. Patients and their parents completed several self-report measures that examined the following variables: 1. Demograptiic variables. Patient ages and sex were recorded. Ages were divided into groups aged - and years. For each child, 1 parent completed the Hollingshead Index, a measure of socioeconomic status (SES) which contains questions about family income, marital and occupational status, and education (). Scores from the Hollingshead Index were divided into scores of ~29,2948, and >48 to define lower, middle, and upper SES groups. 9

2 96 A. B. ETTING ER ET AL. 2. Seizure variables. The patient (and parent or parents when necessary) was asked about recent seizures and medications. This interview-based information was supplemented by previous medical reports, including results of laboratory tests and EEG and neuroimaging information. Clinicians subsequently determined each child s seizure type, epilepsy duration, age of recurrent seizure onset, and medication history. Seizures were classified in two ways: (a) as convulsive (generalized tonic-clonic or partial secondarily generalized) or nonconvulsive (e.g., absence, partial complex). If both were present, seizures were specified as convulsive; and (b) in terms of the following epileptic syndromes: localization idiopathic (including benign childhood epilepsy with centrotemporal spikes), localization symptomatic, generalized idiopathic, and other. 3. Depression. Each patient completed the Child Depression Inventory (CDI) (13), a 2-item multiple choice questionnaire that identifies and assesses the severity of symptoms of depression. It has wellestablished concurrent and discriminate validity and high internal consistency and reliability (14). CDI scores of >13 are conventionally considered a clinically meaningful cutoff score to identify significant depressive symptomatology. Also examined were CDI subscores (Negative mood, Interpersonal problems, Anhedonia, and Negative Selfesteem). We also determined the percentage of epilepsy patients exceeding 1 and 2 SD above the mean expected for normal controls, for total scores, and subscores (Table 1). We assessed responses to specific questions. 4. Anxiety. Patients completed the Revised Children s Manifest Anxiety Scale (RCMAS) (1), which consists of 3 questions that measure the level and nature of anxiety. The RCMAS provides a global summary score as well as three subscores in the areas of wonyloversensitivity, social concernskoncentration, physiological anxiety, and a lie scale (Table 2). It has established internal consistency and construct validity, t scores 26 are considered clinically meaningful and suggestive of significant anxiety. Although the CDI and RCMAS do not generate formal diagnoses of depression and anxiety disorders, they are very useful measures for attaining a quantification of symptom severity.. Prior psychiatric history. Finally, we surveyed patient records to identify whether previous caregivers had detected, diagnosed, or treated (with either psychotherapy or psychotropic medications) the child for depression or anxiety. All coding was performed blinded to the child s depression and anxiety scores. TABLE 1. CDI scores of patients t Scores t Scores CDI n MeanlSD Range 2(%) 6-69(%) Negative mood M - yr / M yr 9 1./ F - yr 9 1.6/ F yr Interpersonal problems M - yr / M yr 9.3/. -2 F - yr 9.9/ F yr 1 1.2/ 1. - Ineffectiveness M - yr / M yr 9 1.U 1. - F - yr 9.4/ F yr 1 2.4/ Anhedonia M - yr / M yr 9 3./ F - yr F yr 1 3.9/ Negative self-esteem M - yr M yr 9.9/ 1. - F - yr F yr 1 1./ Total depression M - yr / M yr 9./ F - yr 9./ F yr 1.6/1.8-3 CDI, Children s Depression Inventory Statistics Although the number of patients was too small to provide adequate statistical power for detecting modest effects, we conducted a preliminary set of correlations with several variables, using Pearson correlations to assess the relationship between RCMAS and CDI scores and epilepsy duration, age of seizure onset, and recent seizure frequency, as well as the relation between CDI and RCMAS scores. We used t tests to compare CDI and RCMAS scores between groups for the following: age, type of seizure (convulsive vs. nonconvulsive), epilepsy syndrome, and medications (polytherapy vs. monotherapy). RESULTS The CDI was completed by 42 patients (23 males, 19 females); the RCMAS was completed by 44 patients (24 males, 2 females). Ages ranged from to 18 years (mean age.4 years). Two patients and their parents declined to participate because of inconvenience. Review of records, as well as interviews with parents, indicated

3 DEPRESSION/ANXIETY IN PEDIATRIC PATIEhTS 9 TABLE 2. Correlations among CDI and RCMAS scores RCMAS scores (mean _+ SD) CDI (mean, SD) 1 Total Anxiety (9.?.42) Physiological Anxiety (3.39 f 2.6) wow (3.68 i 3.4) Social Concerns (2. i 2.8) Negative mood (1.9 * 2.31) Interpersonal problems (.93 f 1.28) Ineffectiveness (1.3 i 2.1) Anhedonia (3.3 i 3.) Negative self-esteem (1.16 i 1.9) Total depression (mean 8. i 8.43).6,~ =.1.26,~ = , p =.4.9,~ =.1.38,~ =.18.61, p =.1.9, p =,1.24, p =.3.33,~ =.29.62, p =.1.33.p =.38., p =.2.61,~ =.1.23,~ =.139.4, p =.98.6,~ =.1.36,~ =.1., p =.1.6, p = O.OOO1.2,~ = , p =.91.46,~ =.21.32, p =.3.2, p =.4 CDI, Children s Depression Inventory; RCMAS, Revised Children s Manifest Anxiety Scale. that no patient had been previously identified or treated for depression or anxiety. No patient had participated in a current or previous psychiatric interview. Depression scores Twenty-six percent of the patients with epilepsy exceeded the clinically significant cutoff point for increased self-reported depression (CDI score >13). In addition, increased rates of abnormal CDI subscores were common (t scores >6) (Negative mood 14%, Interpersonal problems %, Ineffectiveness 1%, Anhedonia %, and Negative self-esteem %) (Table 1). Even when we used a cutoff of 2 SD above the mean, % of patients met criteria for high depressive symptoms. Examples of responses to specific CDI questions included the following: % of patients indicated that they would like to kill themselves but would never do it whereas 4.3% simply stated that they would like to kill themselves; 4.4% of patients felt like crying once in a while, and 8.9% felt like crying all the time. Seven percent of patients indicated they that they felt that things bothered them all the time, and 8% felt that they could never be as good as others. (Clinicians caring for patients with high rates of depressive or suicidal symptoms were notified.) Two percent of patients indicated they were sad most of the time, and 16% indicated that they were sad some of the time. Anxiety scores Sixteen percent of epilepsy patients exceeded the clinically significant cutoff point for identifying elevated anxiety (t scores >6). Increased RCMAS subscores were very common (Physiological Anxiety 23%, Worry1 Oversensitivity 2%, and Social ConcernsIConcentration 16%). The Lie scale is considered unreliable for young children. Among children aged >1 years, 28% had standardized scores >6. There was a high correlation between total CDI and RCMAS total scores (p =.61, p =.1) and numerous subscores (Table 2). Demographic variables RCMAS or CDI scores did not differ significantly between age groups or between males and females. Twenty-eight parents completed the Hollingshead Index. Numbers were too low for chi-square analysis of SES, but there were no obvious differences in scores among different SES groups. Seizure variables Mean age of seizure onset was.2 years (mean 4.4 years before the present evaluation). Numbers of seizures in the month preceding evaluation were no seizure, n = 33; one seizure, n = 2; and two or more seizures, n =. Data were missing in four cases. Seizures were convulsive in 3 1 and nonconvulsive in 13. RCMAS and CDI scores were not significantly different for subjects with convulsive as compared with those with nonconvulsive seizures. There were no significant correlations for epilepsy duration, age of seizure onset, or the number of recent seizures with RCMAS and CDI scores. Numbers were too small to allow meaningful examination of differences among epilepsy syndrome types and CDII RCMAS scores (e.g., of 1 patients scoring > on the CDI, had localization idiopathic, 2 had localization symptomatic, and 3 had generalized idiopathic epilepsy). Medications Four patients were not receiving any antiepileptic drug (AED), either because of the absence of recent seizures or because their epilepsy syndrome was benign (e.g., benign childhood epilepsy with centrotemporal spikes). Thirty patients received AED monotherapy, and 9 were treated with more than one AED. AEDs prescribed as monotherapy included phenytoin (n = 4), carbamazepine (n = lo), valproate (n = 1), and lamotrigine (n = 1). No patients were receiving phenobarbital or ethosuximide. CDI and RCMAS scores did not differ significantly between subjects receiving monotherapy and those receiving polytherapy.

4 98 A. B. ETTINGER ET AL. DISCUSSION To our knowledge, ours is the first study to examine and demonstrate significantly increased rates of selfreported symptoms of anxiety and depression among pediatric patients with epilepsy. That no patient in our study was previously diagnosed with a mood disorder, and the paucity of other previously published information in this regard, suggest that such symptoms may be poorly recognized in pediatric patients with epilepsy. Although adults may express depression or anxiety more directly, pediatric patients may present other signs, such as disruptive behaviors or irritability, which may not be readily idenified as signs of depression or anxiety (16). Alternatively, they may present no obvious behavioral signs. Our study suggests that if health care providers do not inquire directly about potential depressive or anxiety-related symptomatology, such symptoms may not be detected. Our findings are consistent with the increased rates of depression reported in adults with epilepsy (1). Psychopathology in adulthood may originate in some cases from psychological distress in childhood and adolescence, lending further importance to detecting such symptoms at an early age. Our results, together with previously reported high representation of epilepsy disorders among suicidal pediatric patients (1 8) suggest that clinicians must be alert to symptoms of depression and anxiety and even suicidal ideation. In the current health care climate in which it may be more difficult to provide multidisciplinary services, our series suggests that psychiatric evaluations may be indicated in a substantial number of patients. Although increases in mean CDI scores have been reported in several other pediatric disorders such as migraine or diabetes mellitus (1-19), several factors may contribute to emotional symptoms in the specific disorder of epilepsy. These influences include CNS variables (e.g., effects of seizures, concomitant CNS conditions giving rise to seizures, and medications), as well as psychosocial factors (e.g., the stigma of having seizures) (2). In one study, external locus of control (which tends to correlate with depression and anxiety) was higher among children with epilepsy as compared with matched normal and diabetic controls (21). In a study of adults (22), depression rates were higher among epilepsy patients as compared with matched controls with other neurologic disorders. Although the patients in our study were from a university-based pediatric service, most of them did not have intractable seizures. Few community-based pediatric neurology services are available nearby. Patients with mental retardation who are likely to have differences in their seizure disorders were excluded from our series. Therefore, our results should be applicable to a broad range of pediatric patients with epilepsy. The high correlation between RCMAS and CDI scores may reflect the common comorbidity of anxiety and depression. Alternatively, the RCMAS and CDI measures may not be sufficiently specific to distinguish the two symptoms, a possibility raised in another study (23). The high rates of symptoms of anxiety and depression in our patients suggest that further investigations into the nature, causes, and treatments of these symptoms should be pursued. Larger series will be needed to detect further correlations among the variables studied and anxiety and depressive symptoms. Longitudinal studies that include psychiatric interviews, neuropsychological testing, and matched control groups would also be helpful. Acknowledgment: We thank Drs. James Davis and Max Fink for reviewing the manuscript REFERENCES Weisbrot DW, Ettinger AB. Epilepsy and behavior: controversies and caveats. Neurologist 199;3:1-2. Pemne K, Congett S. Neurobehavioral problems in epilepsy. In: Devinsky, ed. Neurol Clin 1994;:9-2. 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