Prevalence of depression and associated factors among patients with epilepsy at public hospitals in Addis Ababa, Ethiopia: Institution based cross-sectional Study

doi:10.21203/rs.3.rs-5234453/v1

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Prevalence of depression and associated factors among patients with epilepsy at public hospitals in Addis Ababa, Ethiopia: Institution based cross-sectional Study

https://doi.org/10.21203/rs.3.rs-5234453/v1

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Background: People with epilepsy are more susceptible to psychiatric illnesses. The prevalence of depression is greater among people with epilepsy than among the general population. More severe co-morbid depression with epilepsy is linked to a poorer overall prognosis and a lower quality of life.

Objective: This study assessed the prevalence of depression and associated factors among patients with epilepsy at public hospitals in Addis Ababa, Ethiopia.

Methods: An institution based cross sectional study was conducted from July 1-30, 2023, among 591 epileptic patients in the follow-up units of Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College. The study participants were selected via a systematic random sampling technique. A descriptive statistical method was used to generate frequencies and percentages. A Binary logistic regression model was used to assess the associations between independent variables and depression among epileptic patients. AORs were calculated and independent variables with p-value of ≤ 0.05 was considered significantly associated with depression among epileptic patients. The final model fitness was checked using the Hosmer- Lemshow goodness of fit test.

Results: The prevalence of depression was 42.6%. Residence[AOR=0.26, 95% CI (0.17-0.39)], seizure frequency per month[AOR=2.24, 95% CI (1.23-4.10)], frequency of drug[AOR=1.98, 95% CI (1.19-3.28)] and social support[AOR=0.33, 95%CI (0.21-0.52) for moderate social support and AOR=0.46, 95% CI (0.28-0.77) for strong social support]were found to be significantly associated with depression.

Conclusion: The prevalence of depression among patients with epilepsy at public hospitals in Addis Ababa was high. Healthcare professionals should emphasize epileptic patients with higher seizure frequency per month, a higher frequency of drug use and poor social support.Minster of health Should incorporate depression screening measures into existing epilepsy programs.

Psychiatry

Depression

Epileptic patients

Cross sectional study

Logistic regression

Ethiopia

Epilepsy is a persistent, non-communicable neurological condition. It is defined by recurrent seizures, which are brief bursts of involuntary movement that can affect the entire body or just a portion of it. They can also include loss of consciousness and control over bowel or bladder movements. Epilepsy is one of the most prevalent neurological conditions worldwide, affecting about 50 million individuals. Nearly 80% of epilepsy sufferers reside in low- and middle-income nations(1).

Depression is a mood disorder characterized by a depressed mood and a lack of interest or pleasure. Almost all depressed patients (97 percent) lament having less energy; they struggle to complete chores, perform poorly at work and school, and lack motivation to start new projects. Approximately 80% of patients reported having difficulty sleeping, particularly early morning awakenings and frequent nighttime awakenings. While many patients experience decreased appetite and weight loss, some also experience increased appetite and weight gain while sleeping longer than normal. Their thought patterns frequently involve non-delusional ruminations on loss, guilt ,suicide and death(2).

People with epilepsy are more susceptible to psychiatric illnesses: PWE have 9% higher rates of psychiatric illness than the general population(3). While the lifetime prevalence of depression is estimated to be 10% in the general population, it is believed to be 30% in PWE(4). Among the 50 million PWE globally, 9.5–85% are likely to also have depressive disorders, and more than 80% of them live in low-income areas where psychiatric co-morbidities are frequently not recognized and are undertreated(5).

According to a regional subgroup study, the pooled prevalence of depression in PWE in East Africa was 34.52%, and in Southern and West Africa, it was 29.69%(6). The prevalence of depression in PWE in Nigeria was 11.9%(7), 14.2% in Rwanda(8), 68% in Kenya(9) and 67.3% in Burkina Faso(10).

According to Systematic review and meta-analysis on depression in patients with epilepsy, the pooled magnitude of depression among epileptic patients in Ethiopia was 43.14.The pooled prevalence of depression was 46.15% in Oromia, 52.07% in the Southern Nation Nationality Peoples area, and 36.58% in Central Ethiopia and the Amhara region(11). Its prevalence according to institutional studies was 34.8% and 37% at Ayder Comprehensive Specialized Hospital and Mekelle General Hospital and University of Gondar Comprehensive Specialized Hospital respectively(5, 12).

More severe co-morbid depression with epilepsy is linked to significantly worse overall seizure recovery, more severe seizures, increased cognitive, emotional, and physical illness(6), reduced post-surgical results, an increased chance of drug resistance (4), an increased chance of adverse antiepileptic drug (AED) effects, a poorer overall prognosis, and a greater risk of suicide (13). Compared with individuals without depression, those with epilepsy tend to use medical services more frequently and have a lower quality of life(14).

The complicated and possibly bidirectional nature of the relationship between epilepsy and depression raises the possibility of a shared Pathophysiology(15). Previous studies have indicated that demographic factors (female gender and older age), sociopsychological factors (unemployment, lack of social support and perceived stigmatization), and epilepsy factors(higher frequency of seizures and drug-resistant epilepsy) are possible risk factors for co-morbid depression(16).

Several studies have been conducted on the prevalence of depression and associated factors among patients with epilepsy worldwide and in Africa but the literature in Ethiopia is limited. The Previous studies in Ethiopia did not identify whether the type of seizure and electroencephalogram findings are associated with depression among epileptic patients. These are unknown factors and are worthy of investigation. Therefore, this study fills these gaps by identifying whether the type of seizure and EEG findings are associated with depression among epileptic patients and assessing the prevalence and associated factors of depression among people living with epilepsy.

Study design, period and area

An institution based cross sectional study design was employed. The study was conducted from July 1-30, 2023, in the capital city of Ethiopia, which is Addis Ababa. It was conducted at three selected public hospitals in Addis Ababa; Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College.

Study population

The study population included all selected epilepsy patients in the follow-up unit of Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College from July 1-30, 2023, who fulfilled the inclusion criteria of the study.

Patients aged 18 years and above with a diagnosis of epilepsy and who were receiving treatment for at least 6 months were included in the study. Patients who were critically ill and unable to communicate during the time of data collection were excluded.

Sample size determination

The sample size was calculated using Single population proportion formula with 95% confidence level, a proportion of 37% from a previous study held at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia (5), a 5% margin of error , a 10% non-response rate and a design effect of 1.5. The final sample size was 591.

Sampling procedure

Among the 12 public hospitals in Addis Ababa three (Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College) were selected by using simple random sampling (lottery) method. The data were collected over a one month period and before the data were collected the total number of patients who visited the epilepsy OPDs of the three hospitals for the previous 12 months was taken from patient records and the average number of patients per month was subsequently calculated. After that the required sample size was proportionally allocated for each hospital.

Where n= the number of epilepsy patients in the follow-up unit of each hospital in the one month period

Ni= final sample size of the study

N= Total number of epilepsy patients in the follow up unit of Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College over a one month period

To select study participants from the three hospitals, a systematic random sampling method was used. The k value (sampling interval) was calculated by dividing the total study population who had followed up for one month before the data collection period (1250) by the total sample size (591). The sampling interval ( k ) is 1250/591=2. The first study participant was selected by lottery method from each hospital separately and the next study participants were selected at a regular interval (every 2) individual at the outpatient department.

Operational definitions

Depression: was assessed by the Patient Health Questionnaire-9 which has been validated and extensively used in Ethiopia(17). In this study a PHQ-9 total score of ≥10 was considered as having depression.

Substance use: was measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), a structured interview developed by the World Health Organization (WHO) (18).

Perceived stigma: was assessed by the kilifi stigma scale (KSS) which was developed and validated in kilifi, Kenya and adopted in Ethiopia(19). A score above the 66^thpercentile of the data measured by the kilifi stigma scale of epilepsy indicates the presence of perceived stigma(20).

Social support: was measured with the Oslo-3 items social support scale (Oslo SSS). A score of 3–8 is considered “poor social support”, a score of 9–11 is considered “moderate social support” and a score of 12–14 is considered “strong social support(21).

Data collection procedures, and quality assurance

The data were collected using interviewer administered structured questionnaire and a data abstraction tool. The questionnaire had four parts. The first part contains sociodemographic data , the second part contains clinical and substance related factors, the third part contains psychosocial factors and last part contains a patient health questionnaire-9 to assess depression. The data abstraction format was designed to collect data from patient charts about EEG reports.

The questionnaire and data abstraction tool were pretested prior to the actual data collection on 5% of the final sample size(randomly selected charts and patients ) at Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College and Yekatit 12 Hospital Medical College and necessary amendments to the data collection tool were made. The study units for the pretest were not included in the final data collection. To guarantee that all participants could comprehend it, the questionnaire and data abstraction tool were translated into Amharic and then back translated into English to maintain consistency.

Depression was assessed via the Patient Health Questionnaire-9 and the internal consistency of the Cronbach’s alpha of the PHQ-9 in this study was 0.857. Perceived stigma was measured by kilifi stigma scale with a Cronbach’s alpha of 0.774. Social support was assessed by Oslo-3 items social support scale and its internal consistency of the Cronbach’s alpha in the current study was 0.934.

Four psychiatric nurses and three supervisors received training from the principal investigator on the basics of the questionnaire and data abstraction tool on June 29, 2023, for one day. Data were collected from July 1-30, 2023.The supervisors reviewed the process of data collection on daily basis to verify its completeness, correctness, and consistency by checking the questionnaire and data abstraction tool.

Data management and data analysis

The collected data were coded and entered into Epi Info, cleaned, stored and exported into SPSS. The data were analyzed using SPSS version 27.0 software. A descriptive statistical method was used to generate frequencies and percentages. Categorical variables were summarized using proportions and numerical variables were checked for normality and summarized with a mean value (± standard deviation). If normality failed (skewed data), the data were summarized as median( inter quartile range).

A binary logistic regression model was used to assess the associations between independent variables and depression among epileptic patients. Univariate analysis was used and independent variables with p-value of ≤ 25% were selected for multivariable binary logistic regression analysis. AORs were calculated and independent variables with p-value of ≤ 0.05 were considered significantly associated with depression among epileptic patients.

The final model fitness was checked using the Hosmer- Lemshow goodness of fit test. The adequacy of the final model was assessed using goodness of fit test and the final model fitted the data well (Pearson x ² =13.997, p-value = 0.082)

Sociodemographic characteristics of the respondents

The sociodemographic characteristics of the participants are presented in Table 2. As shown, a total of 591 participants provided a response rate of 100%. The median age of the participants was 38.0 (IQR, 28.0 - 49.0) years. The majority of the participants (24.2%) were in the age range of 35–44 years and 53.3% of the participants were males. Among all the participants, 42.3 % were single, 60.9% were living in urban areas and 27.4 % had received primary school education. Among all the participants, 26.2% were self -employed and their monthly income was in the range of 1401-2500 ETB for 28.1% of the participants.

Description of respondents by clinical and substance related factors

As shown in Table 3, among the 591 participants, 54.0% had epilepsy with an onset age of 18 years or older, and 58.9% had lived with epilepsy for at least 11 years. In 58.5 % of the individuals, the type of seizure was generalized and 50.4% reported having seizures 1–3 times a month. With respect to the number of drugs 58.2% were on monotherapy, 37.2% were taking the medication twice a day, and 88.7% had no side effects from antiepileptic drugs. The majority (86.3%) of the patients had no Co-morbidity and 87.0% of them had no family history of mental illness. Concerning on lifetime substance use 60.1% had no lifetime substance use, 27.4% had current substance use and 39.1% had a normal EEG pattern.

Description of respondents by psychosocial factors

The psychosocial characteristics of the participants are presented in Table 4. As shown in table 4, 34.0% of the 591 participants reported that they were stigmatized by other people because of their illness and 40.8 % of the study participants had moderate social support.

Prevalence of depression among epileptic patients

The patient health questionnaire with the lowest score was 0, and its maximum score was 27. A PHQ-9 total score ≥ 10 was considered as having depression. As shown in Figure 1, the prevalence of depression was 42.6% [95% CI (0.386-0.467)].

Factors associated with depression

Table 5 presents the results of univariate and multivariate analyses conducted to identify factors associated with depression among the participants. As shown, the univariate analysis revealed that residence, educational status, seizure frequency per month, frequency of drug use, co-morbidity, family history of mental illness, and social support were significantly associated with depression at the 25% level of significance.

Accordingly, after adjusting for other covariates the odds of having depression were 74% less likely among participants who lives in urban areas as compared with rural areas [AOR=0.26, 95% CI (0.17-0.39)].

In addition to this, compared to those patients who had poor social support the odds of having depression among patients who had moderate social support and strong social support were 67% and 54% less likely, respectively[AOR=0.33, 95%CI (0.21-0.52) for moderate social support and AOR=0.46, 95% CI (0.28-0.77) for strong social support].

In this study, the prevalence of depression among epileptic patients was 42.6% [95% CI (0.386-0.467)]. This result is similar with other studies conducted in Rajasthan (41.19%)(22). In contrast to this, the results of this study show a lower prevalence of depression than the studies conducted in Saudi Arabia (76.7%) (23), Kenya(68%)(9), Burkina Faso(67.3%) (10) and China(52.6%) (24). This could be because of differences in the inclusion criteria used and the use of different diagnostic criteria to diagnose depression. In the study conducted in Burkina Faso, patients whose duration of follow-up was less than 3 months were included and the Hamilton Depression Rating Scale was used for diagnosing depression(10).

In contrast, the results of this study exceed the prevalence of depression reported in Sri Lanka (22%)(25), Nigeria(26.6%)(26), Himalayan country(31%)(3), Ayder Comprehensive Specialized Hospital and Mekelle General Hospital in Ethiopia(34.8%)(12) and University of Gondar Comprehensive Specialized Hospital in Northwest Ethiopia(37%)(5).This is due to differences in the study areas, cultures of the study participants, inclusion criteria and diagnostic tools. Symptoms of depression were screened with the Beck Depression Inventory II in a study conducted in Sri Lanka(25) and the inclusion criteria for the study in Nigeria was participants aged between 18 and 60 years(26).

After multivariate binary logistic regression, residence, seizure frequency per month, frequency of drug use and social support were found to be significantly associated with depression. Accordingly, after adjusting for other covariates the odds of having depression were 74% less likely among participants who lives in urban areas as compared with rural areas. This could be because patients living in rural areas have limited access to and availability of health care services, fewer resources for mental health and restricted availability of medical experts which leads to inadequate coping mechanisms for their sickness. The result is similar to a study conducted in Gondar specialized hospital, Ethiopia(5).

On the other hand the odds of having depression were 2.24times higher among those who experience seizure 4 and above times per month than those who did not experience seizure per month. This result is in line with studies in Gondar specialized hospital, Ethiopia(5), Burkina Faso(10), Rajasthan(22) and Sri Lanka(25).This is due to patients with higher number of seizure frequency experience depression because of fear of recurrent seizures and may experience constant discomfort as a result of not knowing when their next seizure would happen as a result of this they can establish boundaries on themselves by abstaining from public places or social events. Owing to the repeated frequency of seizures, these patients exhibit socially inappropriate behaviors, such as mouth foaming and loss of bladder control, which leads to discrimination and social stigma.

The odds of having depression were 1.98times higher among patients who were taking antiepileptic drugs more than twice a day as compared with patients who were taking antiepileptic drugs once a day. The possible cause might be, higher frequency of drug increases the side effect, the burden of antiepileptic drugs, the cost of drug and antiepileptic medications have a deleterious impact on behavior and mood(27). These findings were in line with the study conducted in Himalayan country(3).

In addition to this, compared to those patients who had poor social support the odds of having depression among patients who had moderate social support and strong social support were 67% and 54% less likely, respectively. This result is also similar to a study conducted in Himalayan country(3) and Gondar specialized hospital, Ethiopia(5). A possible reason for this is that poor social support results social isolation, which can have unfavorable effects on mental and physical health, including depression. In addition to this having strong social support reduces anxiety and stress related to the illness.

Strengths and limitations of the study

Strengths of the study

To minimize interviewer bias the same standard diagnostic tools and questionnaires were used for data collection for all study participants.

Limitations of the study

There might be social desirability response bias for substance-use-related factors.
Some of the independent variables, such as age of onset of epilepsy, duration of illness, and seizure frequency are based on the patient's past medical history, which may lead to recall bias.

The prevalence of depression among patients with epilepsy at public hospitals in Addis Ababa was high. The study revealed that residence, seizure frequency per month, frequency of drug use and social support were significantly associated with depression.

Recommendations

Healthcare professionals

Therefore, epileptic patients with higher seizure frequency per month, a higher frequency of drug use and poor social support should be prioritized.
To reduce the higher frequency of drug use by switching antiepileptic drugs to once-daily dosing regimens in epilepsy patients.

Minster of health

Should incorporate depression screening measures into existing epilepsy programs
To provide training programs for health professionals on factors associated with depression(higher seizure frequency per month, higher frequency of drug use and poor social support)

Researcher: expected to do other researchers may use cohort studies and incorporate additional aspects not addressed in this study.

AOR

Adjusted odds ratio

EEG

Electroencephalogram

OPDs

Out patient departments

PHQ

9-Patient Health Questionnaire-9

PWE

People with epilepsy

Ethics approval and consent to participate

The research was conducted after obtaining ethical clearance from the Gamby Medical and Business College Ethical Review Board, Eka Kotebe General Hospital, St. Paul Hospital Millennium Medical College, and Addis Ababa Health Bureau. The study adhered to the ethical standards outlined in the Declaration of Helsinki (1964) and its subsequent amendments.

All participants provided informed consent before participating in the survey. They were fully informed about the study's purpose, procedures, potential risks, and benefits. Participation was entirely voluntary, and participants were assured that their responses would remain confidential and be used solely for research purposes.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors.

Disclosure statement

The authors declare that there are no conflicts of interest.

Availability of data and materials

The data and materials used in this study are available upon reasonable request. Owing to privacy concerns and institutional policies, the data cannot be made publicly accessible. Interested parties may contact [email protected] to request access to the data and materials.

Author Contributions:

1. Bemnet Yacobe Sayid: Led the research, including the study design, data collection, data analysis, manuscript drafting, and revision. Managed research coordination and ensured the overall quality and integrity of the research. Corresponding author.

2. Haileleul Mekonnen Tilinty: Participated in data collection and contributed to the interpretation of the results. Provided critical revisions and feedback on the manuscript.

3. Abel Melese Teka: Assisted with data collection and contributed to the interpretation of results. Provided critical revisions and feedback on the manuscript.

4. Kidist Abomsa Bedane: Contributed to the data collection, the interpretation of the results, reviewed and provided feedback on the manuscript.

5. Nahom Zewdu Yemane: Responsible for the data collection, data analysis and review of the manuscript.

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Tables 1 to 5 are available in the Supplementary Files section

The authors declare no competing interests.

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Prevalence of depression and associated factors among patients with epilepsy at public hospitals in Addis Ababa, Ethiopia: Institution based cross-sectional Study

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Abstract

Figures

Introduction

Methods

Results

Sociodemographic characteristics of the respondents

Description of respondents by clinical and substance related factors

Prevalence of depression among epileptic patients

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

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