Detection and impact of co-morbid mental health conditons in people with epilepsy in rural Ethiopia
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Date
2023-09
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Addis Ababa University
Abstract
Background:Research evidence from around the world indicates high levels of co-morbid
mental conditions among people with epilepsy (PWE) compared to the general population.
Nevertheless, there is very limited evidence regarding the detection or impact of co-morbid
mental health conditions in PWE from low-income country settings.
Therefore, the main aim of this PhD thesis was to investigate the detection, impact and lived
experience of co-morbid mental health conditions in PWE in a rural Ethiopian setting.
Specific objectives were to:
To synthesis evidence examining the association of co-morbid mental health
conditions in people with epilepsy with quality of life or functioning in LAMICs.
Evaluate the performance of primary health care workers (PHC) in identification of
co-morbid mental health conditions in PWE attending PHC.
Examine the association of co-morbid mental health conditions with quality of life,
functioning and seizure control.
Explored the experiences of mental ill-health in the contexts of the lives of PWE.
Methods:First, a systematic review and meta- analysis (Study 1) was conducted to examine the
evidence on the association between co-morbid mental health conditions and quality of life
and functioning of PWE in low- and middle-income countries. We searched five main
databases from their dates of inception to January 2022. Cohen‟s d was calculated from the
mean difference in quality-of-life score between people with epilepsy who did and did not
have a co-morbid depression or anxiety condition.
Second, a prospective cohort of people with epilepsy was carried out in four districts of
south-central Ethiopia. PWE were ascertained in the community, refererred and recruited at
the PHC facility after diagnostic confirmation of convulsive seizures. Co-morbid common
mental disorder (CMD) symptoms (depression, anxiety and somatic symptoms) and risky
substance use (exposures) were measured using the culturally validated Self Report
Questionnaire (SRQ-20) and Alcohol, Smoking and Substance Involvement Screening Test
(ASSIST), respectively. Clinician-diagnosed co-morbid mental disorders were measured
using a standardised, semi-structured clinical interview (Operational Criteria for Research;
OPCRIT+) administered by mental health professionals. The main outcome, quality of life
(QoL) was measured at baseline and 6 months using the Quality of Life in Epilepsy
questionnaire (QOLIE-10P). Functional disability was measured using the 12-item World
Health Organization Disability Assessment Schedule (WHODAS-2). Seizure frequency was
measured at baseline and during the follow-up period (6 months).
Study 2: The sensitivity, specificity, positive predictive value (PPV) and negative predictive
value (NPV) of PHC worker diagnosis against the reference standard clinical diagnosis was
calculated. Logistic regression was used to examine the factors associated with
misdiagnosis of clinically diagnosed co-morbid mental disorder by PHC workers.
Study 3: Univariate analysis followed by multiple linear regression modelling was used to
cross-sectionally examine the association between clinically diagnosed co-morbid mental
disorder (primary exposure) and quality of life, adjusting for potential confounding factors
identified a priori.
Study 4: Multivariable linear regression was employed to evaluate whether co-morbid CMD
symptoms predicted a change in QoL and functional disability after adjusting for baseline
levels and pre-defined potential confounders. Structural equation modelling (SEM) was
employed to examine direct and indirect pathways linking co-morbid CMD symptoms with
QoL or functional disability.
Study 5: A qualitative study using a phenomenological approach was employed, comprising
in-depth individual interviews with PWE. Thematic analysis was used, supported by
OpenCode software.
Results:Study 1: The search strategy identified a total of 2,101 articles, from which 33 full text
articles were included in the review. A large standardized mean effect size (ES) in quality of
life score was found (pooled effect size (ES) -1.16, 95% confidence interval (CI) -1.70, -0.63)
between those participants with co-morbid depression compared to non-depressed
participants (meta-analysis of 19 studies). There was significant heterogeneity between
studies (I2= 97.6%, p<0.001). The median ES (IQR) was -1.20 (-1.40, (-0.64)). An
intermediate standard effect size for anxiety on quality of life was also observed (pooled ES -
0.64, 95% CI -1.14, -0.13). There was only one study reporting on functioning in relation to
co-morbid mental health conditions.
Study 2: The prevalence of clinically diagnosed co-morbid mental disorders was 13.9% (95%
CI 9.6%, 18.2%). PHC workers identified 6.3% of clinic attendees as having a mental health
condition (95%CI 3.2%, 9.4%). The sensitivity and specificity of PHC worker diagnosis
against the clinical standardised reference diagnosis were 21.1% and 96.1%, respectively.
Against the reference diagnosis, the optimum cut-off for SRQ-20 (CMD symptom scale) was
9 or above, which identified 41.5% of attendees as „probable CMD‟, 95% CI 35.2%, 47.8%.
In those diagnosed with co-morbid mental disorders by PHC workers, only 6 (40%) had
SRQ-20 score of 9 or above. When a combination of both diagnostic methods (SRQ-20
score ≥9 and PHC diagnosis of depression) was compared with the standardised reference
diagnosis of depression, sensitivity increased to 78.9% (95% (CI) 73.4, 84.4%) with
specificity of 59.7% (95% CI 53.2, 66.2%). Only older age was significantly associated with
misdiagnosis of co-morbid mental disorders by PHC (adjusted odds ratio, 95% CI= 1.06,
1.02 to 1.11).
Study 3 - Comorbid mental disorders were associated with poorer quality of life (Adjusted
(Adj.) β -13.27; 95% CI -23.28, -3.26) and greater disability (multiplier of WHODAS-2 score
1.62; 95% CI 1.05, 2.50) after adjusting for hypothesised confounding factors. Low or very
low relative wealth (Adj. β -12.57, 95% CI -19.94, -5.20), higher seizure frequency (Adj.β
coef. -1.92, 95% CI -2.83, -1.02), and poor to intermediate social support (Adj. β coef. -9.66,
95% CI -16.51, -2.81) were associated independently with decreased quality of life. Higher
seizure frequency (multiplier of WHODAS-2 score 1.11; 95% CI 1.04, 1.19) was associated
independently with functional disability.
Study 4: In the multivariable regression model, neither CMD symptoms (β coef= -0.37,
95%CI -1.30, +0.55) nor moderate to high risk of alcohol use (β= -0.70, 95% CI -9.20, +7.81)
were significantly associated with change in QoL, and there was no effect modification by
treatment engagement. Frequent seizures were associated with a negative change in QoL.
In SEM, QoL at 6 months was significantly predicted by seizure frequency. The summative
effect of CMD on QoL was significant (B= -0.27, 95%CI -0.48, -0.056), although direct and
indirect associations were non-significant. Change in functional disability was not associated
with baseline CMD symptoms (β coef.= -0.03, 95% CI-0.48,+0.54) or with moderate to high
risk of alcohol use (β coef.= -1.31, 95% CI -5.89, 3.26) and there was no evidence of effect
modification by treatment engagement. However, in the SEM model, functional disability at 6
months was predicted by both baseline CMD symptoms (B=0.24, 95% CI 0.06, 0.41) and
seizure frequency (B=0.67, 95% CI 0.46, 0.87) independently.
Study 5: Twenty-two PWE were interviewed (8 women, 14 men). The following themes were
identified: expression of ill-health; the essence of emotions; the emotional burden of epilepsy
and aspirations and mitigating impacts. Participants reported multiple bodily (e.g. fatigue)
and emotional (e.g. irritability, sadness) experiences which were tied up with their
experience of epilepsy and not separable into physical vs. mental health. Emotions were
considered inherently concerning, with emotional imbalance spoken of as a cause or trigger
for seizures. These emotional burdens resulted in difficulties fulfilling occupational and social
life obligations, in turn exacerbating the stigma-related experienced from others.
Conclusion:In this rural Ethiopian setting, comorbid mental disorders were associated with functional
imairemnt and poor quality of life of people with epilepsy. Co-morbid CMD symptoms and
seizure frequency in PWE independently predicted functional disability. The association
between CMD symptoms and quality of life was less conclusive. Routine detection of co-
morbid mental disorder by PHC workers was very low. Combining clinical judgement with
use of a screening scale holds promise but needs further evaluation.
People living with epilepsy in this rural Ethiopian setting experience various emotional,
financial, occupational and interpersonal problems which are crucially interwoven with one
another and with the experience of epilepsy. A people-centred approach to supporting
recovery of PWE requires consideration of mental health alongside physical health, as well
as interventions outside the health system to address poverty and stigma
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Keywords
co-morbid mental health, epilepsy, Rural Ethiopia