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Depression is the most common comorbid psychiatric condition associated with epilepsy, with a prevalence of up to 50% in patients with recurrent seizures and 10% in patients with controlled seizures.1317 It is generally underrecognized and undertreated and is incompletely understood, but it is thought to be the result of a combination of psychosocial and neurological factors. Although there is an association between chronic illness and depressive disorders, there seems to be an over-representation of depressive symptoms in patients with neurological disorders, and this is further increased if that neurological disorder includes epilepsy.16

Depression, it is argued, may not simply result from an understandable reaction to the difficulties of living with epilepsy; depression and epilepsy may in fact share common pathogenic mechanisms, including a shared genetic predisposition and neurotransmitter dysfunction with biogenic amines, gamma-amino-butyric acid (GABA), decreased metabolic and frontal lobe function all being implicated.91618 The seizures may themselves be involved, with suggested seizure-related variables including seizure type (complex partial seizures), location (temporal lobe), severity (increased depression rates with poorly controlled seizures), and laterality (left-sided focus) all being described.

Psychosocial factors, including perceived stigma, fear of seizures, discrimination, joblessness, and lack of social support have been implicated in the development of depressive disorders in people who have epilepsy. The relationship between psychosocial factors, depression, and epilepsy show that psychosocial variables are related to epilepsy, not just those people with epilepsy and depression.1 9 When a psychosocial inventory was applied to a community sample of patients with epilepsy, it demonstrated that those no longer taking medication for their epilepsy were better adjusted than those who were on medication but who had had no seizures for a year, and this group was better adjusted than the group who were taking medication, but who had had a seizure in the past year. The authors conclude that the severity of epilepsy was associated with the severity of the self-reported psychosocial problems.20

Suicide, sudden unexpected death in epilepsy (SUDEP), accidents, and drowning are the most common cause of epilepsy-related death in people with epilepsy. With the advances in medication, status epilepticus is now less frequently registered as the cause of death in epilepsy in developed countries.21 The suicide rate in epilepsy is fivefold higher than in the general population and is most significantly increased in patients with temporal lobe epilepsy (25-fold). Suicide appears to represent a serious problem to those attending specialist epilepsy clinics because they have more complex epilepsy.21,22 In a retrospective analysis of suicide at a specialist epilepsy center, 10,739 patients were seen over a 12-year period. Five people completed suicide in this population. In an attempt to better understand why patients may have suicidal intent, the authors recognized an "interictal dysphoric disorder" (depressive mood, irritability, anxiety, headaches, insomnia, phobic fears, and aner-gia are prominent symptoms) which occurs independently of seizures, appears suddenly, and may last for hours to a couple of days. This mood disorder responds to antidepressant treatment, and the authors use a combination of treatments.i2 A second study of 1,722 patients attending an epilepsy center over a 14-year period revealed six completed suicides. The important findings were that suicide occurred soon after a seizure in patients with TLE, were more common in men, and were often related to psychotic episodes.21

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