Attention-deficit hyperactivity disorder in adults with epilepsy: An indirect relationship with suicide risk.

PURPOSE: Studies on attention-deficit hyperactivity disorder (ADHD) are scarce in adults with epilepsy. This study aimed to investigate the risk factors for ADHD and determine whether ADHD is directly associated with the risk of suicide in adults with epilepsy. METHODS: ADHD was assessed using the Structured Clinical Interview for the DSM-5 Disorders Clinical Version. The Mini International Neuropsychiatric Interview (MINI) Plus 5.0.0, Neurological Disorders Depression Inventory for Epilepsy (NDDIE), and Generalized Anxiety Disorder-7 (GAD-7) were also used. Suicide risk was defined as a MINI suicidality score of ≥ 1. Stepwise logistic regression and mediation analyses were conducted. RESULTS: Of the 157 adults with epilepsy, 19 (12.1 %) were diagnosed with ADHD, including inattentive (5.7 %), hyperactive (3.8 %), and combined (2.5 %) types. Thirty-two subjects (20.4 %) had a risk of suicide. ADHD was insignificantly associated with any epilepsy-related factors. The diagnosis of ADHD was not associated with suicide risk independent of NDDIE ≥ 14 and GAD-7 ≥ 7. Mediation effects of ADHD on suicidality using NDDIE ≥ 14 (odds ratio [OR] 2.850, 95 % confidence interval [CI] 1.398-5.811, p = 0.004) or GAD-7 ≥ 7 (OR 3.240, 95 % CI 1.537-6.828, p = 0.002) were statistically significant, with the proportion mediated being 84.5 % or 92.0 % of the total ADHD effect, respectively. These models were adjusted for age, sex, and composite epilepsy severity scores. CONCLUSIONS: ADHD was diagnosed in 12.1% of adults with epilepsy and was not associated with any epilepsy-related factors. ADHD was indirectly associated with the risk of suicide resulting from depression and anxiety in adults with epilepsy.

Differences in factors associated with insomnia symptoms between patients with epilepsy with and without depressive symptoms.

OBJECTIVE: To determine if insomnia-related factors differ depending on the presence of depression in patients with epilepsy. METHODS: This cross-sectional multicenter study collected data on depressive symptoms, insomnia symptoms, and excessive daytime sleepiness, which were defined as a Patient Health Questionnaire-9 (PHQ-9) score of ≥ 10, an Insomnia Severity Index (ISI) score of ≥ 15, and an Epworth Sleepiness Scale (ESS) of ≥ 11, respectively. Further, uncontrolled seizures were defined as one or more seizures per month during antiseizure medications treatment. A stepwise logistic regression analysis was conducted, with a logistic regression with interaction terms performed to identify differences in insomnia-related factors depending on depressive symptoms. RESULTS: Of 282 adults with epilepsy (men, 58 %; mean age, 40.4 ± 13.9 years), a PHQ-9 score ≥ 10, an ISI score ≥ 15, an ESS score ≥ 11 were noted in 23.4 % (n = 66), 20.2 % (n = 57), and 12.8 % (n = 36), respectively. More patients with depressive symptoms had an ISI score ≥ 15 (56.1 % vs. 9.3 %; p < 0.001) than those without. In multiple logistic regression, uncontrolled seizures (odds ratio [OR], 4.896; p < 0.01), daytime sleepiness (OR, 5.369; p < 0.05), and a history of psychiatric disorders (OR, 3.971; p < 0.05) were identified as significant factors that were more likely to be associated with an ISI score ≥ 15; however, this was only true in patients without depressive symptoms. In contrast, use of perampanel (OR, 0.282; p < 0.05) was less likely associated, while female sex (OR, 3.178; p < 0.05) was more likely associated with an ISI score ≥ 15 only in patients with depressive symptoms. CONCLUSIONS: Insomnia-related factors in patients with epilepsy may differ between patients with and without depression. Our findings of different insomnia-related factors based on the presence of depression may facilitate the management of patients with epilepsy.

Emotional and behavioral profiles of adolescents with epilepsy: Associations with parental perception of epilepsy-related stigma.

PURPOSE: We evaluated self-reported psychopathology in adolescents with epilepsy (AWE) and determined which types of psychopathology were associated with the parental perception of stigma towards AWE. METHODS: This was a cross-sectional, multicenter study of 289 adolescents aged 11 to 18 years. Psychopathology was evaluated using the Youth Self-Report scale, which consists of eight narrowband and three broadband syndrome scales. We analyzed the raw score and T-score of each syndrome scale. The parental perception of stigma was assessed using the modified three-item Epilepsy Stigma Scale. RESULTS: Of the 289 AWE (180 boys and 109 girls), 18.3% had at least one emotional or behavioral problem in the clinical range. Social problems were the most common (10.0%), followed by attention problems (6.9%) and aggressive behaviors (4.2%). Externalizing problems (11.8%) were two times more common than internalizing problems (6.2%). Females and older AWE had a higher level of internalizing problems. Social problems were more common in girls (15.6%) than in boys (6.7%), whereas thought problems were more common in boys (3.9%) than in girls (0%). Epilepsy-related factors, especially antiseizure medication polytherapy, were significantly associated with various emotional and behavioral problems. A quarter of parents felt stigma towards their children with epilepsy. Male sex, antiseizure medication polytherapy, and longer duration of epilepsy were more likely to be associated with the parental perception of stigma. Parental perception of stigma was significantly associated with psychopathology in AWE, particularly externalizing problems and social problems. CONCLUSIONS: Emotional and behavioral problems in AWE are common and vary depending on demographic, clinical, and parental factors. Early identification and proper management of these problems are crucial for decreasing comorbid psychopathology in AWE.

General self-efficacy differentially moderates depressive symptoms in adults with epilepsy depending on seizure severity.

PURPOSE: We evaluated whether the relationship between general self-efficacy and depressive symptoms in patients with epilepsy differed depending on age, sex, and seizure status. METHODS: This multicenter, cross-sectional study was conducted on 299 adults with epilepsy, using the Beck Depression Inventory (BDI) and the General Self-efficacy Scale (GSES). We performed stepwise linear regression analysis and analysis of covariance with interaction terms. RESULTS: The stepwise linear regression analysis showed that BDI scores were negatively correlated with GSES scores and positively correlated with age ≥ 40 years, unemployed status, recurrence of generalized or focal to bilateral tonic-clonic seizures (GTCS or FBTCS), and antiseizure medication polytherapy. The final model explained 38.9% of the variance in BDI scores. The analysis of covariance revealed that the moderating effect of GSES scores on BDI scores was less in subjects who had seizure freedom for at least 1 year than in those who did not. In contrast, the moderating effect of GSES scores on BDI scores was greater in subjects who had an age ≥ 40 years and those who experienced GTCS or FBTCS during the previous year than in those who did not. The negative relationship between GSES and BDI scores tended to be stronger in men than in women, but it did not reach statistical significance (p = 0.098). All models were adjusted by significant factors in the linear regression analysis of BDI scores. CONCLUSIONS: The negative relationship between general self-efficacy and depressive symptoms may be stronger in older patients and patients with poorer seizure outcomes.

Sex differences in the relationship between aggression and symptoms of depression and anxiety in adults with refractory focal epilepsy.

PURPOSE: To determine whether sex affects the relationship between aggression and symptoms of depression and anxiety in adults with refractory focal epilepsy. METHODS: This cross-sectional study was conducted in 85 adults with refractory focal seizures, which are defined as one or more seizures recurring per month even when the patient is treated with two or more antiseizure medications. We used the Buss-Perry Aggression Questionnaire (AQ) and the Hospital Anxiety and Depression Scale (HADS) to evaluate aggression and symptoms of depression and anxiety, respectively. We performed multivariate linear regression and analysis of covariance with interaction terms. HADS-depression and HADS-anxiety scores were separately evaluated to avoid multicollinearity between both of them. RESULTS: The HADS-depression and HADS-anxiety scores, male sex, an antiseizure medication load of ≥3, and the use of pregabalin were independently correlated with at least one of the AQ total and subscale scores. These models for depressive and anxiety symptoms explained 34.2% and 32.5%, respectively, of the variance of the AQ total score. Although the AQ total scores did not differ between the sexes, sex significantly affected the relationships between aggression and symptoms of depression and anxiety. Specifically, HADS-depression and HADS-anxiety scores were positively associated with the AQ total scores, especially scores of verbal aggression and anger subtypes, in men but not in women. CONCLUSIONS: These findings support the importance of including anger management and other strategies targeted toward aggression in the development of psychological interventions to reduce anxiety and depression in adults with refractory focal epilepsy. Tailoring those interventions to the needs of males and females will be important to consider. .

Effects of Continuous Positive Airway Pressure on Sleep State Misperception in Patients With Obstructive Sleep Apnea.

BACKGROUND: Little is known regarding the effects of continuous positive airway pressure (CPAP) on sleep misperception in obstructive sleep apnea (OSA). METHODS: Sleep state perception was measured by subtracting the objective total sleep time from the subjective sleep duration. Sleep underestimation and overestimation were defined as ± 60 minutes sleep perception. Insomnia and depressive symptoms were assessed using questionnaires. Finally, nonparametric statistical analyses were performed. RESULTS: Of the 339 patients with OSA included in the study, 90 (26.5%) and 45 (13.3%) showed sleep underestimation and overestimation, respectively. Overall, a significant underestimation of sleep was noted during CPAP titration comparing to a diagnostic PSG (P < 0.001). OSA patients with insomnia or depressive symptoms did not show any changes in sleep perception between diagnostic and CPAP titration studies, whereas those without insomnia or depressed mood showed significantly underestimated sleep duration during CPAP titration. Patients with OSA and either underestimated or overestimated misperception showed perceptual improvements during CPAP titration regardless of the presence of insomnia or depressive symptoms. However, of 204 patients with normal sleep perception, 138 (67.6%) and 10 (4.9%) had underestimation and overestimation of sleep during CPAP titration. CONCLUSION: CPAP titration may improve sleep perception with moderate to severe OSA who have sleep misperception. However, CPAP titration may result in sleep misperception especially underestimation of sleep in those who have normal sleep perception.

Concealment behaviors in Korean adults with epilepsy: Their relationships to social anxiety and seizure severity independent of felt stigma.

PURPOSE: This study assessed whether seizure severity and social anxiety were related to self-disclosure or concealment behaviors independent of felt stigma in Korean adults with epilepsy. METHODS: This multicenter, cross-sectional study used the Disclosure Management Scale (DMS), the short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6), and the Stigma Scale-Revised to evaluate Korean adults with epilepsy. Seizure severity was measured as a composite variable, and multivariate linear regression analyses were performed to assess whether seizure severity and social anxiety were related to concealment behaviors. RESULTS: The 315 subjects included 132 (41.9%) women and 183 (58.1%) men. Of these subjects, 212 (67.3%) reported rarely or never talking to others about their epilepsy, whereas only 98 (31.1%) stated that they rarely or never kept their epilepsy secret from others. Linear regression analyses showed that concealment behaviors were positively correlated with degree of social anxiety (on separate models using the SIAS-6 and SPS-6) and felt stigma, and negatively associated with level of seizure severity. Both models accounted for about 14% of the variance in DMS scores. CONCLUSIONS: The majority of Korean adults with epilepsy choose concealment and selective disclosure strategies. Social anxiety and seizure severity along with felt stigma play significant roles in deciding whether to disclose or conceal a diagnosis of epilepsy. The explanatory power of these models was weak.

Felt stigma may potentiate the relationship between perceived stress and depressive symptoms in persons with epilepsy.

PURPOSE: This study assessed the strengths of association among perceived stress, felt stigma, and depression in adults with epilepsy, and evaluated whether felt stigma altered the association between perceived stress and depression. METHODS: This multicenter, cross-sectional study included adults with epilepsy. Depression was assessed using the Beck Depression Inventory (BDI), and perceived stress was evaluated using the 10-item Perceived Stress Scale. Felt stigma was determined using the three-item Stigma Scale for Epilepsy, with individuals categorized as positive for felt stigma if they answered "yes" to at least one of these items. A hierarchical linear regression analysis and an analysis of covariance with interaction terms were performed. RESULTS: The 316 adults with epilepsy included 171 men and 145 women; of these, 109 (34.5%) reported felt stigma. A hierarchical linear regression analysis showed that perceived stress was the most important correlate of depressive symptoms, followed by felt stigma, being unemployed, recurrence of generalized or focal to bilateral tonic-clonic seizures, and being married. The model explained 54.0% of the variance of BDI scores. Significant interactions between felt stigma and perceived stress on BDI scores was identified in both crude and adjusted models (p < 0.05 each). Specifically, in an adjusted model, BDI scores were more strongly associated with perceived stress in persons with (p < 0.001, partial eta2 = 0.225) than without (p < 0.001, partial eta2 = 0.205) felt stigma. CONCLUSIONS: Perceived stress was the most significant correlate of depressive symptoms in adults with epilepsy, followed by felt stigma. The interaction between perceived stress and felt stigma on depressive symptoms was significant. These findings may help in developing cognitive behavioral therapy for stigma and stress management in persons with epilepsy.

Dual burdens of felt stigma and depressive symptoms in patients with epilepsy: Their association with social anxiety, marriage, and employment.

PURPOSE: The present study evaluated whether patients with epilepsy with dual conditions of felt stigma and depressive symptoms are more strongly associated with social anxiety, being unmarried, and being unemployed than those with depressive symptoms or felt stigma alone. METHODS: This multicenter, cross-sectional study evaluated subjects using the Stigma Scale-Revised, the Patient Health Questionnaire-9, and the six-item versions of the Social Interaction Anxiety Scale, and the companion Social Phobia Scale. Subjects were grouped by depressive symptoms and felt stigma into four groups. Multivariate logistic regression analyses were performed. RESULTS: The 298 subjects included 173 men and 125 women. Of these subjects, 35 (11.7%) had depressive symptoms alone, 33 (11.1%) had stigma alone, and 27 (9.1%) had both depressive symptoms and felt stigma. Multivariate logistic regression analyses showed that, compared with the control group having neither depressive symptoms nor felt stigma, the odds ratios (ORs) for social interaction anxiety and social phobia were highest in the group of dual conditions (OR 18.7 and 13.5, respectively), followed by the depression-alone (OR 7.7 and 4.6, respectively) and stigma-alone (OR 5.0 and 2.8, respectively) groups. Similarly, the ORs for being unmarried (OR 29.2) and unemployed (OR 3.1) were significant only in the group of dual conditions. In addition, male sex and younger age were independently associated with being unmarried whereas seizures recurring ≥1 per month were independently associated with being unemployed. CONCLUSIONS: Dual conditions of felt stigma and depressive symptoms may be more strongly associated with social anxiety, being unmarried, and being unemployed than depressive symptoms or felt stigma alone in patients with epilepsy.

Aggression is more strongly associated with suicidality, independent of depression, than emotional instability and impulsivity in people with epilepsy.

PURPOSE: We evaluated the relative contributions of emotional instability, impulsivity, and aggression to the presence of suicide risk in people with epilepsy after adjusting for depressive symptoms. METHODS: This was a cross-sectional study that used the short form of the Affective Lability Scale (ALS-18), the Barratt Impulsiveness Scale Version 11 (BIS-11), the Brief Aggression Questionnaire (BAQ), and the Patient Health Questionnaire-9 (PHQ-9). Suicidality was assessed using the Mini International Neuropsychiatric Interview (MINI), and the presence of suicide risk was defined as a MINI suicidality score ≥1. Stepwise logistic regression and mediation analyses using a two-stage regression method were performed. RESULTS: Of the 171 subjects (63.2% men) included, suicide risk was present in 38 subjects (22.2%). The stepwise logistic regression analysis identified four variables that were independently associated with suicide risk: higher PHQ-9 score, higher BAQ score, longer duration of epilepsy, and unemployment. The univariate analysis showed that ALS-18 and BIS-11 scores were significantly associated with suicide risk; however, they were backward eliminated from the logistic model according to the criterion of p > 0.1. The mediating effects of ALS-18 and BIS-11 scores on suicide risk via PHQ-9 scores (but not BAQ scores) were significant, with the proportion mediated 61.5% and 54.0% of the total effect, respectively. CONCLUSIONS: Alongside depressive symptoms, aggression may be a more useful concept than emotional instability and impulsivity for identifying suicidal risk in people with epilepsy.

Factors associated with sleep state misperception in patients with obstructive sleep apnea.

PURPOSE: Little is known regarding the prevalence of sleep state misperception and the factors related to this in patients with obstructive sleep apnea (OSA). METHODS: This retrospective study included patients with OSA defined by an apnea-hypopnea index (AHI) of ≥ 5 and used the Insomnia Severity Index (ISI), the Epworth sleepiness scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7. Underestimation and overestimation of sleep state perception were defined as < 80% and > 120%, respectively, of the ratio between subjective and objective total sleep time. An ISI score > 14 indicated clinically significant insomnia and an AHI ≥ 30 indicated severe OSA. A multinomial logistic regression was conducted with the category of sleep state perception as an outcome variable. RESULTS: Of the 707 patients with OSA, underestimation and overestimation of sleep state perception were noted in 22.5% and 10.6% of subjects, respectively. The median absolute differences (and percentages of the ratio) between subjective and objective total sleep time were 116 min (66.9%) and 87 min (127.3%) in the underestimated and overestimated perception groups, respectively. In the adjusted model, the underestimated group was more likely to have an ISI score > 14 (OR = 1.812, P = .006). The overestimated group was more likely to be older (OR = 1.025, P = .025) and has severe OSA (OR = 1.729, P = .035). CONCLUSIONS: There are two patterns of sleep state misperception in patients with OSA: underestimation associated with comorbid insomnia symptoms and overestimation associated with severe OSA. These findings enhance understanding of the pathophysiology of sleep state misperception in patients with OSA.

Clinical characteristics of periodic limb movements during sleep categorized by continuous positive airway pressure titration polysomnography in patients with obstructive sleep apnea.

PURPOSE: The presence of periodic limb movements during sleep (PLMS) varies among patients with obstructive sleep apnea (OSA) undergoing treatment with continuous positive airway pressure (CPAP). The factors associated with this variation are unknown. METHODS: PLMS were defined as a periodic leg movements index of > 15/h. Patients with OSA and PLMS were categorized into four groups depending on diagnostic and CPAP titration polysomnography (PSG). A multinomial logistic regression analysis was performed using a non-PLMS group as the reference category. RESULTS: This study included 861 patients with OSA who underwent a full-night CPAP titration PSG. The proportions of the subjects with PLMS on both PSGs (persistent PLMS), those with CPAP-emergent PLMS, and those with CPAP-resolved PLMS were 12.9%, 9.2%, and 3.9%, respectively. Compared with the non-PLMS group, the persistent group was more likely to be of older age and male sex and has a higher body mass index and restless legs syndrome (RLS). Patients in the CPAP-emergent group were also older and more likely to have RLS as well as more severe apnea. Patients in the CPAP-resolved group were more likely to be women, of older age, have a higher body mass index, but less severe apnea. CONCLUSIONS: PLMS elicited by CPAP are more likely to occur in older patients with more severe sleep apnea and comorbid RLS, whereas OSA patients in which PLMS resolve after CPAP are more likely to be women and have milder sleep apnea. Persistent PLMS share clinical characteristics with PLMS in general population.

Periodic limb movements during sleep are associated with poor health-related quality of life in patients with obstructive sleep apnea.

PURPOSE: The clinical significance of the comorbidity of periodic limb movements during sleep (PLMS) in sleep-disordered breathing remains unclear. This study aimed to determine whether or not the presence of PLMS is related to depressed mood and poor quality of life in subjects with obstructive sleep apnea (OSA). METHODS: We defined PLMS as a periodic leg movement index of > 15/h. Scores for the Medical Outcomes Study Short Form Health Survey and Beck Depression Inventory were assessed with multiple logistic or linear regression analyses. RESULTS: Of 1370 subjects with OSA, a prevalence of PLMS was 14.1%. Older age, men, and obesity were positively associated with PLMS. PLMS occurred in 17%, 15%, and 12% of mild, moderate, and severe subjects with OSA, respectively. Severe OSA was less likely to be associated with PLMS than mild OSA. PLMS negatively correlated with physical and mental component summary scores of the health survey but not with Beck Depression Inventory scores after controlling for confounding variables. PLMS were significantly associated with poor sleep architecture on polysomnography. However, the relationship between PLMS and disturbed sleep was no longer significant after adjusting for age. CONCLUSIONS: Health-related quality of life, including physical and mental health but not depressive symptoms, was worse in subjects with OSA and PLMS than in those without PLMS.

Physicians' attitudes toward driving by persons with epilepsy in Korea: 2009 versus 2017 survey.

PURPOSE: This study compared physicians' attitudes toward the fitness of persons with epilepsy to drive between 2009 and 2017 in Korea. METHODS: A questionnaire focusing on physicians' opinions about driving issues for persons with epilepsy was developed from literature reviews. Korean physicians were then surveyed anonymously via the online questionnaire in 2009 and in 2017. RESULTS: The numbers of valid respondents were 118 in 2009 and 160 in 2017. The majority of respondents were neurologists. The preferred criterion for eligibility to drive in both surveys was 2 years free from seizure (41.5% in 2009 and 45.6% in 2017). However, the minimum seizure-free criterion for driving eligibility declined between 2009 and 2017. The changes in attitudes toward driving were significant only among physicians who had more than 10 patients with epilepsy per week. However, the proportion of physicians who agreed with 6-month seizure freedom as a criterion for fitness to drive was lower in 2017 than in 2009. CONCLUSIONS: Although the preference of a 2-year seizure-free period as a criterion for fitness to drive did not change between 2009 and 2017, the minimum criterion for the seizure-free period did decline, particularly among physicians who had more than 10 patients with epilepsy per week in their clinic. The data support sustained efforts to promote education regarding aspects of epilepsy related to driving.

Felt stigma in seizure-free persons with epilepsy: Associated factors and its impact on health-related quality of life.

PURPOSE: We investigated felt stigma in seizure-free persons with epilepsy with regard to associated factors and its impact on health-related quality of life (HRQoL). METHODS: This cross-sectional study included 81 patients who had been seizure free for at least 2 years and 52 controls who had only had one seizure in the last 2 years. All patients completed the Stigma Scale, Quality of Life in Epilepsy Inventory-31 (QOLIE-31), short form of the Eysenck Personality Questionnaire-Revised (EPQ-RS), Hospital Anxiety Depression Scale (HADS), Rosenberg Self-esteem Scale, and the enacted stigma questionnaire. RESULTS: The proportion of felt stigma was not significantly different between controls (25%) and patients in seizure remission (21%). A stepwise logistic regression analysis revealed that enacted stigma and higher EPQ-RS Neuroticism scores were more likely to be associated with felt stigma of patients in remission. Quality of Life in Epilepsy Inventory-31 scores were significantly higher in patients in seizure remission than in controls. In the stepwise linear regression analysis, felt stigma was not associated with the total QOILE-31 scores. Sobel tests showed that felt stigma had indirect effects on the QOLIE-31 scores through EPQ-RS Neuroticism scores, but its statistical significance was lost after controlling for the presence of enacted stigma, anxiety, and depressive symptoms. CONCLUSION: One-fifth of seizure-free patients continued to feel stigmatized, even though they had not had a seizure in more than 2 years. Experience of enacted stigma and a neurotic personality trait were the most important correlates of felt stigma for these patients. Health-related quality of life was significantly better in patients in remission than in patients with rare seizures. Felt stigma was not a significant or independent factor associated with worse HRQoL in patients in remission.

Difficulties obtaining private insurance reported by persons with epilepsy in Korea.

PURPOSE: This study determined the proportion of persons with epilepsy (PWE) that possessed insurance policies and the difficulties they experienced in trying to obtain insurance in South Korea. METHODS: Persons with epilepsy and healthy control subjects were asked to complete a questionnaire in which they were asked if they had experienced problems obtaining four types of insurance, including life, medical indemnity, critical illness, and motor insurance. Insurance policies obtained before diagnosis of epilepsy were excluded in the analysis. RESULTS: This study included 106 adults with epilepsy and 87 healthy control subjects. The proportion of patients covered by at least one insurance type was significantly lower (54.7%) than that of controls (90.8%; p < 0.001). The proportions of patients insured did not differ according to freedom from seizures. Of 86 patients who tried to obtain insurance, 66% thought that it was much more difficult for them to obtain insurance than for those without epilepsy, and 48% had been refused one or more types of insurance because of their epilepsy. Difficulties in obtaining insurance differed depending on the types of insurance. Medical information about epilepsy was requested from 13% of patients. Of the insured patients, 71% did not disclose their epilepsy; 32% of these patients said it was because they were worried the insurance company would refuse to insure them. CONCLUSIONS: Persons with epilepsy reported that obtaining private insurance was very difficult for them in South Korea. The findings suggest that PWE per se are excluded from private insurance in South Korea and emphasize the need for an evidence-based individual risk assessment for PWE.

Neuroticism and extraversion affect health-related quality of life of persons with epilepsy independently from depression and anxiety symptoms.

PURPOSE: We determined whether neuroticism and extraversion are associated with health-related quality of life (HRQoL) independently from other psychological factors in persons with epilepsy. METHODS: This was a cross-sectional study of 357 adults with epilepsy. The Quality of Life in Epilepsy Inventory-31 (QOLIE-31), short form of the Eysenck Personality Questionnaire-Revised, Hospital Anxiety Depression Scale, Rosenberg Self-esteem Scale, and Stigma Scale for Epilepsy were used. A hierarchical linear regression analysis and Sobel test were performed. RESULTS: The final model explained 64.2% of the variance in the QOLIE-31. Demographic factors, entered in step 1 of the hierarchical linear regression, explained <1% of the variance. Social factors entered in step 2 and epilepsy-related factors in step 3 explained an additional 9.3% and 9.6% of the variance, respectively. Psychological factors, entered in the final step, explained 44.7% of the variance. Except for extraversion, all psychological factors assessed were independently associated with QOLIE-31 scores. When entered in step 1 of the regression analysis, neuroticism explained 36.1% of the variance, following only depression (49.0%) and anxiety (44.9%) according to the Hospital Anxiety Depression Scale. Both neuroticism (B = -0.264, p = 0.001) and extraversion (B = 0.189, p = 0.009) had indirect effects on QOLIE-31 scores mediated by depressive symptoms. CONCLUSIONS: Neuroticism is the third most important factor for HRQoL of persons with epilepsy, following depressive symptoms and anxiety. Both neuroticism and extraversion indirectly affect HRQoL through depressive symptoms.

Gender differences in factors associated with resilience for health-related quality of life in persons with epilepsy.

PURPOSE: We determined whether resilience factors such as self-efficacy, stress coping styles, and social support were differentially associated with health-related quality of life (HRQoL) in men and women with epilepsy after controlling for depression, anxiety, and daily-life stress. METHODS: This was a cross-sectional study of 129 adults with epilepsy. The Quality of Life in Epilepsy Inventory-31 (QOLIE-31), Epilepsy Self-Efficacy Scale, Way of Stress Coping Checklist, Social Support Scale, Beck Depression Inventory (BDI), Beck Anxiety Inventory, and Daily Hassles Scale were used. Stepwise linear regression analyses were performed. RESULTS: Except for medication effects, there were no gender differences in the QOLIE-31 and its subscales. The medication effects score was higher in men than in women after controlling for BDI scores. The BDI scores were independently associated with the QOLIE-31 score in men and women. Epilepsy self-efficacy was associated with the QOLIE-31 in men, whereas social support was associated with the QOLIE-31 in women. Coping strategies were associated with the QOLIE-31 in neither men nor women. Seizure frequency, daily-life stress, and anxiety were also negatively associated with the QOLIE-31, but only in men. The coefficients of determination were 0.637 and 0.587 in the men's and women's models, respectively. CONCLUSIONS: The influence of self-efficacy and social support on HRQoL differed between men and women with epilepsy even after controlling for psychological distress. These findings could contribute to the development of successful gender-specific psychosocial interventions to improve HRQoL in men and women with epilepsy.

Gender differences in seizure recurrence and antiepileptic drug polytherapy predicting health-related quality of life of persons 1 year after diagnosis of epilepsy.

PURPOSE: The aim of this study was to determine whether gender influences the prediction of health-related quality of life (HRQoL) in persons with newly diagnosed epilepsy (NDE). METHODS: This was a 1-year longitudinal study. Persons with NDE were assessed with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), the Hospital Anxiety Depression Scale (HADS), the Stigma Scale, and the Rosenberg Self-esteem Scale. An analysis of covariance (ANCOVA) with interaction terms was used. RESULTS: Among 134 adults with NDE, there were no gender differences in the scores of the QOLIE-31 and its subscales. A multivariate linear regression analysis showed that the HADS-anxiety scores at diagnosis (p = 0.005) and seizure recurrence after diagnosis (p = 0.050) negatively predicted QOLIE-31 scores in persons with NDE. There were significant effects of the gender interaction with seizure recurrence (F = 8.745, p = 0.004, partial eta2 = 0.066) and antiepileptic drug (AED) polytherapy (F = 6.320, p = 0.013, partial eta2 = 0.049) in the adjusted model. Specifically, seizure recurrence negatively predicted the QOLIE-31 scores only in men. By contrast, AED polytherapy negatively predicted the QOLIE-31 scores only in women. CONCLUSIONS: There are gender differences in certain epilepsy-related factors predicting HRQoL at 1 year in persons with NDE.

Factors associated with alexithymia in adults with epilepsy.

PURPOSE: The relationship between epilepsy and alexithymia, characterized by the inability to feel or express emotion, remains incompletely understood. We investigated alexithymia and its association with epilepsy-related factors in patients with epilepsy (PWE). METHODS: In this cross-sectional study, PWE and healthy control subjects were recruited. Alexithymia was assessed using the Toronto Alexithymia Scale-20 (TAS-20). The Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) were also administered to assess depression and anxiety, respectively. Mediation analysis was conducted using a two-stage regression method. RESULTS: Ninety adult PWE and 161 healthy control subjects were included in the study. PWE had significantly higher TAS-20 scores (B = 2.445, p = 0.014) than controls, but the prevalence of alexithymia, defined as TAS-20≥61, did not differ between PWE and control subjects after controlling for confounders (15.6% vs. 6.2%, respectively; p = 0.873). Uncontrolled seizures significantly increased alexithymia through depression (B = 3.536, p = 0.006), and this effect was responsible for 61.2% of the total effect on alexithymia. The direct effects of uncontrolled seizures on alexithymia were not significant. In contrast, AED polytherapy had significant direct effects on alexithymia (B = 4.489, p = 0.037) independent of depression. The indirect effects of AED polytherapy via depression did not reach statistical significance (B = 2.371, p = 0.066). CONCLUSIONS: Alexithymia was more severe, but not more prevalent, in PWE than in healthy controls. AED polytherapy was directly associated with alexithymia, while uncontrolled seizures were indirectly related to alexithymia through depressive symptoms.