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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 144-152

Psychiatric morbidity and its impact on quality of life in patients with epilepsy: A cross-sectional study


1 Department of Psychiatry, PGIMS, Rohtak, Haryana, India
2 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission06-Jun-2021
Date of Acceptance26-Jun-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_132_21

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  Abstract 


Aim: The aim of this study is to evaluate the prevalence psychiatric comorbidities by using a structured diagnostic instrument and it impact on quality of life among patients with idiopathic epilepsy. Methodology: Using a cross-sectional study design, 120 patients with idiopathic epilepsy were assessed for psychiatric morbidity by using MiniInternational Psychiatric Interview-PLUS version for psychiatric morbidity and Quality of life in Epilepsy-31 scale. In addition, all the patients were also assessed on Beck Depression Inventory-II and generalized anxiety disorder-7 (GAD-7) to rate the severity of depressive and anxiety symptoms, respectively. Results: The present study showed that the prevalence of current and lifetime psychiatric diagnosis as per Mini International Neuropsychiatric Interview-PLUS is 68.3% and 75%, respectively. Among various psychiatric disorders, depressive disorders were the most common (54.16%), followed by GAD (8.3%). In terms of severity of depressive symptoms, 10.8% patients had mild depression, 25.8% moderate depression, and 14.2% had severe depression. On GAD-7, 28.3% were found to have mild, 15% had moderate and 15.8% had severe anxiety. Psychiatric morbidity both current and lifetime was associated with poorer quality of life in all the domains. Conclusion: Psychiatric morbidity is highly prevalent in patients with epilepsy and it has significant negative impact on the quality of life. These findings suggest that there is a need for close liaison between the psychiatrist and the neurologist to address psychiatric issues among patients with epilepsy.

Keywords: Idiopathic epilepsy, psychiatric disorders, quality of life


How to cite this article:
Malik YK, Mattoo SK, Kharbanda PS, Grover S. Psychiatric morbidity and its impact on quality of life in patients with epilepsy: A cross-sectional study. J Mental Health Hum Behav 2021;26:144-52

How to cite this URL:
Malik YK, Mattoo SK, Kharbanda PS, Grover S. Psychiatric morbidity and its impact on quality of life in patients with epilepsy: A cross-sectional study. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Jun 26];26:144-52. Available from: https://www.jmhhb.org/text.asp?2021/26/2/144/337161




  Introduction Top


Epilepsy is the world's most common serious neurological disorder, affecting approximately 50 million individuals worldwide, with 25% unable to have adequate control of seizures despite taking treatment.[1] Psychiatric comorbidities or neuropsychiatric symptoms are quite frequently reported in patients with epilepsy. Studies suggest that psychiatric disorders are the most common comorbid disorders among patients with epilepsy. Further, it has been seen that psychiatric diagnoses were the only comorbid illnesses which figured among the top five comorbidities for all age groups.[2] These comorbidities assume greater importance as epidemiological data show that psychiatric comorbidity is associated with impaired function and quality of life.[3]

Actual prevalence rates for psychiatric illnesses in epilepsy patients are unclear, due to differences in sampling and diagnostic strategies and the heterogeneity of epilepsy syndromes. Among the various psychiatric disorders, mood disorders are the most common psychiatric disorders noted in subjects with epilepsy. Different studies have estimated the prevalence of mood disorders to vary from 24% to 74%, with an average of 30%. Anxiety disorders account for 10%–25% of psychiatric comorbidities. Other psychiatric disorders such as psychoses (2%–7%) and personality disorders (1%–2%) have lower prevalence rates, when compared to mood and anxiety disorders. Other comorbidities, i.e., aggressive behavior, pseudoseizures, comorbid alcohol and drug abuse, and potential psychiatric effects of antiepileptic drugs (AEDs) are also seen in patients with epilepsy.[4] A review of population-based studies suggested that compared to controls, the prevalence of depression (17.4% vs. 10.7%), anxiety disorders (22.8% vs. 11.2%), suicidal ideations (5.0% vs. 13.3%), and other psychiatric disorders (35.5% vs. 20.7%) are more common among patients with epilepsy.[5]

Higher prevalence of depression among persons with epilepsy has been found to be associated with various factors. Older studies reported that severity, type of epilepsy, type of AED, and controlled/drug resistant nature of epilepsy affect the prevalence of depression in persons with epilepsy. In terms of type of epilepsy, some of the studies have shown that the prevalence of depression is higher among patients with temporal lobe epilepsy and this finding provides credence to the view that the location of epileptogenic focus/type of epilepsy shares something biological to cause more depression, but these findings have not been replicated with uniform consistency by all studies.[6] However, recent studies have not found similar links and it is suggested that this question needs more scientific studies and examination in future.

The research from India on the prevalence of psychiatric comorbidity in patients with epilepsy is limited. Studies which have used DSM-IV or MiniInternational Neuropsychiatric Interview (MINI) to make the diagnosis of a psychiatric disorder and have reported the prevalence ranging from 28.7% to 52%.[7],[8],[9] Common psychiatric disorders in these studies included anxiety disorders followed by depressive disorders.[10] The presence of psychiatric disorders has been shown to be associated with poor functionality, high expressed emotions,[11] poor quality of life[12] longer duration of seizures, increased frequency of seizures, recent recurrence of seizures,[13] anticonvulsant polypharmacy, poor compliance with medications, and family history of seizures.[14] Although many studies have evaluated the prevalence of psychiatric disorders in patients with epilepsy, very few studies have evaluated psychiatric morbidity by using structured instruments by a psychiatrist. There is the limited data on quality of life of patients with epilepsy and no study has evaluated the impact of psychiatric morbidity on the quality of life. In this background, this study aimed to evaluate the prevalence of axis-I psychiatric comorbidities and it impact on quality of life among patients with idiopathic epilepsy.


  Methodology Top


This cross-sectional study was conducted at a tertiary care multispecialty teaching hospital. All the participants were recruited after obtaining written informed consent. The study was approved by the ethics committee of the institute. Purposive sampling was be used to recruit the study population during the period of January 2016 to December 2016. To be included the study, the participants were required to fulfil the diagnosis of idiopathic epilepsy,[15] of at least 1 year duration and aged 16–50 years. Patients who were too severely ill to cooperate for the interview, psychiatric morbidity preceding the onset of epilepsy, diagnosis of intellectual disability, and patient currently not on antiepileptic medicines were not recruited.

All the patients with clinical diagnosis of epilepsy, attending the outpatient services or admitted to the inpatient unit of neurology services were approached. They were explained about the nature of the study and written informed consent was obtained. Those fulfilling the selection criteria were assessed on MINI for the presence of psychiatric comorbidity. Those patients diagnosed to have depression and anxiety as per MINI PLUS[16] were further assessed for severity of depression and anxiety by using Beck Depression Inventory-II (BDI-II)[17] and generalized anxiety disorder-7 (GAD-7),[18] respectively. Quality of life was evaluated by using Quality of life in Epilepsy (QOLIE-31).[19]

Participants were assessed on: MiniInternational Neuropsychiatric Interview PLUS

The MINI-PLUS is a structured interview designed to make the diagnosis of various psychiatric disorders in DSM-IV and ICD-10. It is divided into modules corresponding to diagnostic categories.[16] MINI has been shown to have high validity and reliability in studies comparing the same with the Structured Clinical Interview for DSM-III-R: patient version (SCID) and the Composite International Diagnostic Interview for ICD-10.

Beck depression inventory-II for assessing severity of depression

The 21-item self-report instrument is used to assess the severity of depression. Each item is rated on a four point scale (0–3), with scores of 14–19, 20–28, and 29–63 suggestive of mild, moderate, and severe depression, respectively.[17] The patients diagnosed with depression as per MINI-PLUS were administered BDI-II to assess the severity of depression.

Generalized Anxiety Disorder 7

It is a 7-item scale, used for screening and assessment of severity of GAD. Severity is assessed by adding the scores of all the items.[18]

Descriptive analysis was carried out using mean, standard deviation (SD), and range for continuous variables. Discontinuous variables were assessed in the form of frequency and percentages. Those with and without psychiatric comorbidities were compared using t-test and Chi-square test.

Quality of life in Epilepsy-31

This is a epilepsy specific QOL inventory. It has seven domains: worry about seizure, overall quality of life, emotional well-being, energy-fatigue, cognitive functioning, medication effects, and social functioning. The overall score ranges from 1 to 100; a higher score indicates higher QOL.[19]

Brief Psychiatric Rating Scale

It is a 18-item scale, which has been designed to assess psychotic and nonpsychotic symptoms. Each of the 18 items are rated on a scale of 1–7, yielding a range of 18–126.[20] It is meant to be used by a trained clinician as a semi-structured interview, and the rating is done on the basis of observed behavior of the patient and interactions over the preceding 2–3 days.

Descriptive analysis was carried out using mean, standard deviation (SD), and range for continuous variables. Discontinuous variables were assessed in the form of frequency and percentages. Those with and without psychiatric comorbidities were compared using t-test and Chi-square test.


  Results Top


The present study included 120 patients, with a mean age of the study sample was 29.3 (SD-8.83; range: 17–48) years and mean duration of education was 11.17 (SD-3.85; range: 0–20) years. Males (55.8%) outnumbered the females (44.2%). Those educated beyond matric outnumbered the subjects educated less than matric (47.5%). Currently, single (49.2%) and currently married (51.8%) participants had nearly equal distribution. More than half of the participants were Hindu by religion (64.2%), came from extended/joint family (60.8%), and lower socioeconomic status (55%).

The mean age of onset of epilepsy of 17.09 (SD-6.9) years, a mean duration of illness of 11.99 (SD-7.5) years, and a mean duration of treatment at the time of assessment for this study of 10.50 (SD-7.32). Only a few patients (14.2%) had comorbid physical illnesses and a family history of epilepsy (18.3%). The mean number of lifetime episodes of seizures was 71.62 (SD-120.3) with a median of 30. The mean number of episodes in the last 6 months was 2.33 (SD-3.81) with a median of 1.00. Status epilepticus and episodes while driving were reported by 10% and 5.8% patients, respectively. Epileptic episodes in public were reported by 71.7% patients with a mean of 7.09 episodes (SD: 17.51; median: 3.00). The mean number of hospital visits in previous 3 months were 1.82 (SD-1.12) and medications were supervised by someone at home for 55% patients [Table 1].
Table 1: Clinical profile of study sample

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In terms of type of antiepileptic medication, Valproate (49.17%) was the most commonly used antiepileptic, followed by Levetiracetam (26.7%) and Phenytoin (22.5%) and The mean doses (mg per day) were Phenytoin 300 (SD-79.66), Valproate 903.39 (SD: 274.15), and Levetiracetam 1156.25 (SD: 340.48). More than one antiepileptic medication was being used by 38.33% patients [Table 2].
Table 2: Treatment profile (n=120)

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As per the assessment on MINI-PLUS, three-fourth (75%) of the study sample fulfilled at least one lifetime psychiatric diagnosis, while 68.3% had a current psychiatric diagnosis. In terms of Axis-I diagnosis, 59.2% patients had at least one current diagnosis other than the substance use disorders and 15.8% had a diagnosis of substance use disorders. More than one psychiatric diagnosis, including substance use disorders, was present in 16.7% patients. Among various psychiatric disorders, depressive disorders were the most common (54.16%), followed by GAD (8.3%). Fewer patients had agoraphobia, psychosis, specific phobia, and socialphobia. Among the depressive disorders, the most common diagnosis was that of major depressive disorder (35%), followed by recurrent depressive disorder (8.3%) [Table 3].
Table 3: Psychiatric diagnosis as per mini international neuropsychiatric interview PLUS

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Severity of depressive, anxiety, and psychotic symptoms

Irrespective of the psychiatric diagnosis, all the study participants were rated on BDI, GAD GAD-7, and Brief Psychiatric Rating Scale (BPRS). The mean scores were BDI 16.43 (SD-10.84), GAD-7 7.33 (SD-5.67) and BPRS 27.08 (SD-10.40). As per BDI, the depression was moderate in 25.8% patients, and as per GAD-7, anxiety was mild in 28.3% [Table 4].
Table 4: Severity of depressive, anxiety and psychotic symptoms

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The mean quality of life score was the highest for the overall quality of life and this was followed by the domains of cognitive impairment, emotional well-being, medication side effects, social function, and least score was noted for the domain of seizure worry [Table 4].

For further analysis, the study sample was further divided into those with (n = 90) and without (n = 30) lifetime psychiatric diagnosis and those with current psychiatric diagnosis including substance use disorders (n = 82) and patients without (n = 30) lifetime psychiatric diagnosis.

When the sociodemographic and clinical profile of those with and without lifetime psychiatric disorders were compared, no significant difference was seen between the two groups, except for the fact that those with lifetime psychiatric diagnosis were more often male (P = 0.04), had significantly higher lifetime episodes of epilepsy (P < 0.001), higher number of episodes in last 6 months (P < 0.001), higher proportion of them had more than one episode in a single day (P < 0.001) and had episodes in public (P = 0.035) and had higher number of episodes in the public place (P = 0.002) [Table 5]. In terms of type and dose of antiepileptic medications, the patients with lifetime psychiatric diagnosis weremore often receiving clobazam (P = 0.001) and higher proportion of them were receiving more than one antiepileptic medications (P < 0.001). In terms of dose of antiepileptic medications, compared to those without psychiatric, those with psychiatric diagnosis were receiving higher doses of valproate (P = 0.009) and were receiving higher number of antiepileptic medications (P < 0.001) [Table 5]. Compared to patients without lifetime psychiatric diagnosis those with lifetime psychiatric diagnosis had significantly higher BDI score, GAD-7 score and BPRS total score, scores in the domains of affect, negative symptom and activation. Compared to patients without lifetime psychiatric diagnosis those with lifetime psychiatric diagnosis had poorer quality of life in all the domains of epilepsy quality of life scale.
Table 5: Significant differences between patients with and without lifetime psychiatric morbidity as per mini international neuropsychiatric interview PLUS

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When patients with current psychiatric diagnosis were compared with those without lifetime psychiatric disorders, no significant differences emerged except for the fact that those with lifetime psychiatric diagnosis were more often male, higher number of lifetime episodes of epilepsy, higher proportion of them had more than one episode in a single day, had episodes in public places, had higher number of episodes in public places and had more number of hospital visits in previous 3 months, were more often receiving - clobazam, higher proportion of them were on more than one antiepileptic medication, were receiving higher doses of valproate, higher mean number of antiepileptic medications, had significantly higher BDI score, GAD-7 score and BPRS total score, scores in the domains of affect, negative symptom, and activation domains of BPRS [Table 6]. Compared to patients without lifetime, psychiatric diagnosis those with current psychiatric diagnosis had poorer quality of life in all the domains of epilepsy quality of life scale.
Table 6: Significant differences between patients with current psychiatric diagnosis including substance use disorders and those without lifetime psychiatric morbidity as per MiniInternational Neuropsychiatric Interview PLUS

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  Discussion Top


Although psychiatric disorders are reported to have the high prevalence among persons with epilepsy, the prevalence varies widely across different studies. As it is not feasible for every person with epilepsy to be evaluated by a psychiatrist, researchers have mainly used screening instruments to assess psychiatric morbidity and very few studies have relied on the use of structured diagnostic interviews.[16] Further, the studies which have assessed the psychiatric morbidity using screening instruments have focused on only one or two disorders and have not assessed the whole spectrum of the psychiatric disorders in persons with epilepsy.[17],[18]

Knowledge about the prevalence of psychiatric comorbidities and its impact on quality of life among persons with epilepsy can help in understanding the role of mental health professionals among persons with epilepsy and providing holistic care to these patients. Accordingly, this study relied on the assessment of psychiatric morbidity by using MINI-PLUS by a mental health professional. Many studies have assessed quality of life among persons with epilepsy; however, data on QOL by using a disease specific QOL scale QOLIE-31 is limited. Assessment on MINI-PLUS involved assessment of both current and lifetime disorders which had an onset after the onset of epilepsy. Patients with psychiatric disorders having onset before onset of epilepsy were excluded from the study cohort, to ensure that all the psychiatric morbidity assessed as part of this study, could be a true reflection of psychiatric morbidity, which is associated with epilepsy. Assessment of quality of life by using disease specific scale can provide a better information about impairment of quality of life and impact of psychiatric morbidity on the same.

The demographic profile of the participants in the present study is similar to earlier studies which have evaluated patients with epilepsy from India and other parts of the world.[21],[22],[23],[24] Hence, the study sample can be considered representative of patients attending this hospital with epilepsy.

In the present study, three-fourth of the study sample fulfilled at least one lifetime psychiatric diagnosis, with 68.3% having a current psychiatric diagnosis. In terms of Axis-I diagnosis, 59.2% patients had at least one current diagnosis other than the substance use disorders and 15.8% had an independent or comorbid diagnosis of substance use disorders. More than one psychiatric diagnosis, including substance use disorders, was present in 16.7% patients.Among the various psychiatric disorders, depressive disorders were the most common (54.16%), followed by GAD (8.3%). Fewer patients had agoraphobia (7.5%), psychosis (3.3%), specific phobia (1.6%), and social phobia (0.8%). Among the depressive disorders, the most common diagnosis was that of major depressive disorder (35%), followed by recurrent depressive disorder (8.3%). When the findings of the present study are compared with the existing literature, certain similarities are apparent. Previous studies have estimated the prevalence of mood disorders to vary from 24% to 74%, with an average of 30%.[4],[5],[25] Anxiety disorders account for 10%–25% of psychiatric comorbidities.[26] Other psychiatric disorders such as psychoses (2%–7%) and personality disorders (1%–2%) have lower prevalence rates, when compared to mood and anxiety disorders. Other comorbidities, i.e., aggressive behavior, pseudoseizures, comorbid alcohol and drug abuse, and potential psychiatric effects of AEDs are also seen in patients with epilepsy.[27] A systematic review and meta-analysis of 58 studies estimated the pooled prevalence rate of psychosis in epilepsy to be 5.6% (95% confidence interval: 4.8–6.4).[28] The prevalence of depressive, anxiety, and psychotic disorders observed in the present study is in the reported range. These findings suggest that there is a need to screen all patients with epilepsy for psychiatric morbidity. Further, the clinicians managing patients with epilepsy should evaluate these patients for depression from time to time and manage depression by using appropriate strategies. Such clinicians should be well versed with the diagnostic criteria of depression, available screening instruments, and they must be encouraged to use the screening instruments routinely. There is also a need to establish a good liaison with the psychiatric services to manage these patients adequately. For mental health professionals, it is important to develop management strategies for the management of depression in patients with epilepsy. Many of the antidepressants used in clinical practice can lower seizure threshold and also lead to electrolyte imbalance, especially hyponatremia in vulnerable subjects. These can have catastrophic effect on persons with epilepsy. Hence, a cautious approach is required while choosing antidepressants and there is a need for close monitoring, especially for recurrence of seizure and electrolyte imbalance. There is also a need for conducting randomized controlled trials or open-label studies to evaluate the efficacy/effectiveness of antidepressants in patients with epilepsy, so that safety issues about the use of antidepressants can be addressed.

Irrespective of the psychiatric diagnosis, all the study participants were rated on BDI, GAD GAD-7, and BPRS. As per BDI with a cutoff of 14, the depression was moderate in 25.8% of patients, severe in 14.2% of cases and mild in 10.8% of cases. Previous studies which have used BDI among patients with epilepsy have also reported similar prevalence rate of depression and severity.[29],[30] The prevalence of moderate-to-severe depression in about 40% of patients suggests that a significant proportion of persons with epilepsy have depression which requires clinical attention.

In the present study when patients with and without lifetime psychiatric disorders, with and without current psychiatric disorders (with or without concomitant substance use disorders) were compared, no significant difference was observed in terms of demographic profile except for the fact that psychiatric morbidity was more common among males. Previous studies which have evaluated risk factors for psychiatric morbidity has also in general have not reported any association with the demographic factors except for low socioeconomic status and low educational level.[31] However, in the present study, these associations were not observed. Higher prevalence of psychiatric morbidity in male patients, as observed in the present study requires further evaluation.

In the present study among the various clinical variables, the factors which were consistently associated with psychiatric morbidity in various comparisons or were present in one or two comparisons were total number of lifetime episodes, having more than one episode in a single day, higher number of episodes in the last 6 months, having episodes in the public places, having higher number of episodes in public places, higher number of hospital visits, use of more than one antiepileptics, use of clobazam, and higher side effects of antiepileptic medications. Previous studies which have evaluated risk factors for psychiatric morbidity among patients with epilepsy have reported association with age at onset of epilepsy, duration of the disorder, difficulties in adjustment to the consequences of the illness, fear of seizures, social stigma, overprotection by families, legal limitations (i.e., driving regulations), low self-esteem, neuropathological damage to areas connected with psychic functioning (i.e., amygdala, limbic system, frontal cortex, and basal ganglia), emotional and cognitive side effects of AEDs and forced normalization.[31] Studies from India have linked psychiatric disorders among people with epilepsy with poor functionality, high expressed emotions, poor quality of life, longer duration of seizures, increased frequency of seizures, recent recurrence of seizures, anticonvulsant polypharmacy, poor compliance with medications, and family history of seizures.[3],[32],[33],[34],[35] Studies which have evaluated factors associated with depression in persons with epilepsy have reported severity, type of epilepsy, type of AED, and controlled/drug resistant nature of epilepsy affect the prevalence of depression in persons with epilepsy. However, these findings have not been consistently shown by all studies uniformly.[6],[36] Some of the findings of the present study, i.e., association of psychiatric morbidity with anticonvulsant polypharmacy, higher number of lifetime episodes, more number of episodes in last 6 months, and more severe illness (suggested by presence of higher number of episodes in lifetime and last 6 months, use of more than one epileptic) are in concurrence with the existing literature.[37] Other associations like having episodes in the public places, having higher number of episodes in public places and higher number of hospital visits, can be understood from the perspective of stigma and low self-esteem which have shown to be associated with psychiatric morbidity.

The present study suggests that psychiatric morbidity is associated with poor quality of life. There is limited data on such association.[38] The present study expands such data and suggests that the management of psychiatric morbidity should be part and parcel of management of epilepsy to improve the overall outcome of patients with epilepsy.

The present study has certain limitations. The study sample was relatively small, and the study was limited to a clinic attending population. Accordingly, the findings cannot be generalized to community sample. The present study did not evaluate other psychiatric aspects like impact of epilepsy on personality. The study also did not evaluate other symptoms/disorders such as sleep disturbances/sleep disorders, which have close association with both psychiatric morbidity and also epilepsy. The present study did not evaluate the relationship of psychiatric morbidity with different types of epilepsy. Future studies must attempt to overcome the limitations of the present study.


  Conclusion Top


To conclude, the present study suggests that three-fourth of the patients with epilepsy have a lifetime psychiatric diagnosis, with two-third having a current psychiatric diagnosis. Among the various psychiatric diagnoses, depressive disorders form the largest diagnostic category, seen in more than half of the patients with epilepsy. Anxiety disorders form the second largest diagnostic category and few patients had psychosis. About one-sixth of the patients also used alcohol and/or tobacco. Psychiatric morbidity, both current and lifetime, are associated with poor quality of life. These findings suggest that there is a need for close liaison between the psychiatrist and the neurologist to address psychiatric issues among patients with epilepsy. Clinicians dealing with patients with epilepsy must be made aware of the high psychiatric morbidity, must be trained to screen patients for various psychiatric disorders and cognitive dysfunction. Mental health professionals working in consultation-liaison psychiatry set-up need to evaluate various pharmacological and nonpharmacological treatments among patients with epilepsy for effectiveness and must develop treatment modules, to help patients with epilepsy with comorbid psychiatric disorders to improve quality of life of patients with epilepsy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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