By Hai Chen, MD, PhD
Synopsis: In this systematic review and meta-analysis, the prevalence of most psychiatric disorders was significantly higher in persons with epilepsy than in those without epilepsy. These findings show the high burden of psychiatric comorbidities in persons with epilepsy and underscore the importance of appropriately identifying and treating psychiatric comorbidities in epilepsy patients.
Source: Kwon CS, Rafati A, Ottman R, et al. Psychiatric comorbidities in persons with epilepsy compared with persons without epilepsy: A systematic review and meta-analysis. JAMA Neurol. 2024; Nov 25:e243976. doi: 10.1001/jamaneurol.2024.3976. [Online ahead of print].
Many psychiatric disorders have been found to occur in persons with epilepsy (PWE). This systematic review and meta-analysis aimed to estimate the prevalence of common psychiatric disorders in PWE. The authors systematically reviewed epidemiological studies examining the occurrence of psychiatric disorders among PWE compared with persons without epilepsy (PWOE). Three databases were queried: MEDLINE, Embase, and PsycINFO, using main search terms including epilepsy, psychiatric comorbidity, mental health, and specific psychiatric disorders.
Among 10,392 records identified through the systematic search, 27 studies were included in the final analysis, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses reporting guidelines. A risk of bias evaluation showed both good quality (n = 17) and fair quality (n = 10) studies, involving 565,443 PWE and 13,434,208 PWOE.
Anxiety disorders were reported in 15 studies, including in 174,378 PWE and in 6,094,835 PWOE. The pooled analysis showed a higher prevalence of anxiety disorders in PWE than in PWOE (8.4% vs. 5.7%; odds ratio [OR], 2.11). In the subgroup analysis, there was a higher prevalence of anxiety disorders in PWE than in PWOE when determined by either structured clinical interview using a questionnaire (24.6% vs. 8.1%; OR, 2.43) or administrative databases (8.3% vs. 5.7%; OR, 2.01).
For each anxiety disorder, a significantly higher prevalence of generalized anxiety disorder (10.7% vs. 4.9%; OR, 2.34) and specific phobia (11.2% vs. 6.1%; OR, 1.73) was observed in PWE compared with PWOE. However, no significant difference was observed in the prevalence of social phobia or agoraphobia between the two groups.
Sixteen studies, involving 417,208 PWE and 10,870,521 PWOE, reported depression. The prevalence of depression was significantly higher in PWE than in PWOE (13.7% vs. 9.3%; OR, 2.45). A significantly higher prevalence of bipolar disorder among PWE compared with PWOE also was observed (1.2% vs. 1.1%; OR, 3.12) in pooled analysis in 60,816 PWE and 2,200,233 PWOE from four studies.
A higher prevalence of suicidal ideation was found in PWE than in PWOE, from three studies including 500 PWE and 43,952 PWOE (20.0% vs. 11.7%; OR, 2.25). However, there was no significant difference in prevalence in suicide attempt between PWE and PWOE.
The pooled analysis, including 151,235 PWE and 4,404,204 PWOE in eight studies, showed a significantly higher prevalence of any psychotic disorder in PWE than in PWOE (14.8% vs. 6.3%; OR, 3.98).
Schizophrenia was reported in six studies, accounting for 147,677 PWE and 4,665,066 PWOE. A higher prevalence of schizophrenia also was observed in PWE than in PWOE (3.3% vs. 0.9%; OR, 3.72).
Obsessive-compulsive disorder (OCD) was reported in two studies and was compared between 5,928 PWE and 1,042,880 PWOE. The prevalence of OCD was significantly higher in PWE than in PWOE (0.4% vs. 0.1%; OR, 2.71). In two studies involving 2,039 PWE and 1,036,037 PWOE, post-traumatic stress disorder was significantly more frequent in PWE than in PWOE (5.6% vs. 3.7%; OR, 1.76).
Three studies accounting for 59,162 PWE and 1,178,543 PWOE reported eating disorders. The meta-analysis indicated that eating disorders were significantly more prevalent in PWE than in PWOE (1.2% vs. 0.7%; OR, 1.87).
Alcohol use disorders were studied in three subsections: alcohol misuse, alcohol abuse, and alcohol dependence. Alcohol misuse and alcohol dependence were reported in six and two studies, respectively. The pooled analysis showed that the prevalence of alcohol misuse or alcohol dependence was significantly higher in PWE compared with PWOE (6.8% vs. 2.6%; OR, 3.64 and 3.3% vs. 1.1%, respectively; OR, 4.94). However, there was no significant difference in the prevalence of alcohol abuse between PWE and PWOE.
A significantly higher prevalence in substance use disorders also was observed in PWE than in PWOE (6.4% vs. 5.2%; OR, 2.75). Autism spectrum disorder was reported in six studies (7,941 PWE and 1,192,423 PWOE) and the prevalence was significantly higher in PWO than in PWOE (10.9% vs. 1.0%; OR, 10.67).
Finally, a pooled analysis of six studies (27,862 PWE and 3,024,942 PWOE) showed a significantly higher prevalence of attention-deficit/hyperactivity disorder in PWO than in PWOE (13.0% vs. 3.4%; OR, 3.93).
Commentary
This meta-analysis study included 27 studies, involving more than a half-million PWE and more than 13 million PWOE. PWE have higher odds of experiencing multiple psychiatric disorders than PWOE. Shared risk factors encompassing neurobiology, psychosocial aspects, bidirectional influences, medication effects, and common genetic predispositions may account for the findings. Further investigation of underlying reasons is warranted.
The presence of psychiatric disorders in PWE has a further negative effect on activities of daily life in PWE and their families. These findings expand our knowledge of psychiatric disorder comorbidities in PWE and help to improve the quality of healthcare for PWE.
Hai Chen, MD, PhD, is Assistant Professor of Clinical Neurology, Weill Cornell Medical College.
In this systematic review and meta-analysis, the prevalence of most psychiatric disorders was significantly higher in persons with epilepsy than in those without epilepsy. These findings show the high burden of psychiatric comorbidities in persons with epilepsy and underscore the importance of appropriately identifying and treating psychiatric comorbidities in epilepsy patients.
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