Original Article

Journal of Child Neurology

1-7
Mental Health of Adolescents With Epilepsy ª The Author(s) 2020
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in Enugu, Nigeria: A Cross-Sectional Study DOI: 10.1177/0883073820954060
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Chukwubike Onyebuchi Nnajekwu, MBBS, FMC Paed1 ,

Uchenna Chiagoziem Nnajekwu, MBBS, FMC Paed1 ,
Nnaemeka Anthony Ikefuna, MBBS, FMC Paed, FRCP1,2, and
Chinyelu Ngozi Ojinnaka, MBBS, FWACP, MPH1,2

Abstract
Adolescence is an important period, marked by significant changes in biological and psychosocial domains. Epilepsy is a chronic
neurologic disorder associated with social stigma and prejudice. The etiology of depression in epilepsy appears to be a complex
interplay between psychosocial and neurobiologic factors. This period may be too taxing for the adolescent with epilepsy to steer,
as epilepsy can affect the development of independence by its social, educational, and mental health effects. The study aimed to
compare the burden of depression in adolescents with epilepsy with the general population.
One hundred forty-five adolescents with epilepsy and their classmates matched for age and gender were studied over a
9-month period. Zung Self-rating Depression Scale was used to determine the burden of depression in the study population.
Among the subjects, 70 (48.3%) had scores in the depressive range to varying degrees compared to 38 (26.2%) controls. The
difference in scores was significant (OR¼2.628, P < .001). Among the population with positive scores, mild depression category
was the commonest for both groups (40% and 22.8%, respectively). There was a statistically significant relationship between
gender, seizure type, and depression, whereas there was no significant relationship between age, social class, number of anti-
epileptic drugs, seizure frequency in the last 12 months, and depression.
Adolescents with epilepsy had higher rates of depression than the general population. Hence, there might be need for routine
screening of adolescents with epilepsy for early detection and management of depression to improve their overall well-being and
quality of life.

Keywords
epilepsy, seizures, adolescents, depression, mental health problems

Received May 9, 2020. Received revised July 19, 2020. Accepted for publication August 7, 2020.

Epilepsy is a chronic disease characterized by recurrent sei-
zures and is the most common neurologic disease seen in most
pediatric neurology clinics in the developing countries.1 Epi-
lepsy is sometimes associated with various forms of psychiatric
disturbances, of which depression is the most frequent, with a
prevalence of 10% to 30% in children and adolescents with
epilepsy.2
Adolescence is a developmental period during which issues
such as self-image and worries about the future emerge and
stress from any chronic disease often results in psychiatric and
personality disorders.3 There is a high level of emotional dis-
tress and turmoil during this period.4
The etiology of depression in epilepsy appears to be a com-
plex interplay between psychosocial and neurobiologic factors.
Chronic stress arising from the unpredictability of the seizures
and stigmatization associated with epilepsy are key factors in
the etiology of depression, especially in adolescents.3 Chronic
stress leads to uncontrolled release of corticosteroids, with loss
of negative feedback from the hypothalamo-pituitary-
adrenocortical axis.5 This could make the hippocampus vulner-
able to damage by metabolic or neurotoxic agents as has been
observed in some patients with major depression and post-
traumatic stress disorder.6 In addition, some antiepileptic drugs
like levetiracetam are important neurobiologic risk factors.7
These factors, coupled with the stress of adapting to the biolo-
gical and psychosocial changes that characterize adolescence
1
University of Nigeria Teaching Hospital, Enugu, Nigeria
2
College of Medicine, University of Nigeria, Nsukka, Nigeria
Corresponding Author:
Chukwubike Onyebuchi Nnajekwu, MBBS, FMC Paed, University of Nigeria
Teaching Hospital, Enugu 400001, Nigeria.
Email: cnnajekwu@gmail.com
2 Journal of Child Neurology XX(X)

may be too much for the adolescent with epilepsy to handle. Table 1. Sociodemographic Characteristics of the Study Population.
Depression and the chronicity of epilepsy, increase the morbid-
Subjects, Controls,
ity and mortality associated with the disease.8 n (%) n (%) Chi-square P Value
Most of the available studies on depression in epilepsy
involve children and young adults, not necessarily adolescents. Gender
It is therefore necessary to evaluate adolescents with epilepsy Male 82 (56.6) 82 (56.6) 0.000 >.99
for these mental health problems, in order to detect these early Female 63 (43.4) 63 (43.4)
Age groups
and offer adequate and necessary interventions that may
Early adolescent 61 (42.1) 61 (42.1) 0.000 >.99
include psychotherapy and antidepressants. This will improve Mid adolescent 57 (39.3) 57 (39.3)
the overall well-being, quality of life, and mortality of these Late adolescent 27 (18.6) 27 (18.6)
children. Socioeconomic class
The study aimed to determine the prevalence of depression Lower 29 (20.0) 14 (9.7) 8.415 .015*
in adolescents with epilepsy and compare with controls. Middle 47 (32.4) 41 (28.3)
Upper 69 (47.6) 90 (62.1)
*Statistically significant.
Materials and Methods
The study was cross-sectional and hospital based, carried out between Depression Scale index of 50 to 59 indicates mild depression, 60 to
January and September 2016 at the Paediatric Neurology clinic of 70 indicates moderate depression, and an index greater than 70 indi-
University of Nigeria Teaching Hospital (UNTH), Enugu. The study cates severe depression.10 The Zung Self-rating Depression Scale was
population consisted of adolescents with epilepsy who have been on used to assess the mental health of the study participants for the
follow-up at the clinic for at least 1 year, whereas the controls were following reasons: it offers early identification of individuals at poten-
classmates of the subjects who were age and gender matched with tially high risk for depression, it is brief, and as such can be adminis-
them. The controls had no chronic illness, including epilepsy. Ado- tered as part of a routine clinical visit, and it can also be easily
lescents with other neurologic conditions other than epilepsy were administered by clinicians, support staff, and patients with little train-
excluded from the study. Approval was obtained from the Health ing. The adolescents who were screened to be depressed were coun-
Research Ethics Committee before commencement of the study. selled, further assessed, and in some cases referred to the psychiatrists
Informed consent was obtained from the caregivers, and assent was for further evaluation and management. Adolescents were classified
obtained from the study participants. The study was at no cost to the into early (10-13 years), mid (14-16 years), and late adolescence (17-
participants. Confidentiality of all information obtained was assured. 19 years) based on the stages in the physical and psychosocial devel-
Information regarding age and gender of the adolescents, educa- opment in the progression from childhood to adulthood.12
tional status and occupation of their caregivers, and the subject’s The data were analyzed using the Statistical Package for Social
clinical history were obtained by the investigator using an Sciences (SPSS) version 19.0. Frequency tables were generated for
interviewer-administered questionnaire designed for this study and sociodemographic variables. The chi-square test was used to test for
recorded on a proforma administered by the investigator. Epilepsy significant association between proportions. Results were presented in
was classified according to the 2017 International League Against prose, tables, and figures. All analyses were done at the 5% level of
Epilepsy (ILAE) classification. Each patient attending the neurology significance, and a P value less than .05 was considered statistically
clinic obtains an EEG (electroencephalogram) as part of the initial significant.
workup, and such information is documented in the records. The
seizure type was obtained from the EEG report in the patient’s records,
whereas the other seizure variables (number of antiepileptic drugs and
number of seizures in the past 12 months) were obtained from both the Results
records and interviewing the subject and parent. The socioeconomic Sociodemographic Characteristics of Subjects
status of the families of the subjects and the controls was determined
using the social classification system by Oyedeji.9 Classes 1 and 2 of and Controls
the Oyedeji classification were grouped into the upper social class, The subjects were made up of 82 males and 63 females, with a
class 3 the middle social class, and classes 4 and 5 into the lower social male-female ratio of (1.3:1). Most of the study participants
class. were early adolescents. The controls were similarly distributed
The Zung Self-rating Depression Scale is a self-administered psy-
for age and gender. The majority of the subjects and controls
chometric screening instrument for symptoms of depression.10 It pro-
belonged to the upper social class as shown in Table 1. The
vides a simple quantitative assessment of an individual’s experience of
depression.10 Its reliability and validity have been documented, and it difference between the social classes of the subjects and con-
has been validated for use in Nigeria.10,11 It is a 20-item questionnaire trols was statistically significant.
with a score of 1 to 4 for each item.10 The minimum raw score on the
Zung Self-rating Depression Scale is twenty while the maximum is
eighty.10 The sum of the scores of the 20 items is divided by the Distribution of Adolescents With Epilepsy by Seizure
maximum possible number (80) and multiplied by hundred to get the Type
Zung Self-rating Depression Scale index. 10 A Zung Self-rating
Depression Scale index of 50 and above signifies the presence of The distribution of adolescents with epilepsy by seizure type is
depression in the adolescents.10 Additionally, a Zung Self-rating shown in Figure 1. The most common type of seizure in the
Nnajekwu et al 3

70 65 (44.8%)

60

50
31 (21.4%)
40

30
15 (10.3%) 16 (11.0%)
15 (10.3%)
20

10 3 (2.1%)

0
Generalised Atonic Absence Focal Focal to Focal Aware
Tonic Clonic impaired bilateral
awareness Tonic Clonic

Figure 1. Distribution of subjects with epilepsy (recurrent seizure) by seizure type prevalence of depression in study population.

Table 2. Prevalence of Depression in the Study Population. seizures in the past 12 months), and depression was not
significant.
State of Subjects, Control, 95% C.I
health n (%) n (%) P value OR for OR Relationship Between Seizure Variables and Severity
Normal 75 (51.7) 107 (73.8) <.001 2.628 1.605 – 4.303
of Depression
Depressed 70 (48.3) 38 (26.2) There was no significant relationship between seizure variables
Total 145 (100.0) 145 (100.0) and severity of depression as shown in Table 6.
Abbreviations: C.I, confidence interval; OR, odds ratio.

subjects was the generalized tonic-clonic seizure (44.8%), fol-
lowed by focal impaired awareness seizures (21.4%).
Table 2 shows the prevalence of depression in the study
population. Amongst the subjects, 70 (48.3%), had scores in
the depressive range compared to 38 (26.2%) of controls. The
odds of being depressed was 2.6 times higher in the subjects
than in the controls. The difference in the scores was significant
(P < .001, OR ¼ 2.628).
Severity of Depression in the Study Population
As seen in Table 3, most of the subjects and controls with
depression had mild disease (40% of subjects, and 22.8% of
controls). The odds of being mildly and severely depressed
were significantly higher in the subjects than in controls
(P > .001 and P ¼ .049, respectively).
Relationship Between Sociodemographic Variables,
Seizure Variables, and Depression
Tables 4 and 5 show the relationship between sociodemo-
graphic, seizure variables, and depression. There was a statis-
tically significant relationship noted between the gender,
seizure type, and depression, whereas the relationship between
other sociodemographic variables (age and socioeconomic
class), seizure variables (number of AEDs, and number of
Discussion
The prevalence of depression was significantly higher in the
subjects compared to the controls. This corroborates the find-
ings from other studies.8,13-16 This finding could be explained
by a complex interplay between psychosocial and neurobiolo-
gic factors, chronic stress of the illness, in addition to mala-
daptation to the biologic and psychosocial changes of
adolescence.3,5
The prevalence of depression in this study was similar to the
rate obtained by Iloeje,7 but much higher than the figures
obtained in other studies.8,17-20 This difference could be
because of different study tools used. This study and that of
Iloeje13 used screening tools, whereas the other studies used
diagnostic tools. Screening tools are known to overestimate
prevalence rates, leading to higher prevalence rates than diag-
nostic tools.
In this study, mild depression was the most common type of
depression observed. This finding supported reports from other
studies.13,21,22 On the other hand, moderate to severe depres-
sion was more common in a study by Pereira and Valente.23
The difference observed could be due to the study populations.
The former studies were on adolescents with different types of
epilepsy, whereas the latter studied adolescents with temporal
lobe epilepsy. The hippocampus is deeply embedded in the
temporal lobe and could be prone to damage by metabolic and
neurotoxic agents released following the effects of chronic
4 Journal of Child Neurology XX(X)

Table 3. Severity of Depression in the Study Population.

Subjects, Control,
Severity of Depression n (%) n (%) P value OR 95% C.I for OR

Mild 58 (40.0) 33 (22.8) .001* 2.507 1.492, 4.215

Moderate 6 (4.1) 4 (2.8) .251 2.140 0.584, 7.845
Severe 6 (4.1) 1 (0.7) .049* 8.560 1.010, 72.572
Abbreviations: C.I, confidence interval; OR, odds ratio.
*Statistically significant.

Table 4. Relationship Between Sociodemographic Variables and Depression in the Study Population.

Subjects, Control, Total,

Sociodemographic variable n (%) n (%) n (%) Chi-square P value

Age Group 0.373 .846

Early adolescence 30 (42.9) 14 (36.8) 44 (39.9)
Mid adolescence 22 (31.4) 13 (34.2) 35 (32.8)
Late adolescence 18 (25.7) 11 (28.9) 29 (27.3)
Total 70 (100.0) 38 (100.0) 108 (100.0)
Gender 5.064 .024*
Male 36 (51.4) 11 (28.9) 47 (40.2)
Female 34 (48.6) 27 (71.1) 61 (59.8)
Total 70 (100.0) 38 (100.0) 108 (100.0)
Socio-economic class 1.975 .373
Lower 12 (17.1) 3 (7.9) 15 (12.5)
Mid 26 (37.1) 14 (36.8) 40 (37.0)
Upper 32 (45.7) 21 (55.3) 53 (50.5)
Total 70 (100.0) 38 (100.0) 108 (100.0)

*Statistically significant

Table 5. Relationship Between Seizure Variables and Depression. stress and uncontrolled release of corticosteroids seen in epi-
SDS lepsy,6 and thus could account for the more severe cases seen in
their study.
Normal, Depressed, Chi- P There was no significant relationship between age and
Seizure variables n (%) n (%) square value depression, though depression was more common in early and
Seizure type mid-adolescence. Studies have shown that age is not a consis-
Generalized Tonic Clonic 27 (36.0) 38 (54.3) 17.299 .004* tent predictor of depression.24-27 Karanja24 in Kenya also found
Atonic 6 (8.0) 9 (12.9) higher prevalence of depression in children aged between 10
Absence 10 (13.3) 6 (8.6) and 12 years, whereas Oguz et al25 and Thome-Souza et al26
Focal impaired 24 (32.0) 7 (10.0) observed depression to be higher during mid to late adoles-
awareness
cence. Rodenburg et al27 and Dunn et al20 found no relationship
Focal to bilateral Tonic 5 (6.7) 10 (14.3)
Clonic between age and depression. The differences observed could be
Focal Aware 3 (4.0) 0 (0.0) due to the different cultures of the study participants and the
Total 75 (100.0) 70 (100) study tools used.
Number of seizures in the past one year Gender was found to be a significant predictor of depression
None 31 (41.3) 17 (24.3) 4.775 .092 in this study, with depression more common in the male gender
1-12 36 (48.0) 44 (62.9) amongst the subjects. This was similar to the finding by
Greater than 12 8 (10.7) 9 (12.9)
Stores28 and Bilgic et al,29 but varies with other studies.17,30
Total 75 (100.0) 70 (100)
Number of AEDs Studies show that the finding of more depression in females is
1 56 (74.7) 49 (70.0) 0.395 .530 due to specific hormonal changes that occur during pub-
More than 1 19 (25.3) 21 (30.0) erty.17,30 The reason for the increased prevalence of depression
Total 75 (100) 70 (100) in males in this study is not clear.
Abbreviations: AEDs, antiepileptic drugs; C.I, confidence interval; SDS, Zung
The prevalence of depression was slightly higher in upper
Self-rating Depression Scale. social class, though not significant. In contrast, Resinger et al31
*Statistically significant. and Carson and colleagues32 found that low socioeconomic
Nnajekwu et al 5

Table 6. Relationship between seizure variables and Severity of Depression.

Severity of depression

Mild, Moderate,
Seizure variables n (%) n (%) Severe Chi-square P value

Seizure type
Generalized tonic clonic 32 (55.2) 3 (50.0) 3 (50.0) 14.367 .073
Atonic 9 (15.5) 0 (0.0) 0 (0.0)
Absence 4 (6.9) 0 (0.0) 2 (33.3)
Focal impaired awareness 7 (12.1) 0 (0.0) 0 (0.0)
Focal to bilateral tonic clonic 6 (10.3) 0 (0.0) 1 (16.7)
Focal aware 0 (0.0) 3 (50.0) 0 (0.0)
Total 58 (100.0) 6 (100.0) 6 (100.0)
Number of seizures in the past 12 months
None 15 (25.9) 0 (0.0) 2 (33.3) 4.508 .342
1-12 36 (62.1) 4 (66.7) 4 (66.7)
Greater than 12 7 (12.1) 2 (33.3) 0 (0.0)
Total 58 (100.0) 6 (100.0) 6 (100.0)
Number of AEDs
One 41 (70.7) 3 (50.0) 5 (83.3) 0.395 .530
More than 1 17 (29.3) 3 (50.0) 1 (16.7)
Total 58 (100.0) 6 (100.0) 6 (100.0)
Abbreviation: AEDs, antiepileptic drugs.

class was a dependent risk factor for depression in epilepsy.
The reason for the difference observed may be due to the dif-
ferent study tools used for social classification and the different
cut-offs for interpretation.
There was a significant relationship between depression and
seizure type in this study, and depression was more common in
adolescents with generalized seizures. Adewuya and col-
leagues8 in Western Nigeria reported no relationship between
seizure type and epilepsy, whereas Hoie et al14 and Iloeje13
documented a significant relationship between depression and
seizure type. Several studies show that depression is more
common in patients with temporal lobe epilepsy because of the
location of the hippocampus to the temporal lobe.33-35
There was no significant relationship found between the
number of AEDs used for treatment and depression in adoles-
cents with epilepsy. This finding varies with studies8,30,36,37
that showed that polytherapy with AEDs was a significant
predictor of psychosocial dysfunction. The disparity obtained
could be because a screening tool was used for this study unlike
the diagnostic tools used in the other studies which differentiate
specific psychiatric diagnosis.
There was no relationship between seizure frequency and
depression in this study. Caplan and colleagues 30 in the
United States also reported similar findings. This varies with
findings from other authors.8,37-40 This finding deviates from
the expected. Increased frequency of seizures could lead to
chronic stress, which in turn leads to unregulated release of
corticosteroids via the hypothalamo-pituitary-adrenal axis.5
The excessive corticosteroids released could make the hippo-
campus prone to injury from metabolic and neurotoxic agents,
which could be linked to the occurrence of depression.6 The
reason for this deviation from the norm is not clear. The study
was conducted in a hospital setting, and as a result, may have
underestimated the true prevalence of depression in adoles-
cents with epilepsy. In addition, the study tool used was a
screening tool, and this may affect accuracy of the results
presented. Hence, there is need for community-based studies
with diagnostic tools for generalizations beyond this popula-
tion to be made.
It is thus concluded that depression was more common in
adolescents with epilepsy when compared with controls, with
mild disease as the most frequent category. There was a sig-
nificant relationship between gender, seizure type, and depres-
sion, but no relationship between age, socioeconomic class,
seizure frequency, number of antiepileptic drugs, and
depression.
The author recommends routine screening for depression in
adolescents with epilepsy for early diagnosis and management.
This will reduce the burden of the disease on these adolescents
and improve their quality of life.
Author Contributions
CON, NAI, CNO contributed to conception and design. UCN contrib-
uted to conception, design, acquisition, and analysis. CON contributed
to acquisition, analysis, and interpretation. NAI contributed to acqui-
sition and analysis. CNO contributed to analysis and interpretation.
CON, UCN, NAI, CNO drafted manuscript, critically revised manu-
script, gave final approval and agrees to be accountable for all aspects
of work ensuring integrity and accuracy.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
6 Journal of Child Neurology XX(X)
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
ORCID iDs
Chukwubike Onyebuchi Nnajekwu, MBBS, FMC Paed https://
orcid.org/0000-0001-6032-1787
Uchenna Chiagoziem Nnajekwu, MBBS, FMC Paed https://orcid.
org/0000-0002-2933-8043
Chinyelu Ngozi Ojinnaka, MBBS, FWACP, MPH https://orcid.org/
0000-0002-4162-9943
Ethical Approval
Ethical consent was obtained from the Health Research and Ethics
Committee of University of Nigeria Teaching Hospital, Enugu.
(Approval number NHREC/05/01/2008B-FWA00002458-IRB00
002323) Consent was obtained from the parents and caregivers of the
study participants. Assent was obtained from the study participants.
References
1. World Health Organization. Epilepsy. Geneva: WHO, 2019.
https://www.who.int/news-room/fact-sheets/detail/epilepsy.
Accessed January 25, 2020.
2. Jones JE, Austin JK, Caplan R, Dunn D, Plioplys S, Salpekar JA.
Psychiatric disorders in children and adolescents who have epi-
lepsy. Pediatr Rev. 2008;29:e9-e14.
3. Baker GA, Spector S, McGrath Y, Soteriou H. Impact of epilepsy
in adolescence: a UK controlled study. Epilepsy Behav. 2005;6:
556-562.
4. Macleod JS, Austin JK. Stigma in the lives of adolescents with
epilepsy: a review of the literature. Epilepsy Behav. 2003;4:
112-117.
5. Fuchs E, Flugge G. Stress, glucocorticoids and structural plasti-
city of the hippocampus. Neurosci Biobehav Rev. 1998;23:
295-300.
6. Brown ES, Rush AJ, McEwen BS. Hippocampal remodelling and
damage by corticosteroids: implications for mood disorders.
Neuropsychopharmacology. 1999;21:474-484.
7. Hoppe C, Elgar C. Depression in epilepsy: a critical review from a
clinical perspective. Nat Rev Neurol. 2011;7:462-472.
8. Adewuya AO, Ola BA, Okeniyi JAO. Psychiatric morbidity in
Nigerian adolescents with epilepsy. J Paediatr Neurol. 2005;3:
153-158.
9. Oyedeji GA. Socioeconomic and cultural health background of
hospitalised children in Ilesha. Niger J Paediatr. 1985;12:11-17.
10. Zung WWK. A self-rating depression scale. Arch Gen Psychiatr.
1965;12:63-70.
11. Adewuya AO. Parental psychopathology and self-related quality
of life in adolescents with epilepsy in Nigeria. Dev Med Child
Neurol. 2006;48:600-603.
12. Hofmann AD, Greydanus DE, eds. Adolescent medicine. 2nd
edition. New York: Appleton and Lange; 1989. 631 p.
13. Iloeje SO, Ojinnaka NC, Onyeama GM. Depressive symptoms in
adolescents and young adults with epilepsy. J Coll Med. 2000;5:
42-44.
14. Hoie B, Sommerfelt K, Waaler PE, Alsaker FD, Skeidsvoll H,
Mykletun A. Psychosocial problems and seizure related factors
in children with epilepsy. Dev Med Child Neurol. 2006;48:
213-219.
15. Davies S, Heyman I, Goodman R. A population survey of mental
health problems in children with epilepsy. Dev Med Child Neurol.
2003;45:292-295.
16. Lagunju IA, Bella-Awurah TT, Takon I, Omigbodun OO. Mental
health problems in Nigerian children with epilepsy: associations
and risk factors. Epilepsy Behav. 2012;25:214-218.
17. Turkey A, Beavis JM, Thapar AK, Kerr MP. Psychopathology in
children and adolescents with epilepsy: an investigation of pre-
dictive variables. Epilepsy Behav. 2008;12:136-44.
18. Ettinger AB, Weisbrot DM, Nolan EE, et al. Symptoms of depres-
sion and anxiety in pediatric epilepsy patients. Epilepsia. 1998;
39:595-599.
19. Alwash RH, Hussein MJ, Matloub FF. Symptoms of anxiety and
depression among adolescents with seizures in Ibrid, northern
Jordan. Seizure. 2000;9:412-416.
20. Dunn DW, Austin JK, Huster GA. Symptoms of depression in
adolescents with epilepsy. J Am Acad Child Adolesc Psychiatry.
1999;38:1132-1138.
21. Siqueira NF, Oliveira FL, Siqueira JA, Pedroso de Souza EA. In
adolescents with epilepsy, high scores of anxiety and depression
are associated with occurrence of seizures in public places. Arq
Neuropsiquiatr. 2015;73:205-211.
22. Gebauer-Bukurov KE, Nikolasevic ZD, Hajder DS, Zivanovic
ZD, Ignjatovic VVB. Evaluation of symptoms of depression and
anxiety in adolescents with epilepsy in a tertiary-level medical
center in Serbia. Ann Indian Acad Neurol. 2019;22:419-425.
23. Pereira A, Valente K. Severity of depressive symptomatology and
functional impairment in children and adolescents with temporal
lobe epilepsy. Seizure. 2013;22:708-712.
24. Karanja SW. Prevalence of emotional and behavioural problems
in children with epilepsy attending the child neurology clinic at
Kenyatta National Hospital, Kenya. (dissertation). Nairobi:
University of Nairobi. 2017. 82 p.
25. Oguz A, Kurul S, Dirik E. Relationship of epilepsy-related factors
to anxiety and depression scores in epileptic children. J Child
Neurol. 2002;17:39-40.
26. Thome-Souza S, Kuczynski E, Assumpcao F, et al. Which factors
may play a pivotal role on determining the type of psychiatric
disorder in children and adolescents with epilepsy? Epilepsy
Behav. 2004;5:988-994.
27. Rodenburg R, Stams GJ, Meijer AM, Aldenkamp AP, Dekovic M.
Psychopathology in children with epilepsy: a meta-analysis.
J Pediatr Psychol. 2005;30:453-468.
28. Stores G. School-children with epilepsy at risk for learning and
behaviour problems. Dev Med Child Neurol. 1978;20:502-508.
29. Bilgic A, Yilmaz S, Tiras S, Deda G, Kilic EZ. Depression and
anxiety symptom severity in a group of children with epilepsy and
related factors. Turk Psikiyatri Derg. 2006;17:165-172.
30. Caplan R, Siddarth P, Gurbain S, Ott D, Sankar R, Donald Shields
W. Psychopathology and paediatric complex partial seizures:
seizure-related, cognitive and linguistic variables. Epilepsia.
2004;45:1273-1281.
Nnajekwu et al
31. Reisinger EL, Dilorio C. Individual, seizure-related and psycho-
social predictors of depressive symptoms among people with epi-
lepsy over six months. Epilepsy Behav. 2009;15:196-201.
32. Carson J, Weir A, Chin R, McLellan A. Socioeconomic depriva-
tion is an independent risk factor for behavioural problems in
epilepsy. Epilepsy Behav. 2015;45:105-109.
33. Kondziella D, Alvestad S, Vaaler A, Sonnewald U. Which clinical
and experimental data link temporal lobe epilepsy with depres-
sion? J Neurochem. 2007;103:2136-2152.
34. Gureje O. Interictal psychopathology in epilepsy: prevalence and
pattern in a Nigerian clinic. Br J Psychiatr. 1991;158:700-705.
35. Harden CL. The co-morbidity of depression and epilepsy:
epidemiology, etiology, and treatment. Neurology. 2002;59:
S48-S55.
7
36. Asindi AA, Eyong KI. Stigma on Nigerian children living with
epilepsy. J Paediatr Neurol. 2006;48:213-219.
37. Helal SI, Megahed HS, Salem SM, Youness ER. Monotherapy
versus polytherapy in epileptic adolescents. Maced J Med Sci.
2013;6:174-177.
38. Ogun OC, Gbiri CA, Akinola OA, et al. Psychosocial correlates of
depression in children and adolescents with epilepsy in a Nigeria
neuro-psychiatric hospital. J Clin Case Rep. 2012;2:152-156.
39. Olley BO. Psychosocial and seizure factors related to depression
and neurotic disorders among patients with chronic epilepsy in
Nigeria. Afr J Med Sci. 2004;34:39-44.
40. Vitera E. Stigmatization of patients with epilepsy: a review of the
current problem and assessment of the perceived stigma in Bul-
garian patients. Epilepsy Behav. 2012;25:239-243.