Table 2 presents data showing the demographic and clinical characteristics of the epilepsy

patients in this study. The demographic characteristics of respondents ranged in age from 18 to
60 years, with a mean age of 31.00 ± 10.02 years. The participants included 34 males (44.2%)
and 43 females (55.8%). The majority of subjects had completed 12 years of education, with 26
individuals (33.8%) falling into this category. Employment status revealed that 52 subjects
(67.5%) were unemployed, while almost a third of them (25 subjects) were employed.
Clinically, the study participants were categorized based on the number of anti-seizure
medications (ASMs) they were using. Monotherapy was administered to more than half of the
participants (46 subjects), 27.3% were on dual therapy, and 13.0% were taking >2 ASMs.
Among the people with epilepsy (PWE), 59 patients (76.6%) had controlled seizures, whereas 18
others (23.4%) experienced uncontrolled seizures. For those on monotherapy, 17 PWE (22.0%)
were treated with phenytoin, 15 patients (19.48%) with valproic acid, 6 patients (7.7%) with
levetiracetam, 6 others (7.7%) with carbamazepine, and 2 of them (2.5%) with clobazam.
Table 1. Demographic characteristics and clinical profiles of people with epilepsy (PWE)
Variables n %
Sex Male 34 44.2
Female 43 55.8
Age (in years) 12-18 13 16.9
19-40 48 62.3
41-65 16 20.8
Duration of education < 12 years 51 66.2
> 12 years 26 33.8
Employment status Employed 25 32.5
Unemployed 52 67.5
Number of ASMs Monotherapy 46 59.7
Dual therapy 21 27.3
Polytherapy 10 13.0
Seizure control Controlled 59 76.6
Uncontrolled 18 23.4
Duration of treatment < 1 year 16 20.7
≥ 1 year 61 79.2
Number of seizures per <10 47 61.0
year ≥10 30 38.9
Type of ASM Phenytoin 17 22.0
 (monotherapy) Valproic acid 15 19.48
Levetiracetam 6 7.7
Carbamazepine 6 7.7
Clobazam 2 2.5
Total 77 100.0

In addition to these findings, Table 2 shows no significant difference between age

groups and the incidence of anxiety in PWE, with a p-value of 0.395 (31.00 ± 10.02).
Notably, the 19-40 year age group displays a higher prevalence of anxiety symptoms
compared to the 12-18 and 41-65 year age groups (35.4%, 15.4%, 6.3%, respectively). On
the other hand, the duration of education correlated significantly with the incidence of
anxiety in epilepsy patients, with a p-value of 0.004. Respondents with less than 12 years of
education had a higher prevalence of anxiety disorders compared to those with more than 12
years of education (37.3% vs 3.8%).
Table 2. Correlation between socio-demographic factors and anxiety disorders in
people with epilepsy (PWE)
GAD-7 level
Variables Anxiety No anxiety Total p-value
Median ± SD Median ± SD
Age 31.00 ± 10.02 35.00 ± 13.80 0.395**
n 7 27 34
Male
% 20.6% 79.4% 100.0%
Sex 0.486*
n 13 30 43
Female
% 30.2% 69.8% 100.0%
n 19 32 51
<12 years
Duration of % 37.3% 62.7% 100.0%
education n 1 25 26
>12 years
% 3.8% 96.2% 100.0%
n 6 19 25
Employed
Employment % 24,0% 76.0% 100.0%
1.000*
status Not n 14 38 52
employed % 26.9% 73.1% 100.0%

Furthermore, the analysis of clinical characteristics and anxiety disorders reveals a

significant relationship between polytherapy (>2 types of anti-epileptic drugs) and the
incidence of anxiety in PWE, with a p-value of 0.020. Specifically, the percentage of
patients on polytherapy experiencing anxiety was higher compared to those on dual therapy
and monotherapy (60%, 28.6%, 17.4%, respectively). Moreover, there was a significant
association between uncontrolled seizures and anxiety in patients, with a p-value of 0.013.
The proportion of participants with uncontrolled seizures (50%) who exhibit anxiety
symptoms was greater than that of those with controlled seizures (18.6%). However, there
was no significant difference between the duration of treatment and the incidence of anxiety
in patients (p-value = 0.540), nor between the number of seizures and the incidence of
anxiety (p-value = 0.149), as detailed in Table 3.
Table 3. Correlation between clinical characteristics and anxiety disorders in people
with epilepsy (PWE)
GAD-7 level
Variables No Total p-value
Anxiety
anxiety
Monotherapy n 8 38 46
% 17.4% 82.6% 100,0%
Number of
Dual therapy n 6 15 21 0.020*
ASM taken % 28,6% 71,4% 100.0%
Polytherapy n 6 4 10
% 60.0% 40.0% 100.0%
Controlled n 11 48 59
Seizure control % 18.6% 81.4% 100.0% 0.013*
Uncontrolled n 9 9 18
% 50.0% 50.0% 100.0%
<1 year n 3 13 16
Duration of
% 22.8% 20.8% 20.8% 0.540*
treatment ≥1 year n 17 44 61
% 85.0% 77.2% 79.2%
Number of <10 n 9 38 47
% 45.0% 66.7% 61.0%
seizures per 0.149*
n 11 19 30
≥10
year % 55.0% 33.3% 39.0%

Table 4 illustrates that the p-value exceeds 0.05, indicating no significant relationship
between the type of ASMs used and the presence of anxiety symptoms in respondents to this
study. The ASM types that were used in this study with associated anxiety symptoms were
phenytoin (41.2%), valproic acid (40.0%), carbamazepine (0.0%), levetiracetam (33.3%), and
clobazam (50.0%).
Table 4. Correlation between anti-seizure medications (ASMs) and anxiety disorders
ASM Type GAD-7 level Total p-
 No
Anxiety value
anxiety
n 7 10 17
Yes
Phenytoin % 41,2% 58,8% 100,0% 0.125*
n 13 47 60
No
% 21,7% 78,3% 100,0%
n 6 9 15
Yes
Valproic acid % 40,0% 60,0% 100,0% 0.196*
n 14 48 62
No
% 22,6% 77,4% 100,0%
n 0 6 6
Yes
Carbamazepine % 0,0% 100,0% 100,0% 0.330*
n 20 51 71
No
% 28,2% 71,8% 100,0%
n 2 4 6
Yes
Levetiracetam % 33,3% 66,7% 100,0% 0.647*
n 18 53 71
No
% 25,4% 74,6% 100,0%
n 1 1 2
Yes
Clobazam % 50,0% 50,0% 100,0% 0.455*
n 19 56 75
No
% 25,3% 74,7% 100,0%

DISCUSSION
This study enrolled 77 participants who had been undergoing epilepsy treatment for a
minimum of 2 months and were diagnosed with epilepsy. Screening according to inclusion
criteria identified 20 subjects with anxiety disorders using the validated ILAE screening tool. The
research indicates a higher risk of experiencing anxiety disorders among females (30.2%) in
patients with epilepsy compared to males (20.6%). This finding is consistent with a study in
Brazil, which showed that 39.4% of anxiety disorders in PWE were associated with various
factors, such as female gender, low educational level, and suicidal thoughts (Stefanello et al.,
2011; Borwin B, 2015). Sanchai et al. reported that among 170 PWE with a mean age of 43.5
years (SD = 15.8), a majority were female, and slightly over one-third (36.5%) were currently
unemployed (Sanchai K, 2018). Epidemiological research consistently indicates a higher
prevalence of anxiety symptoms is more prevalent in females than in males (Zhao L, 2020;
Casares et al., 2024). Further analysis highlighted a stronger association between anxiety
symptoms and seizure frequency in females, potentially attributed to the greater psychological
burden faced by females in coping with frequent seizures compared to males (Zhao L, 2020; Lee
et al., 2021).
Our research findings indicate that anxiety symptoms in PWE were most prevalent in the
19-40 year age range, with a p-value of 0.395 (31.00 ± 10.02). This is consistent with Borwin B.
et al., who explained that the median age for the onset of anxiety symptoms is 31 years. An
epidemiological study in Germany found the highest 12-month prevalence rate of anxiety
symptoms occurred in the 18-34 year age group, while panic disorder is highest in the age group
35-49 years (Borwin B, 2015). Prospective studies suggest that anxiety symptoms can be
chronic, potentially lasting for years or decades. However, this does not mean that anxiety
symptoms persist permanently throughout the patient’s life. In a cross-sectional study, Alsaadi et
al. (2015) found that the prevalence of anxiety was 43.5%, with age being statistically significant
(Seid J, 2022).
According to our study, among individuals with epilepsy, 19 subjects (37.3%) with less
than 12 years of education show higher levels of anxiety symptoms compared to those with more
than 12 years of education. This phenomenon is often attributed to parental concerns that their
children may continue experiencing seizures if they remain in school, coupled with feelings of
embarrassment about the condition. This finding aligns with research conducted in Brazil, which
shows that individuals with lower educational attainment possess a limited understanding of the
disease’s nature, making them six times more susceptible to anxiety disorders. Lower levels of
education also contribute to heightened perceptions of stress, stigma, and poorer psychological
adaptation when confronting a situation. Rationalization is a psychiatric disorder belief resulting
in minimized social interactions, reduced self-esteem, and limited participation in social
activities, such as weddings, along with feelings of inadequacy, dependency, and disability (Seid
J, 2022).
In this study, a notable finding was found, in which 9 subjects (50.0%) out of 20
experienced anxiety disorders within the uncontrolled seizure group (p = 0.013). This
observation is consistent with previous research indicating that anxiety symptoms affect 45% of
patients with uncontrolled epilepsy, often associated with mood disorders (Irene G, 2008).
Budikayanti et al. (2019) noted that the prevalence of anxiety disorders in PWE is twice as high
as in the general population, particularly in cases of uncontrolled seizures. A univariate analysis
from a study in China suggested that uncontrolled seizures among PWE may heighten
psychological distress, exacerbated by the adverse effects of ASMs. Seizures occurring
unexpectedly in public settings, often accompanied by urinary incontinence, contribute to
feelings of embarrassment, stigma, and perceived discrimination (Fiest et al., 2016; Shi, W et al.,
2023). These findings are consistent with research from India, which reported that PWE have
higher anxiety levels (32.5%) compared to normal controls (7.5%), correlating with longer
seizure durations and an increased frequency of uncontrolled seizures (Seid J, 2022).
Furthermore, two cross-sectional studies highlighted stress as a significant triggering factor for
seizures (Dussaule C, 2018).
Our study demonstrated a significant association between polytherapy (using more than
two types of ASMs) and high anxiety disorder incidence (p = 0.020) compared to monotherapy
and dual therapy. This is consistent with a cross-sectional study in northwest Ethiopia, which
reported that polytherapy was 2.27 times higher among respondents compared to those taking
only one type of ASM. A study conducted in Northern India with 100 subjects assessed
psychiatric comorbidity using the MINI (Mini International Neuropsychiatric Interview) and
found a higher prevalence of psychiatric comorbidities among subjects receiving polytherapy
compared to those on monotherapy (Nigussie et al., 2021). Specifically, among the 50 subjects
on monotherapy, 4 patients experienced anxiety disorders and 2 had suicidal thoughts, whereas
among the 50 patients on polytherapy, 14 experienced anxiety disorders and 9 had suicidal
thoughts (Yadav J, 2022). Additionally, the perception of stigma was statistically associated with
anxiety disorders (p < 0.05), possibly due to serious side effects, medication costs, and drug
interactions, leading to anxiety disorders (Nigussie et al., 2021).
Our study found no significant relationship between the types of monotherapy (Valproic
Acid, Phenytoin, and Levetiracetam) and the incidence of anxiety in PWE. However,
levetiracetam showed a higher percentage of associated anxiety compared to other ASMs. This
may be attributed to the long-term use of levetiracetam, which leads patients to feel that their
condition is incurable, thus resulting in feelings of worthlessness. An animal study by Cavichioli
et al. (2023) indicated that levetiracetam could weaken the response to anxiety disorders
triggered by adolescent stress in adulthood. In addition, another study using ANOVA
demonstrated a significant effect of stress (F 1.36 = 47.54, p < .0001), but no significant effect of
treatment (F 1.36 = 0.19, p = .66) or interaction between stress and treatment (F 1.36 = 0.56, p =
0.46) (Cavichioli AM et al 2023).