Screening for common mental disorders in people with epilepsy in Goma, in the Democratic Republic of the Congo: A cross-sectional study

INTRODUCTION

According to the International League against Epilepsy, epilepsy is defined as a neurological condition characterized by at least two unprovoked seizures.^[1] Epilepsy has a multidimensional effect on the body, such as limitations on physical, mental, and behavioral functions. Due to factors such as traumatic brain injury, pneumonia, epileptic illness, suicide, and sudden death, epilepsy is associated with a high risk of premature mortality.^[2] The prevalence of common mental disorders (CMDs) among people with epilepsy (PWEs) remains unclear due to methodological difficulties in estimating prevalence, including diagnostic criteria and classification of epilepsy, the selection of populations studied, the choice of survey type and diagnostic instruments, and data interpretation.^[3] However, PWEs are known to suffer more from CMDs than the general population, with over 50% reported in most studies.^[4-8] Unfortunately, CMDs are often poorly recognized and treated, even in well-medicalized countries such as Canada, where 38% of PWEs with depressive disorders received no psychiatric treatment in the year before the survey conducted by Fuller-Thomson and Brennenstuhl.^[9] Untreated CMDs exacerbate and perpetuate epilepsy and reinforce social, educational, and occupational exclusion. Furthermore, CMDs in PWEs create an additional burden for patients and their families, directly impacting quality of life.^[10]

The assessment of CMDs in PWEs and the identification of associated risk factors are more important issues as the risk of cognitive, behavioral, and psychosocial disorders is increased in these patients.^[10,11]

The study found that risk factors associated with CMDs in PWEs were female sex, young age, low income, poor quality of life, unemployment,^[12] family history of psychiatric illness,^[13] high frequency of seizures, low level of education,^[14] duration of epileptic illness, poor adherence to antiepileptic therapy,^[15,16] and medical co-morbidities.^[16,17] These risk factors should be considered in the assessment and identification of CMDs in PWEs.

To our knowledge, no prior research has investigated the prevalence and risk factors of CMDs in PWEs in the Democratic Republic of the Congo (DRC). Therefore, this study aimed to determine the prevalence and identify risk factors for CMDs in PWEs in the DRC. The findings of this study will help fill the gap in knowledge in this area and provide valuable baseline data for future researchers and decision-makers.

MATERIAL AND METHODS

RESULTS

Prevalence of CMDs in PWE

The classification of PWEs as having CMDs was based on a score ≥7 on the SRQ-20 questionnaire, while those with a score <7 on the SRQ-20 were classified as not having CMD. The study found that the prevalence of CMDs was 39.1% (95% CI: 33.7–44.7%) [Figure 1].

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Figure 1:

Prevalence of common mental disorders in people with epilepsy attending the Neuropsychiatric Hospital Center in Goma, in the Democratic Republic of the Congo (n = 302).

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The study found that the most prevalent symptoms of CMDs among participants were headache (50.0%), difficulty working daily (40.1%), nervousness (39.7%), lack of appetite (31.5%), poor sleep conditions (29.5%), and constant fatigue (29.5%). Suicidal ideation was reported by 43 (14.2%) of the participants [Table 3].

Table 3: Self-reporting questionnaire-20.

Items	Yes	No
Do you often have headache?	151 (50.0)	151 (50.0)
Is your appetite poor?	95 (31.5)	207 (68.5)
Do you sleep badly?	89 (29.5)	213 (70.5)
Are you easily frightened?	90 (29.8)	212 (70.2)
Do your hands shake?	93 (30.8)	209 (69.2)
Do you feel nervous, tense, or worried?	120 (39.7)	182 (60.3)
Is your digestion poor?	26 (8.6)	276 (91.4)
Do you have trouble thinking clearly?	93 (30.8)	209 (69.2)
Do you feel unhappy?	96 (31.8)	206 (68.2)
Do you cry more than usual?	60 (19.9)	242 (80.1)
Do you find it difficult to enjoy your daily activities?	95 (31.5)	207 (68.5)
Do you find difficult to make decision?	84 (27.8)	218 (72.2)
Is your daily work suffering?	121 (40.1)	181 (59.9)
Are you unable play a useful part in life?	88 (29.1)	214 (70.9)
Have lost interest in things?	61 (20.2)	241 (79.8)
Do you feel that you are a worthless person?	66 (21.9)	236 (78.1)
Has the thought of ending your life been on your mind?	43 (14.2)	259 (85.8)
Do you feel tired all the time?	74 (24.5)	228 (75.5)
Do you have unpleasant sensations in the stomach?	42 (13.9)	260 (86.1)
Are you easily tired?	89 (29.5)	213 (70.5)

Determinants of CMDs in PWE

Table 1 shows that none of the sociodemographic characteristics studied were significantly associated with CMDs. However, correlations between clinical characteristics and CMDs are shown in Table 2. The study found that the number of seizures in the month preceding the survey, absence of antiepileptic medication, presence of medical co-morbidity, alcohol consumption, and smoking were significantly associated with CMDs (P < 0.05).

Figure 2 displays the findings of multiple logistic regression. Those who experienced 5 or more seizures were approximately 4 times more prone (aOR = 3.8; 95% CI: 1.7–8.3) to developing CMD compared to those who had <5 epileptic seizures. In addition, participants were 3 times more likely to develop CMD if they had medical co-morbidity than those without medical co-morbidity (aOR = 3.1; 95% CI: 1.5–6.4).

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Figure 2:

Multiple logistic regression of determinants of common mental disorders in people with epilepsy.

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DISCUSSION

This study aimed to estimate the prevalence and risk factors of CMDs using SRQ-20 in PWEs in Goma (DRC). The results indicate that CMDs were prevalent in 39.1% of PWEs in the study. The presence of medical co-morbidity and a high number of seizures (≥5) were identified as determinants of CMDs. These findings suggest the need for medical and psychological care to be provided specifically for CMDs when treating PWEs. Therefore, establishing a link between psychiatric and neurological services for PWEs is crucial. The presence of CMDs may negatively impact the outcome of the management of PWEs. As epilepsy is the most common neurological problem with an organic origin that is not always recognized due to mistaken beliefs, assessing the extent of CMDs and their determinants is essential in developing countries such as the DRC.^[19]

Several previous studies have reported comparable prevalences to those found in this study, such as 35–35.8% in Ethiopia,^[16,20] 35.5% in Iceland,^[21] 36.5% in the United States,^[12] and 37% in Europe.^[22] However, some studies found significantly higher prevalence rates, ranging from 45% to 80%.^[15,23-30] while other studies reported lower prevalences ranging from 5.9% to 29%.^[11,31-33] Differences in sample size, assessment instruments used, and epilepsy patterns may explain the variation in prevalence across studies. Unlike other studies that focused only on temporal lobe epilepsy, which has a higher risk of CMD,^[25] this study assessed all types of epilepsy.

Numerous studies have unanimously shown that the most common CMDs in PWEs are anxiety and depression.^[4,34-36] The prevalence of these disorders differs from study to study. This could be explained by methodological differences, mainly concerning the choice of measuring instruments used and the scores used to assess the severity of anxiety and depression symptoms. However, the results of this study showed that the prevalence of CMDs was nearly 3 times that of the World Health Organization report on the global burden of CMDs (14%) in the general population,^[37] indicating that the burden of CMDs in PWEs in the eastern DRC is higher than in the general population. This would be the result of problems faced by PWEs, including the state of epileptic seizures, the financial burden of treatment, the side effects of medicines, and community discrimination related to an epileptic seizure.

The study confirms that the development of CMDs in PWEs is associated with the presence of co-morbid medical conditions (aOR = 3.1; 95% CI: 1.5–6.4). This finding is consistent with a similar Ethiopian study, which reported that PWEs with medical co-morbidities were 3 times more likely to experience CMDs than those without medical comorbidities (aOR = 2.99; 95% CI: 1.95–9.39).^[16] This could be attributed to the negative impact of medical conditions on the quality of life of PWEs, as suggested by other studies.^[38]

Participants with 5 or more seizures were nearly 4 times more likely to develop a CMD compared to those with fewer than 5 seizures in the month before the survey (aOR = 3.8; 95% CI: 1.7–8.3). Consistent with our study, Mekuriaw et al.^[39] reported in a recent Ethiopian study that PWEs who had uncontrolled seizures in the year before the survey were more likely to have CMDs than their counterparts (aOR = 1.96; 95% CI: 1.21–3.18). This association could be explained by the fact that people with uncontrolled epileptic seizures usually become desperate and may lack confidence in drug therapies.^[40]

The persistence of seizures, often due to poor adherence, can lead PWEs to develop additional physical conditions or co-morbidities, as well as feelings of desperation due to the incurability of the disease and medication fatigue.^[39] Non-compliance with medication can result in reduced seizure control, decreased quality of life, decreased productivity, or even job loss due to seizures, as stated by Mekuriaw et al.^[39] Recurrent epileptic seizures that complicate CMDs establish a bidirectional interaction between epilepsy and CMD.

This study has several limitations. The findings may not be applicable to the entire Congolese population, as the research was conducted in only one city. Self-reported questionnaires used to assess mental health issues may be influenced by a positivist bias, overestimating actual mental health values, and recall bias. In addition, due to the cross-sectional nature of the study design, it is difficult to establish causality between CMDs and their associated risk factors.

CONCLUSION

The present study showed that CMDs are common in PWEs in Goma (eastern DRC) and that the number of epileptic seizures ≥5 and the presence of medical co-morbidity are determinants. The management of PWEs must integrate psychosocial support and psychotherapeutic approaches as a complement to the pharmacological intervention of epilepsy while placing greater emphasis on the risk factors of these CMDs. It can also be used as a means to improve treatment adherence, therapeutic relationships, and the overall outcomes of PWE treatment with feasible and cost-effective services.