Transcultural Research at the Interface between Epilepsy & Depression. - Problems, pitfalls & solutions

1. Transcultural Aspects of Depression in
Epilepsy
Dr. Ennapadam.S. Krishnamoorthy
MD., DCN, PhD (Lond), FRCP (Lond, Glas, Edin), MAMS (India)
Founder Director
TRIMED I NEUROKRISH
www.trimedtherapy.com I www.neurokrish.com

2. Neuropsychiatry in Epilepsy:
Transcultural Perspectives- I
• Studies largely confined to the west
• Limited literature from Asia, Africa & South America with the
exception of Japan
• Schizophrenia like psychosis has been well described from
Africa, Japan and the Indian sub-continent
• Some references to “epileptic personality” exist in the
literature from these countries, but hospital or community
research data is lacking
1. Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal
lobe epilepsy: a controlled study. Br J Psychiatry 1979; 135: 411-7; 1.; Asuni T, Pillutla VS.
Schizophrenia-like psychoses in Nigerian epileptics. (A study made in Nigeria). Br J
Psychiatry;113(505):1375-9
1. Shukla GD, Srivastava ON, Katiyar BC, Joshi V, Mohan PK. Psychiatric manifestations in temporal
lobe epilepsy: a controlled study. Br J Psychiatry 1979; 135: 411-7; 1.; Asuni T, Pillutla VS.
Schizophrenia-like psychoses in Nigerian epileptics. (A study made in Nigeria). Br J
Psychiatry;113(505):1375-9

3. Neuropsychiatry in Epilepsy:
Transcultural Perspectives- II
• Post-ictal psychoses has been extensively written
about in the Japanese literature, including the
relative frequency, link to temporal lobe epilepsy,
and lucid interval
• AED linked psychopathology has also been written
about extensively in Japan, and linked to the Forced
Normalization phenomenon
1. Matsuura M & Trimble MR. Psychoses in Epilepsy: A Review of Japanese Studies. Epilepsy &
Behavior 2000; 1: 315-326
1. Matsuura M & Trimble MR. Psychoses in Epilepsy: A Review of Japanese Studies. Epilepsy &
Behavior 2000; 1: 315-326

4. Depression in Epilepsy: Epidemiology
• Number of studies report a high prevalence of depression
in epilepsy- up to 50% in hospital populations and
between 20 and 35% in community populations surveyed
• Depression is significantly commoner in persons with
recurrent seizures than in those with controlled epilepsy
• Is depression more common in epilepsy than in other
neurological disorders? CONFLICTING DATA
• Vast majority of studies from UK/ Europe/ USA
Kanner AM. Biol. Psychiatry 2003; 54: 388-398; Harden CL. Neurology 2002; 59:
S48-S55. Lambert & Robertson. Epilepsia 1999; 40 (suppl.10): S21-S47
Kanner AM. Biol. Psychiatry 2003; 54: 388-398; Harden CL. Neurology 2002; 59:
S48-S55. Lambert & Robertson. Epilepsia 1999; 40 (suppl.10): S21-S47

5. Transcultural aspects of Depression in
Epilepsy
• There have been many more studies of psychoses
than of depression
• Studies from around the world have shown a
significant component of mood and affective
symptoms in epilepsy
• Many studies however end up assessing common
mental disorder symptoms, than depression
specifically
• Reliance on screening instruments/ diagnostic
criteria!

6. Depressive symptoms frequent in
epilepsy: Global perspectives-I
• Indian Subcontinent:
• Shukla (1976)- India: 62 TLE- 70 Grand Mal: 4/5 of TLE had
emotional disturbances- neurosis
• Tejpal (cited in Maheshwari- 2001)- depression in 60% of
151 subjects; ¯ in CSF serotonin metabolites in depressed
pts.
• Africa:
• Gureje (1991): 37% of 204 subjects had psychiatric illness:
two-thirds neurotic/affective symptoms
• Matuja (1990): 60% had some psychological disturbance:
affective symptoms frequent

7. Depressive symptoms frequent in
epilepsy: Global perspectives-II
Middle East (Alwash RF. Seizure 2000;9:412-416)
• Anxiety & depression more common in 101 patients with
epilepsy (48%) than in matched controls (24%) (OR anx=3.66;
p= 0.000/ dep=2.41; p=0.024)
Italy (Beghi E. Epi & Behav. 2002;3:255-261)
• Depression more common in epilepsy group when compared
to diabetes and control groups (OR 7.3; CI: 1.7-35.8)
Spain (Modrego PJ. Eur Neurol 2002;48:80-86)
• Depression significantly more in 63 patients than in 40
unrelated controls (OR=7; 95% CI 2.3-21)

8. Is There Reason To Believe That Cross-cultural
Differences Exist?
• Organic factors in developing nations may increase/alter
burden of psychiatric co-morbidity
• CNS infections, head injury, nutritional factors,
neurodevelopment factors may all have a role
• Neurocysticercosis: Important factor in developing nation
setting; psychiatric manifestations have been described
Trimble MR & Krishnamoorthy ES. Neuropsychiatric Aspects of Epilepsy-
Some Transcultural Issues, In: Transcultural Perspectives in Epilepsy.
Epilepsia 2003; 44 (Supplement-1)
Trimble MR & Krishnamoorthy ES. Neuropsychiatric Aspects of Epilepsy-
Some Transcultural Issues, In: Transcultural Perspectives in Epilepsy.
Epilepsia 2003; 44 (Supplement-1)

9. Are There Cross-cultural Differences In
Prevalence?
• On the face of it
- Depression is a common problem among
patients with epilepsy
- That it is prevalent has been well
described across cultures
• However comparative cross-cultural data is
lacking!

10. Are There Cross-cultural Differences In
Psychopathology?
• Unique manifestations of depression in non-western cultures:
considerable literature outside epilepsy
• Somatisation: presenting symptom of CMD in 97% of subjects
(Patel V. Psychol Med 1998;28(1):135-43)
• Somatisation and somatic attribution may be more common
in non-western cultures (Duddu. Psychopathology 2003;36(2):98-103;
Weiss MG. Br J Psychiatry 1995;166(3):353-9)
• Cross-cultural studies- ethnic minority populations fail to
recognise psychological symptoms as psychological when
compared to native Caucasian populations (Bhatt. J Psychosom Res
2002;33(6): 671-690)
• Consequent physician failure to make a diagnosis

11. Unique Cultural Explanations-
Depression/ Mental Disorders
• Amplification of and attribution to recent somatic illness is
common (Duddu. Psychopathology 2003;36(2):98-103): In
refractory epilepsy the somatic illness is constant
• Attribution of symptoms to black magic, spirits; role of native
and faith healers (Nambi, Nat Med J India 2002;15(6):331-5).
Misattribution and myths about epilepsy are widely prevalent
• Acquisition of psychological models as they pass through the
care process (Patel. Psychol Med 1998;28(1):135-43). Patients
with refractory epilepsy are seldom outside this care process.

12. Are Epilepsy Specific Psychiatric
Disorders Expressed Across Cultures?
• Frequently interface with depression
• Interictal Dysphoric Disorder/ Mesial Temporal Lobe
Syndrome/ Personality
- Described in Indian (Shukla, 1976), Japanese (Murai, 1998),
Spanish subjects (Modrego, 2002)
• Forced Normalization or variants of the same
- Described among Japanese (Matsuura & Trimble, 2000;
Indian (Shukla, 1976) & in African studies
• AED induced psychopathology: Many reports: a number from
Japan (Matsuura & Trimble, 2000)

13. Transcultural Research at the
Interface between Epilepsy &
Depression
- Problems, pitfalls & solutions

14. 1. Collaborative Expertise
• Need for interest in and knowledge of the cultures in
question
- Minority populations in developed countries may
suffer from perceived/ real social isolation, stigma,
linguistic barriers (difficult to penetrate)
- Populations in developing countries: multiple
barriers: pragmatic, cultural, social. May have little
inclination for research; problems of the treatment
gap
• Need for genuine collaborators

15. 2. Case Definition
• Need for acceptable case definition:
- Active epilepsy (well defined)
- Psychiatric disorder (well defined)
- Depression in epilepsy (more
controversial)
• Need to measure both generic and epilepsy
specific psychopathology?
• A case of what?

16. 3. Associated Measures
• Use of acceptable criteria & classificatory system
• Use of valid measures of seizure frequency,
severity, and temporality
• Use of valid measures of quality of life,
disablement & life-course
• Need to operationalise the quantification of these
variables across cultures
• Are predominantly western norms ideal?

17. 4. Choice of Instruments
• Screening versus diagnostic
• Trait versus state versus life-course
• Generic versus epilepsy specific
• Rater- Self, versus carer/observer, versus
expert/observer
• Reliability and validity in population that is being
measured
• Low levels of literacy exist in many developing
countries

18. 5. Novel Approaches
• Combining qualitative with quantitative approaches (method
triangulation)
• Use of “clinical diagnosis of caseness” and “intention to treat”
as gold-standard
• Exploring roots! Collaborating with region of origin
• Twinning of developed and developing centres
• Combining genetics, imaging and other biological measures
with epidemiology
• Provision of care through research to eliminate treatment
gap

19. Bridging The Treatment Gap Through
Transcultural Research
• Barriers to care in a developing nation
- Availability - Accessibility
- Affordability - Acceptability?
Krishnamoorthy ES, Satishchandra P & Sander JWAS. Research in Epilepsy- Development Priorities
for Developing Nations. Transcultural Perspectives in Epilepsy, Epilepsia 2003; Vol. 44 (Supplement-
1): 5-9.
Krishnamoorthy ES, Satishchandra P & Sander JWAS. Research in Epilepsy- Development Priorities
for Developing Nations. Transcultural Perspectives in Epilepsy, Epilepsia 2003; Vol. 44 (Supplement-
1): 5-9.
In a developing nation, there can be no research without service.
In a developing nation, there can be no research without service.
KS Mani
KS Mani

20. Thank You
email: research@neurokrish.com