Neglected psychiatric comorbidity in people with epilepsy in developing countries—response to Tellez‐Zenteno et al.

To the Editors: The study of mental health problems of people with epilepsy (PWE) from the Canadian Community Health Survey, reported by Tellez-Zenteno and colleagues (2007), is presented as one of few such population studies in the literature. It found higher rates of anxiety, suicidal ideation, and depression among PWE compared with the general population. These findings have broad significance not only for high-income countries like Canada, but relevance also for research and health services in low- and middle-income countries, where 80% of the PWE reside (Scott et al., 2001). The following points therefore merit consideration within the context of mental health problems in lower-income countries: (1) the historical link and present practice of psychiatrists treating epilepsy; (2) a different profile of mental health problems emerging from population studies, as compared with clinical specialty studies, of PWE; and (3) higher rates of suicidal ideation, indicating a possible cause of mortality from epilepsy mediated by psychosocial factors. This work highlights an important historical linkage between neurology and psychiatry through epilepsy, reflected not only in the origins of the International League Against Epilepsy itself as an interdisciplinary undertaking of neurology and psychiatry, but also in the inclusion of epilepsy as a current responsibility of WHO's Department of Mental Health and Substance Abuse. It is important to understand that in most countries of the developing world, where neurologists are rare or absent, the majority of PWE are treated by psychiatrists (WHO, 2005). Psychiatric morbidity identified in the Tellez-Zenteno and colleagues study focuses mainly on anxiety and depression, rather than psychoses. Schizophrenia could not be included in the analysis because of technical reasons arising from low-rates. The literature of psychiatry typically regards neuropsychiatric effects of epilepsy as “a range of biologically based psychopathology” (Sadock & Sadock, 2000), which result from central nervous system pathology or from the neuropathophysiology of seizure activity (including postictal or interictal phenomena). Findings of common mental disorders and suicidal ideation, rather than psychoses, suggest an important role of psychosocial, not just biological, factors explaining the impact of epilepsy on mental health. Furthermore, these findings highlight the importance of the impact of stigmatization affecting PWE within their families or communities (Jacoby et al., 2005). A consideration of the psychosocial underpinnings of epilepsy-related psychopathology is essential in responding to the authors' suggestion that findings be applied to “planning health services and provision of adequate medical therapy.” Among traditional segments of society in many developing countries, cultural perceptions of cause strongly influence stigma. Therefore, attention to the social context and its particular impact is crucial in attempts to provide support and encourage help seeking and self-management (Diop et al., 2003). Tellez-Zenteno and colleagues show that the prevalence of suicidal ideation is significantly higher among PWE. This may explain a source of mortality by suicide that reflects the severity of psychosocially-mediated aspects of the illness experience of epilepsy. A mental health component should be introduced into health system operations and sentinel surveillance activities of health demographic surveillance systems. Such a component should ensure that careful consideration of epilepsy, suicide, and indications of mental health problems are included in protocols for eliciting verbal autopsies and population-based health studies. These factors should be considered in establishing local priorities, as well as in North–South collaboration (Doku & Mallett, 2003) between industrialized and developing countries.

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