ORIGINAL ARTICLE Bali Medical Journal (Bali MedJ) 2021, Volume 10, Number 2: 521-525 P-ISSN.2089-1180, E-ISSN: 2302-2914 Description of depression in people with epilepsy in Aceh

Published by Bali Medical Journal Nova Dian Lestari1,2*, Nirwana Lazuardi Sary3, Arina Khairu Ummah4, Zulkarnain3, Nur Astini1,2

1Department of Neurology, Faculty of Medicine, Universitas Syiah Kuala, Banda ABSTRACT Aceh, Indonesia; 2Department of Neurology, Dr Zainoel Background: Depression is the most common comorbid in people with epilepsy (PWE). Detection of depression in PWE is not Abidin Hospital, Banda Aceh, Indonesia; a routine examination at a neurology clinic because it takes a long time. The education of Acehnese people regarding epilepsy 3 Department of Physiology, Faculty of is still limited, leading to discrimination and stigma in society. It is not easy to carry out examinations, and the diagnosis is Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; often overlooked. The objective of this study was to screen and to describe the characteristics of depression in PWE in Aceh. 4Undergraduate Medical Doctor Program, Method: This study was a descriptive observational study with the total respondents involved 41 PWEs. Detection of Faculty of Medicine, Universitas Syiah depression in PWE was conducted using the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), a valid, Kuala, Banda Aceh, Indonesia. reliable, shorter and more straightforward instrument test. The sample was determinate using the probability sampling method with a simple random sampling technique. *Corresponding author: Results: Our results found that 39% of respondents experienced depression, with the most NDDI-E scores ranged between Nova Dian Lestari; 11-15, with a percentage of 41.5%. Out of total, 57.1% of the depression occurred in women and those who aged between Department of Neurology, Faculty of 18-25 years old were more frequent to experience depression. Depression was more frequent among those who had no Medicine, Universitas Syiah Kuala, formal education (66.7%). Banda Aceh, Indonesia; Department of Conclusion: Depression in PWE in Aceh tends to occur in women, those with no education and those who worked as labor Neurology, Dr Zainoel Abidin Hospital, or farmer. Banda Aceh, Indonesia; [email protected] Keywords: Aceh, depression, epilepsy, NDDI-E, people with epilepsy. Received: 2021-04-17 Cite This Article: Lestari, N.D., Sary, N.L., Ummah, A.K., Zulkarnain., Astini, N. 2021. Description of depression in people with Accepted: 2021-06-19 epilepsy in Aceh. Bali Medical Journal 10(2): 521-525. DOI: 10.15562/bmj.v10i2.2389 Published: 2021-06-26

INTRODUCTION factors cause it, the stigma factor and the that often occurs in epileptic patients.11 natural factor of the brain. Self-stigma From a psychological perspective, the Epilepsy is a brain disorder characterized arises from the distrust of having to suffer terms depression and anxiety in epilepsy by a tendency to induce epileptic from epilepsy from the sufferer himself. are expressed as an increased emotional seizures with neurobiological, cognitive, Social stigma by society against PWE also response to seizures’ unpredictable psychological, and social consequences. frequently occurs in several countries, such nature and activity restriction.11 In the Epilepsy accounts for a significant as discrimination, humiliation, fear, and context of the two-way relationship proportion of 0.5% of the world’s disease interaction barriers.7 Another contributing between epilepsy and depression, not burden. As many as 80% of people with factor is a natural brain factor related to only is PWE at greater risk of developing epilepsy (PWE) live in low- and middle- 1–5 the imbalance of brain chemicals in PWE, depressive comorbidities, but patients income countries. Based on data which influences depression, such as low with depression had a four to seven times from the Central Statistics Agency of serotonin levels in the brain.8 Several higher risk of developing epilepsy.12–14 Aceh Province in 2016, epilepsy ranked PET studies have found that serotonin Depressive disorder ranked first in three third in mental health cases in Aceh receptors’ binding is reduced in various decades from 1990 to 2017. Several studies after schizophrenia and acute psychotic 5 PWE brain areas. The site with reduced explain that cases of depression in PWE disorders. serotonin receptor binding potential worldwide are recorded relatively high Epilepsy can occur at any age, gender, is ipsilateral with a resurgent focus, at 9.5-85 percent,15 and according to the and race and causes mortality and early 6 particularly during seizure onset and areas Institute of Health Metrics and Evaluation death. The risk of premature death in of seizure propagation. These factors have (IHME), depression is a factor that people with epilepsy can occur up to three a serious impact on PWE, which causes contributes to a large number of suicides times higher than the general population, sufferers to experience decreased quality in Indonesia.16 The results of primary with the highest early death rates in low- of life, depression, a worse prognosis, and health research (Riskesdas) 2018 by the and middle-income countries and rural 9,10 3 multiple suicidal impulses. Indonesian Ministry of Health showed areas. Proper treatment and diagnosis Depression is a comorbid symptom the prevalence of depression in the total can prevent these mortality rates. Two

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population age more than 15 years old Table 1. Characteristics of respondent, NDDI-E score and depression in Indonesia reached 6.1%. Depressive Percentage Variables Frequency (n=41) disorders have started to occur since the (%) age range of adolescents (15-24 years), Gender with a prevalence of 6.2%.17 The prevalence Male 20 48.8 pattern of depression increases with Female 21 51.2 age. WHO data in 2019 from hundreds Age group (year) of millions of people in Indonesia, one 18-25 14 34.1 18 person dies due to suicide every hour. 26-35 12 29.3 During this time, the detection of 36-45 10 24.4 depression in PWE is not a routine 46-55 4 9.8 examination at the neurology clinic 56-65 1 2.4 because the assessment of depression takes Education a long time and it is difficult to do in the No School 3 7.3 outpatient clinic making this test is often Elementary 4 9.8 not performed. In addition, the diagnosis is Junior high school 8 19.5 19 often missed. Education of the Acehnese Senior high school 10 24.4 people regarding epilepsy is still limited College 16 39.0 due to emergence of discrimination and Profession negative stigma in the community, making Not Working 20 48.8 it more challenging to examine. Until Labor/Farmer 5 12.2 now, research on the characteristics of Entrepreneurial 6 14.6 PWE in Aceh has never been carried out. Private Employees 3 7.3 Therefore, this study sought to explore this Civil Servants/Military 6 14.6 problem by determine the incidence and Retired 1 2.4 the characteristics of depression in PWE NDDI-E Score using a valid, reliable, shorter Simpler 6-10 8 19.5 Neurological Disorders Depression 11-15 17 41.5 Inventory for Epilepsy (NDDI-E) 16-20 14 34.1 instrument. NDDI-E instrument is 21-25 2 4.9 reliable for detecting major depressive Depressive Events disorders in epileptic patients. The results for detection of depression have increased Depression 16 39.0 almost tenfold using this instrument.20 No Depression 25 61.0 NB: Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) METHODS This research is a descriptive observational with NDDI-E. The independentRESULTS study with a cross-sectional design. variables collected in this study included The data used are primary in the form demographic data and basic characteristics The distribution of characteristics of PWE of answers to an online questionnaire of epilepsy patients, including age, sex, in Aceh are presented in Table 1. Out of consisting of assessing depressive education level, and type of work. Then the total patients, 51.4% were women and symptoms in people with epilepsy using NDDI-E score was measured to determine most of the patients aged between 18-25 the Neurological Disorders Depression the condition of the depressive symptoms years old with a percentage of 34.1%. The Inventory for Epilepsy (NDDI-E). This experienced by epilepsy patients. The distribution of the social characteristics study’s sample consisted of 41 respondents NDDI-E score ranges from 6 to 25 divided of PWE can be assessed from the level of from Aceh province, consisting of people into 4 groups. The NDDI-E score > 15 is education and employment. The results with epilepsy who were over 18 years of categorized as a symptom of depression, showed that education for people with age and who did not experience severe while the score below is categorized epilepsy in Aceh was mainly at the college mental disorders obtained by probability as not experiencing depression. The level, with 39%. Based on employment, sampling method. Determining the data obtained were analyzed using the 48.8% of samples were not working (Table sample using a simple random sampling univariate test to explain and describe 1). From the research results on PWE in technique is carried out randomly without each research variable’s characteristics and Aceh, 46.3% did not have a regular income paying attention to the strata that exist in its relation with depression in epilepsy every month and did not have dependents the population members. patients in Aceh. that tended to dominate with a percentage The dependent variable of this study of 61%. was depressive symptoms measured

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Table 2. Prevalence of depression based on patients’ characteristics and depression with social life. They found Depressive Event that out of 441 respondents, as many as 130 Variables Depression (n=16) No Depression (n=25) respondents had jobs, only 58 respondents 27 N % N % have a regular income. Gender The results of the study of 41 Male 4 20.0 16 80.0 respondents found that the incidence Female 12 57.1 9 42.9 of depression was found that 61% of Age group (year) PWE had no depression and 39% had 18-25 6 42.9 8 57.1 depression. It was obtained based on 26-35 6 50.0 6 50.0 an assessment using NDDI-E with the 36-45 4 40.0 6 60.0 highest scores ranging from 11-15 with 46-55 0 0.0 6 100.0 a percentage of 41.5%. Lacey’s previous 56-65 0 0.0 1 100.0 research in 2015 explained that in PWE, 11-84% experienced depression.28 Also, Education community-based studies of the epilepsy No School 2 66.7 1 33.3 population reported an incidence rate of Elementary 1 25.0 3 75.0 9–22% of depression, while hospital-based Junior high school 2 25.0 6 75.0 samples reported a much higher rate of Senior high school 5 50.0 5 50.0 epileptic patients with depression at 27– College 6 37.5 10 62.5 58%.29 Profession Our study found that the respondents Not Working 11 55.0 9 45.0 who experience depression tend to occur Labor/Farmer 3 60.0 2 40.0 in women with a percentage of 51.2%. Entrepreneurial 0 0.0 6 100.0 Research conducted previously by Qian Private Employees 1 33.3 2 66.7 Li in 2019 demonstrated that the female Civil Servants / 1 16.7 5 83.3 gender is at higher risk for depression in Military PWE. Another study comparing the degree Retired 0 0.0 1 100.0 of depression in male and female gender conducted by Adele in 2017 using the Patient Health Questionnaire-9 (PHQ-9) Our data suggested that the incidence Natashia et al in 201910 also found that also showed a significant value for female of depression was found in 39% while 61% epilepsy are predominantly in female.10 gender as a risk factor for depression in of samples had no depression (Table 1). It Based on age, each study had different age epileptic sufferers.29 Research conducted was obtained based on an assessment using characteristics.23 A survey by Ivanmorl by Herzorg in 2003 related to depression NDDI-E with the most of the patients had et al in 2018 at the Neurology Polyclinic in women with epilepsy explained that score between 11-15 with a percentage of RSUD dr. M. Haulussy Ambon showed as hormonal changes due to the use of OAE 41.5%. many as 50% of people with epilepsy aged could lead to impaired sexual function The study results suggested that 17-25.24 in women, and that can be one of the respondent who experimented depression Based on level of education, the results factors of depression in women. But in a tend to occur in women with a percentage are more heterogeneous among studies. study conducted by Zeva in Czech in 2011 of 51.2% (Table 2). Based on the research For example a study by Nastasia et al in found no significant relationship between shown in Table 2, PWE who did not Sikka Flores Regency (2019), found that the two variables.30,31 It is important to attend school tended to be depressed that the level of education is primarily note that although previous studies of with a percentage of 66.7%. Our data also elementary school graduates10 and a study depression risk among patients with suggested that PWE who did not work by Kaur et al among those aged between neurologic disease in common medical and those who worked as a laborer/farmer 21-60 years at the Dayanand Medical conditions found that women were more tend to have depression. College Neurology Clinic, Ludhiana in likely to be depressed than men, this northwest India found that 40.1% had gender difference was not consistently DISCUSSION graduated from college.25 Qian et al in observed in groups.30,31 2019 stated found that as many as 48% of Research in Turkey from 100 respondents Our study found that PE tends not to PWE in eastern China did not have a job; found that 51 people consisted of show the incidence of depression, this it is also influenced by the stigmatization women.21 Study in the Indonesian region is explained in several previous studies of the community towards PWE.25,26 Our in 2019 at the Jambi city hospital found such as Naess (2007),32 Nubukpo (2004),33 study found that 46.3% did not have a that 54.1% of the people with epilepsy and Mensah (2006).31 However, there are regular income every month and 61% did was women.22 Studies by Tedrus et al differences in each study, such as a study not have dependents. A previous study research in 2015, Qian et al in 2019,9 and conducted by Yanhong Yang in 2020, was to assess the relationship of anxiety

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which explained that the older age group FUNDING 8. Kaplan&Sadock. Buku Ajar Psikiatri is associated with an increased risk of Klinis. 2nd, cetakan ed. husny muttaqin experiencing depression.23 In contrast, This research did not receive any specific retna neary elseria sihombing, editor. the research conducted by Shiv Kumar in grant from funding agencies in the public, USA: Lippicott Williams & Wilkins; 2009. 191 p. 2020 demonstrated that the younger age commercial, or not-for-profit sectors. 9. Li Q, Chen D, Zhu L na, Wang H jiao, group was more likely to are depressed ETHICAL STATEMENT Xu D, Tan G, et al. Depression in people compared to the older age group. Therefore with epilepsy in West China: Status, depressive examination of the young age The Ethical Clearance Committee of risk factors and treatment gap. Seizure. group is more needed.34 Faculty of Medicine Universitas Syiah 2019;66(November 2018):86–92. Our study also found that PWE Kuala approved the study protocol 10. Suryawijaya N, Sam CIL, Gelgel AM. who did not attend school tended to MKEPPKN registration number: Perilaku Terhadap Penyandang Epilepsi be depressed. Several previous studies, 1171012P. Pada Masyarakat Kewapante , Kabupaten such as Lee et al (2018), Bifftu’s (2015), Sikka. 2019;2:90–7. 11. Kotwas I, Mcgonigal A, Bastien-Toniazzo and Tsegabrhan (2014), explained that AUTHOR CONTRIBUTION M, Bartolomei F, Micoulaud-Franchi educated PWE is less likely to be at risk Nova Dian Lestari is responsible in JA. Stress regulation in drug-resistant depression.35–37 In addition, our study conceived and designed the analysis, epilepsy. Epilepsy Behav. 2017;71:39–50. also found that PWE who did not work collected the data, contributed data 12. Kanner AM. The treatment of depressive and those who worked as laborer or disorders in epilepsy: What all neurologists or analysis tools and wrote the paper. farmer tended to have depression. A should know. Epilepsia. 2013; Nirwana Lazuardi Sary conceived and study conducted by Ruth et al (2017) and 13. Hesdorffer DC, Allen Hauser W, designed the analysis and contributed data Wang et al (2018) explained that PWE Olafsson E, Ludvigsson P, Kjartansson O. or analysis tools. Arina Khairu Ummah with stable employment is less likely to Depression and suicide attempt as risk collected the data, contributed data or factors for incident unprovoked seizures. develop depression and Yanghong et al in analysis tools, performed the analysis and Ann Neurol. 2006; 2020 hypothesized that this is because the wrote the paper. Zulkarnain contributed in 14. Hesdorffer DC, Ishihara L, Mynepalli L, emotional support is important in PWE. data analysis and statistical analysis. Nur Webb DJ, Weil J, Hauser WA. Epilepsy, In addition, having a permanent job could Astini is responsible in collecting the data. suicidality, and psychiatric disorders: A reduce the maladaptive behavior that bidirectional association. Ann Neurol. All authors have contributed intellectually leads to affective disorders, one of which is 2012; in this manuscript and have read the final depression.23,38,39 15. Engidaw NA, Bacha L, Kenea A. manuscript. There are some limitations of the Prevalence of depression and associated study. The sample size was relatively small. factors among epileptic patients at Ilu REFERENCES Ababore zone hospitals, South West However, this sample size was adequate to Ethiopia, 2017: A cross-sectional study. 1. Perhimpunan KSE, Indonesia DSS, answer the study objective. In addition, Ann Gen Psychiatry. 2020; Tatalaksana (PERDOSSI). Pedoman in this study the number of assessed 16. Institute for Health Metrics and Evaluation Tatalaksana Epilepsi. 5th ed. Pusat independent variables was limited. More (IHME). Findings from the Global Burden Penerbitan dan Percetakan Unair (AUP). variables might need to assessed in the of Disease Study 2017. Lancet. 2017; 2014. 17. Kementerian Kesehatan RI. Hasil Utama future to provide more comprehensive 2. WHO. Epilepsy in the WHO South East Riset Kesehatan Dasar 2018. Kementrian findings. Asian Region Bridging the Gap. The Kesehat Republik Indones. 2018; Global Campaign Against Epilepsy “Out 18. World Health Statistic. Monitoring Health CONCLUSION of the Shadows.” 2011; for the SDGs. World Heal Stat. 2019; 3. Organization WH. Epilepsy Fact Sheet Our data suggested that women tend 19. Rahmi I, Budikayanti A, Lastri DN. UJI [Internet]. 2019. Available from: http:// VALIDITAS DAN REABILITAS THE to experience depression compared to www.who.int/mediacentre/factsheets/. NEUROLOGICAL ( NDDI-E ) VERSI men, with a percentage of 57.1%. Age 2019. INDONESIA Validity and Reliability test characteristics do not indicate a tendency 4. Organization WH. Epilepsy Fact Sheet of The Neurological Depression Disorders for depression to occur in PWE. PWE [Internet]. Available from: http://www. Inventory. 2013;31(1). who.int/mediacentre/factsheets/fs999/ tended to have depression when they 20. Friedman DE, Kung HD, Laowattana S, en/#. 2015. had no formal school and those who had Kass JS, Hrachovy RA LH. Identifying 5. Ramdani. Kemandirian dan Transparansi no occupation and those who worker as depression in epilepsy in a busy clinical Data BPS Ketika berbicara Masalah laborers farmers. setting enhanced with systemic screening. Kesehatan Jiwa Di Aceh Menjadi Visi dan Seizure. 2009; Misi. Artik Kesehatan. 2016; 21. Cengiz GF, Tanık N. Validity and reliability CONFLICT OF INTEREST 6. World Health Organization. WHO | of the Turkish version of the Neurological Epilepsy: a public health imperative. None of the authors have any conflicts of Disorders Depression Inventory for World Health Organisation. 2019. interest to disclose. Epilepsy (NDDI-E). Epilepsy Behav. 7. Lim KS, Tan CT. Epilepsy stigma in Asia: 2019;99. The meaning and impact of stigma. Neurol Asia. 2014;19(1):1–10.

524 Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 521-525 | doi: 10.15562/bmj.v10i2.2389 ORIGINAL ARTICLE

22. Ekaputri TW, Larassati., Verbty NA, and Predictors of Depression Among 35. Lee S-A, Jeon JY, No S-K, Park H, Kim Kusdyah E. 1 ​ 1 ​. Med Malahayati. Patients With Epilepsy, Stroke, and O-J, Kwon J-H, et al. Factors contributing 2020;4(April):112–9. Multiple Sclerosis Using the Cleveland to anxiety and depressive symptoms in 23. Yang Y, Yang M, Shi Q, Wang T, Jiang M. Clinic Knowledge Program Within the adults with new-onset epilepsy. Epilepsy Risk factors for depression in patients with Neurological Institute. Psychosomatics. Behav. 2018;88:325–31. epilepsy: A meta-analysis. Epilepsy Behav. 2018;59(4):369–78. 36. Tsegabrhan H, Negash A, Tesfay K, Abera 2020;106:107030. 30. Ford DE, Erlinger TP. Depression and M. Co-morbidity of depression and 24. Ruspanah I. KARAKTERISTIK C-Reactive Protein in US Adults: Data epilepsy in jimma university specialized ANSIETAS PADA PASIEN EPILEPSI From the Third National Health and hospital, southwest ethiopia. Neurol India. DI AMBON. Molucca Medica. Nutrition Examination Survey. Arch 2014; 2018;11(April):41–9. Intern Med. 2004;164(9):1010–4. 37. Bifftu BB, Dachew BA, Tiruneh BT, Birhan 25. Kaur J, Paul BS, Goel P, Singh G. 31. Mensah SA, Beavis JM, Thapar AK, Kerr Tebeje N. Depression among people with Educational achievement, employment, M. The presence and clinical implications epilepsy in Northwest Ethiopia: a cross- marriage, and driving in adults with of depression in a community population sectional institution based study. BMC Res childhood-onset epilepsy. Epilepsy Behav. of adults with epilepsy. Epilepsy Behav. Notes. 2015;8(1):1–8. 2019;97(October 2017):149–53. 2006;8(1):213–9. 38. Tsigebrhan R, Hanlon C, Medhin G, 26. Gaus V, Kiep H, Holtkamp M, Burkert 32. Naess S, Eriksen J, Tambs K. Psychological Fekadu A. Help seeking and suicidality S, Kendel F. Gender differences in well-being of people with epilepsy in among people with epilepsy in a rural low depression, but not in anxiety in people Norway. Epilepsy Behav. 2007; income country setting: Cross-sectional with epilepsy. Seizure. 2015;32:37–42. 33. Nubukpo P, Preux PM, Houinato D, survey. Int J Ment Health Syst. 2017; 27. Peterson CL, Walker C, Shears G. The Radji A, Grunitzky EK, Avodé G, et 39. Wang HJ, Tan G, Deng Y, He J, He YJ, social context of anxiety and depression: al. Psychosocial issues in people with Zhou D, et al. Prevalence and risk factors Exploring the role of anxiety and epilepsy in Togo and Benin (West Africa) of depression and anxiety among patients depression in the lives of Australian adults I. Anxiety and depression measured using with convulsive epilepsy in rural West with epilepsy. Epilepsy Behav. 2014;34:29– Goldberg’s scale. Epilepsy Behav. 2004; China. Acta Neurol Scand. 2018; 33. 34. Sah SK, Rai N, Sah MK, Timalsena M, Oli 28. Lacey CJ, Salzberg MR, D’Souza WJ. Risk G, Katuwal N, et al. Comorbid depression factors for depression in community- and its associated factors in patients with treated epilepsy: Systematic review. epilepsy treated with single and multiple Epilepsy Behav. 2015;43:1–7. drug therapy: A cross-sectional study 29. Viguera AC, Fan Y, Thompson NR, Lapin from Himalayan country. Epilepsy Behav. B, Chaitoff A, Griffith SD, et al. Prevalence 2020;112:107455.

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