Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
FULL-LENGTH ORIGINAL RESEARCH
Psychiatric comorbidity in epilepsy: A population-based
analysis
Jose F. Tellez-Zenteno, Scott B. Patten, Nathalie Jette, Jeanne Williams, and
Samuel Wiebe
Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan; and Departments of Community
Health Sciences and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
SUMMARY
Purpose: The estimated prevalence of mental
health disorders in those with epilepsy in the
general population varies owing to differences in
study methods and heterogeneity of epilepsy syn-
dromes. We assessed the population-based preva-
lence of various psychiatric conditions associated
with epilepsy using a large Canadian national pop-
ulation health survey.
Methods: The Canadian Community Health Sur-
vey (CCHS 1.2) was used to explore numerous
aspects of mental health in persons with epilepsy
in the community compared with those without
epilepsy. The CCHS includes administration of the
World Mental Health Composite International Di-
agnostic Interview to a sample of 36,984 subjects.
Age-specific prevalence of mental health condi-
tions in epilepsy was assessed using logistic regres-
sion.
Results: The prevalence of epilepsy was 0.6%. In-
dividuals with epilepsy were more likely than indi-
Originally coined by Feinstein, the term comorbidity
is used to refer to the greater than coincidental association
of two conditions in the same individual (Feinstein, 1970).
The psychiatric comorbidities in people with epilepsy have
important clinical and therapeutic implications. Preva-
lence studies on the association between epilepsy and psy-
chiatric disorders have found that epilepsy can precede,
co-occur with or follow the diagnosis of a psychiatric dis-
order (Gaitatzis et al., 2004a). The most frequent psychi-
atric diagnoses reported in people with epilepsy include
Accepted May 21, 2007; Online Early publication July 30, 2007.
Address correspondence and reprint requests to Dr. Samuel Wiebe, Di-
vision of Neurology, Foothills Medical Centre, 140329 St. NW, Calgary,
Alberta, Canada, T2 N 2T9. E-mail: swiebe@ucalgary.ca
Blackwell Publishing, Inc.


C 2007 International League Against Epilepsy
2336
viduals without epilepsy to report lifetime anxiety
disorders or suicidal thoughts with odds ratio of 2.4
(95% CI = 1.53.8) and 2.2 (1.43.3), respectively. In
the crude analysis, the odds of lifetime major de-
pression or panic disorder/agoraphobia were not
greater in those with epilepsy than those without
epilepsy, but the association with lifetime major
depression became significant after adjustment for
covariates.
Conclusions: In the community, epilepsy is associ-
ated with an increased prevalence of mental health
disorders compared with the general population.
Epilepsy is also associated with a higher prevalence
of suicidal ideation. Understanding the psychiatric
correlates of epilepsy is important to adequately
manage this patient population.
KEY WORDS: EpilepsyPsychiatric comorbidity
DepressionAnxiety disordersMood disord-
ersSubstance abuseSuicidal ideationHealth
surveysPopulation-based.
psychoses, neuroses, mood disorders (DSM-IV axis I dis-
orders), personality disorders (DSM-IV axis II disorders),
and behavioral problems (Gaitatzis et al., 2004a). Psychi-
atric symptoms can be classified according to their tem-
poral relationship with seizure occurrence. They can be di-
vided into peri-ictal symptoms (related to the seizure itself)
or interictal symptoms (independent of seizures). Peri-ictal
symptoms can precede the seizure (pre-ictal), occur dur-
ing a seizure itself (ictal), or follow the seizure (postictal)
(Swinkels et al., 2005).
There are few population-based studies evaluating
the prevalence of psychiatric conditions in people with
epilepsy. Most studies involve selected groups of patients
from tertiary centers or specialized clinics. Psychiatric psy-
chopathology may be overrepresented in selected popula-
tions such as patients with temporal lobe epilepsy or those

with refractory seizures. Forsgren (1992) performed a sur-
vey in 713 adults with active epilepsy in northern Swe-
den. In that study, 5.9% of patients reported a psychiatric
disorder: 0.8% had schizophrenia, 0.6% had psychoses,
and 1.7% had personality disorders. Another group (Jalava
and Sillanpaa, 1996) followed a cohort of 94 persons with
epilepsy and 199 without epilepsy from the general pop-
ulation. The lifetime prevalence of psychiatric disorders
was 0.7% in the general population and 24% in people
with epilepsy. Another study using a general practitioner
database (Mensah et al., 2006) evaluated 499 patients with
epilepsy and found that 11.2% had depression. Gudmunds-
son (1966) studied all individuals with epilepsy in Iceland
(n = 987) and found that 52% had some nonpsychotic men-
tal condition and 7% had lifetime psychosis. Some studies
have also been performed in children. Havlova (1990) re-
ported mental abnormalities in 6.7% of 225 patients with
childhood-onset epilepsy, Rutter et al. (Rutter et al., 1970)
reported a prevalence of 27% of psychiatric conditions in
children with epilepsy and 7% in children from the general
population and finally Hacket et al. (1998) reported a 23%
prevalence of psychiatric disorders compared with 8.1% of
children from the general population.
Broad-ranging general population studies using vali-
dated psychiatric diagnoses are essential to understand the
mental health problems of the entire spectrum of people
suffering from epilepsy. Also, the use of standard measures
and definitions, as employed in the broader literature of
psychiatric epidemiological studies, is important for inter-
pretation of population-based estimates. Using data from
the 1.2 cycle of the Canadian Community Health Survey
(CCHS), we assessed the prevalence of psychiatric con-
ditions in individuals with epilepsy compared with those
without epilepsy. This study is one of the few available
studies in the literature exploring psychiatric comorbidities
in people with epilepsy from the general population using
a structured interview based on the DSM-IV criteria.
M ETHODS
Canadian community health surveymental health
and well-being (CCHS-MHWB)
The Canadian community health survey (Cycle 1.2)
The CCHS cycle 1.2 is a cross-sectional survey that col-
lects a wide range of information relating to health status,
health care utilization, and determinants of health for the
Canadian population. Information was collected between
May 2002 and December 2002 from a representative sam-
ple of persons 15 years or older, living in private dwellings
in the ten provinces and the three territories (Gravel and
Beland, 2005). Individuals living on Indian Reserves or
Crown lands, clientele of institutions, full-time members
of the Canadian Armed Forces and residents of certain re-
mote regions were excluded from the sampling frame. One
2337
Psychiatric Comorbidity of Epilepsy in Canada
person aged 15 years or older was randomly selected from
sampled households. A significant effort was made to inter-
view respondents in person at their place of residence (86%
of cases). Interviews were conducted in English, French,
Chinese, or Punjabi (as required or requested by the in-
terviewee). From the initially selected 48,047 households,
there was an 86.5% household-level response rate, and
among responding household, there was an 89.0% person-
level response rate. The overall response rate was thus
77.0%, resulting in a total sample size of 36,984 respon-
dents.
Ascertainment of psychiatric conditions
The CCHS 1.2 mental health interview was based
on the WMH-CIDI (World Mental Health (WMH) Sur-
vey Initiative Version of the World Health Organiza-
tion (WHO) Composite International Diagnostic Interview
(CIDI) (Kessler and Ustun, 2004). A copy of the Cana-
dian adaptation is available on the Statistics Canada web-
site (Statistics Canada, 2003). Trained lay interviewers
using computer-assisted interviewing procedures adminis-
tered the survey. The following disorders were evaluated:
major depressive disorder, mood disorder, anxiety disor-
der, bipolar disorder, social phobia, agoraphobia, panic
disorder, substance dependence and suicidal ideation. Di-
agnostic algorithms followed DSM-IV criteria, with the
exception of the duration requirement for a manic episode.
The CCHS asked only whether manic symptoms had lasted
several days or longer whereas duration of seven days is
required by the DSM-IV when there has not been a need for
hospitalization. In this analysis we differentiated between
major depressive disorder and bipolar disorder by identi-
fying subjects with one or more lifetime manic episodes
according to the WMH-CIDI. The Canadian adaptation
of the WMH-CIDI evaluated subjects for illicit drug de-
pendence, and alcohol dependence was assessed using the
CIDI Short Form (Kessler et al., 1998). In this analysis,
substance dependence was defined as having either WMH-
CIDI drug dependence, CIDI Short Form alcohol depen-
dence, or both. Two disorders, dysthymia and schizophre-
nia were not assessed using a CIDI module, but instead
were assessed by eliciting self reported professional diag-
noses using items similar to those used to assess epilepsy,
see below.
Ascertainment of epilepsy
The presence of epilepsy was probed by an interviewer
asking directly Do you have epilepsy diagnosed by a
health professional? Subjects responding yes were con-
sidered as having epilepsy. This method of ascertainment
creates opportunity for under and overreporting, but it is
the only practical approach to explore population-based,
nation-wide morbidities. We have previously discussed is-
sues of validity of this method, and concluded that anal-
yses of prevalence of epilepsy using these health sur-
veys yield results that are compellingly similar to those of
Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
2338
J. F. Tellez-zenteno et al.
classic epidemiological studies (Hauser and Annergers,
1990) and which are also consistent across several health
surveys explored in the Canadian population (Wiebe et al.,
1999; Tellez-Zenteno et al., 2004, 2005).
Statistic analysis
The CCHS 1.2 used a multistage, stratified cluster de-
sign to select eligible households. To correct for the poten-
tial bias resulting from this complex survey design, Statis-
tics Canada recommends a bootstrap procedure using a set
of replicate weights that they supply. All results presented
here were produced with this approach and are therefore
representative of the targeted population. The standard er-
ror associated with specific estimates, p-values and con-
fidence intervals (95% CI) were adjusted for survey de-
sign effects by the bootstrap procedure. All analyses were
conducted at the Prairie Regional Data Centre of the Uni-
versity of Calgary campus, using SAS software. The same
methodology and analysis has been validated in previous
analysis using this survey (Patten et al., 2006a, 2006b).
Initially, the prevalence of the various mental health dis-
orders was estimated, and 95% confidence intervals for
these estimates were calculated. Stratified analysis and lo-
gistic regression analysis were carried out to explore the
impact of demographic variables on prevalence. In the lo-
gistic regression models, age was added as a continuous
variable, so that the models described the log odds of hav-
ing a disorder as a function of epilepsy status, age (in
years), and sex. Interaction terms were also explored, and
their statistical significance was evaluated using Wald tests
adjusted for design effects as described above. For ease of
presentation, the fitted log odds from the logistic regression
models were exponentiated to produce fitted odds and then
converted to proportions by dividing the fitted odds by the
fitted odds plus one.
R ESULTS
Prevalence of epilepsy
Of the 36,984 CCHS cycle 1.2 participants, 253 reported
having epilepsy (weighted prevalence of 6 per 1,000 people
(95% CI = 57).
Prevalence of psychiatric conditions
in those without epilepsy
The prevalence of mental health disorders in people
without epilepsy was (95% CI): major depressive disor-
der (12 month) 3.9% (3.64.2), major depressive disor-
der (lifetime) 10.7% (10.211.2), dysthymia (12 months)
0.3% (0.30.4), bipolar disorder (12 month) 1.0% (0.8
1.1), panic disorder (12 month) 1.5% (1.31.7), agorapho-
bia (12 month) 0.5% (0.40.7), social phobia (12 month)
3.0% (2.73.2), schizophrenia (12 months) 0.2% (0.20.3),
drug dependence (12 month) 0.8% (0.60.9) and alcohol
dependence (12 month) 2.6% (2.42.8).
Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
The prevalence of any evaluated mood disorder (12
month) was 5.2% (4.95.5), any evaluated anxiety disor-
der (12 months) 4.6% (4.34.9), anxiety disorder (life-
time) 11.2 (10.811.7), mood or anxiety disorder (12
month) 8.0% (7.68.5), mood disorder lifetime (includes
dysthymia 12 month) 13.2% (12.713.7), mood disor-
der/anxiety disorder/dysthymia (lifetime) 19.6% (19.0
20.2), panic disorder/agoraphobia (12 month) 2.0% (1.8
2.2), panic disorder/agoraphobia (lifetime) 3.6 (3.33.9)
and substance dependence (12 month) 3.1% (2.83.3).
The prevalence of any mental health disorder (12 month)
was 10.9% (10.411.3) and for lifetime was 20.7 (19.5
20.7).
Prevalence of psychiatric conditions
in people with epilepsy
The prevalence of mental health disorders in people
with epilepsy was as follows (95% CI): major depres-
sive disorder (lifetime) 17.4% (10.024.9), mood disor-
ders (12 month) 14.1% (7.021.1), mood disorder (life-
time) 24.4 (16.032.8), anxiety disorders (12 month)
12.8% (6.019.7), anxiety disorder (lifetime) 22.8 (14.8
30.9), mood/anxiety disorder (12 month) 19.9% (12.3
27.4), mood disorder including dysthymia (lifetime) 34.2%
(25.043.3), panic disorder/agoraphobia (12 month) 5.6%
(1.99.2) and panic disorder/agoraphobia (lifetime) 6.6
(2.910.3). The prevalence of any mental health disor-
der (12 month) was 23.5 (15.831.2) and for lifetime was
35.5 (25.944.0). This list of estimates of disorder preva-
lence for respondents with epilepsy is not identical to that
presented above for people without epilepsy because in
some cases the epilepsy estimates were too imprecise to
be presented: major depressive disorder (12 month), dys-
thymia (12 month), bipolar disorder (12 month), panic dis-
order (12 month), agoraphobia (12 month), social phobia
(12 month), schizophrenia (12 month), drug and alcohol
dependence (12 month), and substance dependence (12
month).
Suicidal ideation
The lifetime prevalence of suicidal ideation in people
with epilepsy was 25% (17.432.5) compared with 13.3%
(12.813.8) in those without epilepsy.
Odd ratios for lifetime mood, anxiety disorders, and
suicidal thoughts
Individuals with epilepsy were more likely than individ-
uals without epilepsy to report lifetime anxiety disorders
or suicidal thoughts with odds ratio of 2.4 (95% CI = 1.5
3.8) and 2.2 (1.43.3), respectively. The odds of lifetime
major depression or panic disorder/agoraphobia were ele-
vated in those with epilepsy compared with those without
epilepsy to a similar extent as for any anxiety disorder or
suicidal thoughts, although the confidence intervals for the
odds ratios in each case reached the null value of 1.0. The
odds ratio for lifetime major depression was 1.8 (1.03.1)

Table 1. Psychiatric comorbidity in people with epilepsy and the general population
Psychiatric disorder No epilepsy (N = 36,727) (95% CI)
Major depressive disorder (Lifetime)
Mood disorder (Lifetime)
Mood disorder (12 month)
Anxiety disorder (Lifetime)
Anxiety disorder (12 month)
Mood/anxiety disorder (12 month)
Mood disorder/anxiety disorder/dysthymia (lifetime)
Panic disorder/agoraphobia (Lifetime)
Panic disorder/agoraphobia (12 month)
Suicidal ideation (lifetime)
Any mental health disorder (12 month)
Any mental health disorder (lifetime)
CI, confidence interval.
and for panic disorder/agoraphobia was 1.9 (1.03.7), re-
spectively.
Multivariate analysis
In multivariate analyses, several interactions were iden-
tified, providing a more detailed description of the epi-
demiological pattern. Major depressive disorder (12-
month) had a statistically significant age by sex interaction
(Wald 2 = 9.5, p = 0.002), such that the sex difference
(women > men) was seen to decline with age. However,
the difference in the effect of sex over age did not differ
in people with or without epilepsy (Wald 2 = 1.36, p =
0.24), nor was evidence of an age by epilepsy (Wald 2 =
0.96, p = 0.33) and epilepsy by sex interaction (Wald 2
= 1.21, p = 0.27). For this reason, it was possible to iden-
tify a single age- and sex-adjusted odds ratio describing the
association of epilepsy with major depressive disorder (12
month): 2.3 (95% CI = 0.995.23), which was not statisti-
cally significant (Wald 2 = 3.7, p = 0.05).
Because 12-month prevalence is predictably lower than
lifetime prevalence, a comparison of major depressive dis-
order lifetime prevalence is expected to be less vulnera-
ble to Type II error than the 12-month analysis, and to
achieve greater precision of estimation. The logistic re-
gression model for lifetime major depression prevalence
followed the same pattern as that of 12-month prevalence
(an age by sex interaction, but no interactions involving
epilepsy). Here, the age- and sex-adjusted odds ratio was
1.8 (95% CI = 1.13.2), a statistically significant elevation
(Wald 2 = 4.9, p = 0.03).
A model for any 12-month mood disorder produced a
similar pattern. However, with the inclusion of other mood
disorders (bipolar disorder and dysthymia), the OR for
epilepsy became higher (OR = 3.2, 95% CI = 1.75.9).
Panic disorder with agoraphobia (12 month) presented a
more complex epidemiological pattern. There was no age
by sex interaction (Wald 2 = 2.5, p = 0.11) but a sta-
tistically significant epilepsy by disorder interaction was
identified (Wald 2 = 5.8, p = 0.02). Because of this in-
2339
Psychiatric Comorbidity of Epilepsy in Canada
Epilepsy (N = 253) (95% CI)
10.7 (10.211.2) 17.4 (10.024.9)
13.2 (12.713.7) 24.4 (16.032.8)
5.2 (4.95.5) 14.1 (7.021.1)
11.2 (10.811.7) 22.8 (14.830.9)
4.6 (4.34.9) 12.8 (6.019.7)
8.0 (7.68.5) 19.9 (12.327.4)
19.6 (19.020.2) 34.2 (25.043.3)
3.6 (3.33.9) 6.6 (2.910.3)
2.0 (1.82.2) 5.6 (1.99.2)
13.3 (12.813.8) 25.0 (17.432.5)
10.9 (10.411.3) 23.5 (15.831.2)
20.7 (19.520.7) 35.5 (25.944.0)
teraction, a statistical test for the overall effect of epilepsy
is not presented. However, the epilepsy parameter from the
logistic regression model ( = 0.043) indicated no associ-
ation at the baseline age (15 years), OR = 0.6 (95% CI =
0.17.4), and an increasing effect with age. In contrast, age
itself was associated with an odds ratio below 1, indicating
a tendency for panic disorder with agoraphobia to decline
in prevalence with age in people without epilepsy.
The rest of the explored variables are shown in Table 1.
Figs. 1A and B provide a graphic representation of the lo-
gistic regression models predicting the prevalence of men-
tal health disorders (on the y-axis) based on age (on the
x-axis.) and gender. The major depression model displays
a consistent relative effect of epilepsy across the age range
in men and women. In the panic disorder model, the age by
epilepsy interaction indicates that the prevalence of panic
disorder in people with epilepsy increases with age, in
distinction to the pattern seen in people without epilepsy
where a decline with age is seen.
D ISCUSSION
We explored the prevalence of different psychiatric
conditions in people with epilepsy using a large, vali-
dated, general population-based health survey in Canadi-
ans. Few studies have explored the psychiatric comorbidi-
ties of epilepsy using population-based data sources (Ta-
ble 2) (Gaitatzis et al., 2004a). A recent nonsystematic re-
view, found a prevalence of psychiatric disorders in peo-
ple with epilepsy of 6% using population-based data and
20% using more selective populations such as temporal
lobe epilepsy patients (Gaitatzis et al., 2004a). In that re-
view, the prevalence of various psychiatric disorders in per-
sons with epilepsy was: mood disorders 24-74%, depres-
sion 30%, anxiety disorders 1025%, psychoses 27% and
personality disorders 12% (Gaitatzis et al., 2004a).
Several studies have explored psychiatric comorbidi-
ties in nonselected populations of people with epilepsy
Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
2340
J. F. Tellez-zenteno et al.
(Table 2). Studies that used survey methods similar to ours
include those by Forsgren (1992), Strine et al. (2005),
Hacket et al. (1998), Ettinger et al. (2004), Gudmundsson
(1966), Davies et al. (2003) and Pond and Bidwell (1960).
There is extensive variation in the ascertainment methods
of psychiatric comorbidities, the prevalence rates obtained
and the population sources. The only studies using stan-
dardized interviews such as ours are those by Davies et al.
(2003) and Pond and Bidwell (1960). Their findings are
similar to ours, with general prevalence rates of mental
health conditions of 37% (Davis et al.), 29% (Pond and
Bidwell), and 23.5% (our study). Furthermore, all of these
studies found a higher prevalence of mental health disor-
ders in people with epilepsy than in the general population.
The higher rate found in Davies et al.s study (2003) could
be related to the small sample of subjects with epilepsy
in that study (n = 67). Psychiatric epidemiological stud-
ies may include coverage of different sets of mental health
Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
Figure 1.
(A) Logistic regression (fitted)
models predicting the lifetime
prevalence (proportion in per-
centage) of major depressive dis-
order (on the y-axis) based on age
(on the x-axis) and gender. (B)
Logistic regression (fitted) models
predicting the 12-month preva-
lence (proportion in percentage)
of panic disorder/agoraphobia (on
the y-axis) based on age (on the
x-axis) and gender.
Epilepsia

C ILAE
disorders, which can also affect any disorder prevalence
rates. Some disorders, such as specific phobia, are common
and were not included in the CCHS 1.2.
Examples of studies with methodology different from
ours include the studies of Strine et al. (2005) and Kobau
et al. (2006), which only evaluated self-reported depres-
sive and anxiety symptoms, and found higher rates than
with other methods of ascertainment. This is not surprising,
since not all psychiatric symptoms necessarily represent
disorders. The concept of a disorder requires symptoms
to be present, but also imposes additional requirements
such as persistence, associated distress and associated dys-
function. Gudmundsson (1966) used nonstandardized in-
terviews, and found a high prevalence of psychiatric di-
agnoses of 54%. It is conceivable that these studies may
overestimate the prevalence of psychiatric conditions, in
part due to the lack of standardized interviews. Other com-
mon methods of ascertainment include the use of the World
 Table 2. Nonselected populations
Ascertainment Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence
method of Type Use of psychiatric of of anxiety of of of personality of alcohol
psychiatric of of conditions depression disorder schizophrenia psychosis disorders dependence
Author N conditions population controls (%) (%) (%) (%) (%) (%) (%)
Pond, 1960; UK 245 PE Psychiatric interview Open population Only explored 29a NS NS NS NS NS NS
not based on (health survey) psychiatric
DSM-IV Children comorbidity in
epileptics
Gudmudsson, 654 PE Interview with Open population Only explored 54.5a NE NE NE 7a NE NE
1966; Iceland physician (no (health survey) psychiatric
standardized Children and adults comorbidity in
interview) patients with
epilepsy
Rutter, 1970; 63 PE 144 PWE Psychiatric interview Open population Controlled (healthy 28.6/6.8a NE NE NE NE NE NE
Isle of Wight (PBS) Children children)
Edeh, 1987; 88 PE CIS Adults with epilepsy NCOE 48a 22a 15a 1a 3.4a 2.2a NS
London from GP practice
Havlova, 1990; 225 PE Chart review Cohort of children NCOE 6.7c NE NE NE NE NE NE
Prague from a hospital
with a neurology
program in Prague
Forsgren, 1992; 713 PE Chart review Open population NCOE 5.9a NS NS 0.8% 0.7% 0.7% NS
Sweden (health survey)
Adults
Jalava, 1996; 94 PE 199 PWE Chart review and Adults with epilepsy Controlled (random 24/0.7b NS NS NS 3.1/0b NS NS
Finland ICD-9 from different healthy residents
sources of Finland and
employee controls
of a printing
house)
Bredkjaer, 1998; 67,116 people ICD-8 National patient NCOE 16.8% NE NE NE NE NE NE
Denmark with epilepsy register

Continued.
Psychiatric Comorbidity of Epilepsy in Canada
2341

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Epilepsia, 48(12):23362344, 2007
 2342

Table 2. Continued
Ascertainment Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence
method of Type Use of psychiatric of of anxiety of of of personality of alcohol
J. F. Tellez-zenteno et al.

psychiatric of of conditions depression disorder schizophrenia psychosis disorders dependence

Author N conditions population controls (%) (%) (%) (%) (%) (%) (%)

Epilepsia, 48(12):23362344, 2007

Stefansson, 241 PE 482 ICD-9 Adult patients Controlled (same list as 35.3/29.7a NE NE 1.2/0.4a 6.2/2.3a 18.3/21a 5/2.3a

doi: 10.1111/j.1528-1167.2007.01222.x
1998; Iceland PWE receiving disability people with epilepsy)
benefits
Hackett, 1998; 26 PE 1377 ICD-10 Open population Controlled (healthy 23.1/8.1a NE NE NE NE NE NE
India PWE (health survey) adults)
Adults
Davies, 2003; 67 PE 10249 Psychiatric interview Open population Controlled (nonepileptic 37/9a NE NE NE NE NE NE
UK PWE based on DSM-IV (health survey) patients)
criteria Children
Ettinger, 2004; 775 PE CES-D Open population All had epilepsy NE 36.5a NE NE NE NE NE
USA (health survey)
Adults
Gaitatzis et al., 5834 PE ICD-9 Patients from a Controlled (patients 41 in PEa 18.2/9.2a 11.1/5.6a 0.7/0.1a 9/2a NE 2.4/0.4a
2004; UK database generated without epilepsy)
from GP All age
groups
Strine, 2005; 427 PE 30018 Kessler 6 scale Open population Controlled (nonepileptic NE 32.6/15.5a 14.4/6.8a NE NE NE NE
USA PWE (depression and (Health survey) patients)
anxiety symptoms) Adults
Kobau, 2006; 131 PE 4154 Self-reported Open population Controlled (nonepileptic NE 39/15a 39/15a NE NE NE NE
USA PWE prevalence (Health survey) patients)
Children and adults
Mensah, 2006; 499 PE HADS Adults with epilepsy NCOE NS 11.2a NS NS NS NS NS
UK from GP practice
Tellez-Zenteno, 253 PE, 36,984 CIDI Open population Controlled (nonepileptic 23.5/10.9d 17.4/10.8d 12.8/4.7d NE NE NE NE
2007; Canada PWE (health survey) patients)
Adults
a
Point prevalence, b prevalence during a follow-up of 35 years, c lifetime prevalence, d 12 month prevalence. e Combined anxiety and depression symptoms.
PE, patients with epilepsy; PWE, patients without epilepsy; CES-D, Center for Epidemiology Studies-Depression Scale; CIDI, Composite International Diagnostic Interview; CIS,
Clinical Interview Schedule; HADS, Hospital Anxiety and Depression Scale; ICD, International Classification of Diseases; GP, general practionners; PBS, population-based study;
NCOE, noncontrolled, only epileptics; NS, not stated; NE, not examined.

Health Organization International Classification of Dis-
eases (ICD) codes from administrative data (Jalava and Sil-
lanpaa, 1996; Hackett et al., 1998; Stefansson et al., 1998;
Gaitatzis et al., 2004b). Significant variations in the preva-
lence of psychiatric conditions exist among these studies.
Yet, their reported prevalence rates are similar to ours.
Along the same line, there is always the possibility that
some of the epilepsy subjects in our study may have non
epileptic events. However, our prevalence rates of epilepsy
are comparable to that reported in other studies, making
it less likely that it would represent a significant limita-
tion.
Studies using populations like general practitioners reg-
istries such as the studies by Edeh and Toone (1987) and
Gaitatzis et al. (2004a) show higher prevalence rates of
psychiatric conditions (Table 2). The same effect is ob-
served in the study by Stefansson et al. (1998), based on
a list of patients with disability. Studies using administra-
tive data (ICD coding) and lists of selected patients, such
as those by Gaitatzis et al. (2004a) and Stefansson et al.
(1998) show the highest prevalence rates of psychiatric
conditions. Only the Danish national epidemiologic study
(Bredkjaer et al., 1998) using ICD-8 found prevalence rates
of psychiatric conditions similar to ours.
The prevalence of psychiatric conditions may be higher
in children with epilepsy (Pond and Bidwell, 1960; Davies
et al., 2003; Gaitatzis et al., 2004a; Pellock, 2004; Swinkels
et al., 2005). Our study focused on subjects 15 years and
older as did other studies evaluating psychiatric comor-
bidity in nonselected populations (Edeh and Toone, 1987;
Forsgren, 1992; Jalava and Sillanpaa, 1996; Hackett et al.,
1998; Stefansson et al., 1998) and our results are limited to
this age group (Table 2).
Depression is the most common comorbid psychiatric
disorder in patients with epilepsy (Kanner, 2005). We
found a lower prevalence of depression than studies using
scales of symptoms or self reported prevalence of depres-
sion (Strine et al., 2005; Kobau et al., 2006). Ours is one
of the few population-based studies using a well-validated
instrument for psychiatric diagnoses (Kessler et al., 1998;
Kessler and Ustun, 2004). We obtained prevalence rates
similar to those studies using questionnaires to screen for
depression (Edeh and Toone, 1987; Mensah et al., 2006)
and also to studies using ICD coding and administra-
tive data (Gaitatzis et al., 2004b). Ettinger et al. (2004)
used survey methodology and a validated questionnaire to
screen for depression and found a higher rate of depression
compared with ours (Table 2). Our lower prevalence rates
could be explained by the use of a validated instrument
to diagnose rather than screen for psychiatric conditions.
In summary, the prevalence of depression in nonselected
populations such as in our study is lower compared with
the prevalence found in selected populations such as pa-
tients with temporal lobe epilepsy, or in those with refrac-
tory epilepsy where lifetime prevalence ranges between 8%
2343
Psychiatric Comorbidity of Epilepsy in Canada
and 48% (Koch-Weser et al., 1988; Victoroff et al., 1994;
Umbricht et al., 1995; Altshuler et al., 1999), with a mean
estimate of 30% across studies (Hermann et al., 2000). On
the other hand, our study and all the studies performed in
nonselected populations showed consistently higher rates
of depression in people with epilepsy compared with the
general population (Table 1).
The rate of anxiety disorders found in our study was sim-
ilar to the rates obtained in other studies performed in nons-
elected populations using diverse methodologies (Edeh and
Toone, 1987; Gaitatzis et al., 2004b; Strine et al., 2005).
Our study also found a lower prevalence of phobia com-
pared with studies of selected populations where the preva-
lence rates are around 20% (Koch-Weser et al., 1988; Vic-
toroff et al., 1994). This finding may partially be accounted
for by the lack of coverage of specific phobia in our study.
The rate of suicidal ideation in our study was greater
than that in the general population, in keeping with the ex-
isting literature (Jones et al., 2003; Pompili et al., 2005).
This likely explains in part why mortality overall is greater
in those with epilepsy compared with the general popula-
tion. This emphasizes the importance of preventive strate-
gies (Blumer et al., 2002).
The logistic regression models of prevalence by age and
gender provide important new information. The lifetime
prevalence of major depressive disorders declined with age
in women with and without epilepsy, and remains stable in
men, but is overall higher in people with epilepsy (Fig. 1A).
Panic disorder and agoraphobia increased with age only
in people with epilepsy (Fig. 1B). These data demonstrate
that different psychiatric problems vary in prominence with
age in a pattern that is different from the general popula-
tion. This can help raise clinicians alertness for psychiatric
conditions accordingly.
The main strength of our study is the ascertainment
method. The CIDI has been extensively validated to as-
certain psychiatric conditions in large populations (Kessler
et al., 1998; Kessler and Ustun, 2004) and allow us to pro-
vide realistic estimates of the prevalence of various psy-
chiatric conditions associated with epilepsy. Unfortunately,
the prevalence rates of some psychiatric comorbidities such
as bipolar disorder, schizophrenia, personality disorders,
psychosis, and substance dependence could not be calcu-
lated because of the small sample size. The current study
emphasizes the important contribution of medical morbid-
ity to the burden of mental health disorders in modern
society. These findings are important in planning health
services and provision of adequate medical therapy in in-
dividuals with epilepsy and comorbid mental health condi-
tions.
ACKNOWLEDGMENTS
This study was supported by an operating grant from the MSI
Foundation received by Dr. Samuel Wiebe.
Epilepsia, 48(12):23362344, 2007
doi: 10.1111/j.1528-1167.2007.01222.x
2344
J. F. Tellez-zenteno et al.
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