Academic Press Science Direct Epilepsy & Behavior


Mood disorders are linked to health-related quality of life in epilepsy

It comes as no surprise that disorders of mood are linked to health-related quality of life (HRQOL) for people with epilepsy. The report by Au et al.[1] in a recent issue of Epilepsy & Behavior confirms previous findings that depressed mood is closely associated with poor HRQOL among adult epilepsy patients.Perrine et al.[2] noted this association during the validation of the QOLIE-89 [3] comparing mood scores with QOLIE-89 scores.Bot h Perrine et al. [2] and Au et al.[1] pursued this hypothesis based on numerous reports suggesting an association between behavior and psychosocial function (Hermann, Dodrill, etc.). A review of the literature reveals that although depression and HRQOL are negatively correlated in epilepsy, it has not been possible to determine which is the driver. As such, we cannot state whether depressed mood causes low HRQOL in epilepsy or whether poor seizure control leads to depressed mood.

An interesting addition to the literature is the finding by Au et al.[1] that a feeling of lack of control is also correlated with low HRQOL.The concept of "locus of control" is based on understanding a patient's feeling of control over health status.In this observational cohort study, patients whose responses indicated that they perceived that their health (or seizure control) was beyond their control were more likely to have low HRQOL. This finding can logically be explained as a feeling of despair in which patients whose seizures cannot be well managed come to feel that their lives are not controllable.This despair may be expressed as low HRQOL. An associated finding was that satisfaction with social support was moderately correlated with QOLIE-89 domains, but availability of social support was not associated. It is likely that satisfaction and chance locus of control also were significantly correlated with mood, although this correlation was not described in the Au report.

A review of the early literature on psychosocial and behavioral problems among epilepsy patients provides abundant information about mood states. These assessments often used traditional psychosocial or neuropsychological tests [4–6]. The development of HRQOL instruments in recent years has provided a different approach to the assessment of patient perceptions [7]. The difference is the integration of psychological, social,

physical, and epilepsy-related domains into a single instrument. Analyses performed on subscales within the QOLIE-89 also have demonstrated that mood items were negatively correlated with overall HRQOL [2].The report by Au et al. [1] advances the concept that depressed mood spreads to or is impacted by other psychosocial functions.Their patients felt that they had no control over their health (i.e., seizures) and were dissatisfied with social support.

Although the high incidence of depression among epilepsy patients has been documented, the number of patients treated for depression is low. The apparent reluctance of neurologists to document a diagnosis of comorbid depression or to prescribe an antidepressant is difficult to interpret. Of course, treatment with an optimum combination of antiepileptic drugs is the primary goal. Nonetheless, these reports and others in the literature show that depression associated with poor seizure control has far-reaching effects. These data provide support for modification of antiepileptic drug therapy to reduce the burden of drugs that might be exacerbating the dysphoria. Despite the higher cost of second-generation drugs, their lesser adverse effect impact could be an important advantage for patients whose uncontrolled seizures cause an intolerable psychosocial burden [8].

1. Clinical importance

The message to health care providers is that poor seizure control is associated with a cascade of pervasive psychosocial problems that often are neglected as part of the patient's overall care. The lack of an index to guide treatment decisions has resulted in a purgatory of life experience for the many thousands of people with uncontrolled seizures. Ideally, clinicians would like to have a measure similar to a hemoglobin test that could relate low test levels with low energy, and need for intervention. In fact, we have HRQOL instruments that can be used as clinical measures of patient perceptions. Rather than using instinct in addition to seizure frequency to decide when to change or add a medication, HRQOL scores can be a simple guide to neurologists that define individual patient's status and (more importantly) changes in status.

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492 Editorial / Epilepsy & Behavior 3 (2002) 491–492  

A variety of small population surveys provide data for the development of resource information on HRQOL scores. The time has come to pool these data, to expand the amount of information on patients with low seizure frequency, and to make these population "norm" data available for use as benchmarks. The largest amount of data has been collected with the QOLIE-31 [9], but these can readily be converted to QOLIE-10 [10] scores to provide data on two brief, self-administered questionnaires. The QOLIE-10 [10] can be completed and scored (sum of all responses) by the patient before seeing the doctor who can use it as a screening tool. As with any new "laboratory" test the more the doctor sees the test results, the more meaningful and useful the data will become. It takes a while to learn the most appropriate range for a new laboratory test or the most appropriate range of HRQOL scores for a new instrument. When a patient is treated for low red blood cell count, the doctor looks for an increase in hemoglobin. Similarly, when treating for uncontrolled seizures, the neurologist should use HRQOL scores as an index of treatment results in addition to the traditional counting of seizures. HRQ OL is more than a reflection of seizures. Even when seizures are stopped, the HRQOL scores may indicate that burdens remain and require attention.

2. Research implications

The message for behavior researchers is that we need to organize the increasing amount of information available about HRQOL to make it useful for clinicians. I encourage someone to apply for a grant to compile the available HRQOL data toward creation of a global database. In the interim, I encourage investigators who have reported on HRQOL instruments to include them in a central list. The first edition of this compendium was developed under the auspices of the International League Against Epilepsy (ILAE) Subcommission on Outcomes in Epilepsy to provide documentation of the original sources of information about instruments [11]. This compendium was designed to be a resource for all researchers who need to search the literature. Use it to learn what has already been accomplished, and to determine what needs to be done to advance the field of

HRQOL research. It is important for researchers to share cross-cultural translations, population data, comparisons among instruments, and other data. The QOLIE instruments are available at no cost to further research in this area.



Au A, Li P, Chan J, et al. Predicting the quality of life in Hong Kong Chinese adults with epilepsy. Epilepsy Behav 2002;3:50–7.


Perrine K, Hermann BP, Meador KJ, et al. The relationship of neuropsychological functioning to quality of life in epilepsy. Arch Neurol 1995;52:997–1003.


Devinsky O, Vickrey BG, Cramer JA, et al.Developmen t of the quality of life in epilepsy (QOLIE) inventory. Epilepsia 1995;36:1089–104.


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Dodrill CB, Batzel LW, Queisser HR, Temkin NR. An objective method for the assessment of psychological and social problems among epileptics. Epilepsia 1980;21:123–35.


Hermann BP, Whitman S. Behavioral and personality correlates of epilepsy: a review, methodological critique, and conceptual model. Psychol Bull 1984;95:451–97.


Vickrey BG, Hays RD, Rausch R, Sutherling W, Engel J, Brook RH. Quality of life of epilepsy surgery patients as compared with outpatients with hypertension, diabetes, heart disease, and/or epression. Epilepsia 1994;35:597–607.


Cramer JA, Ben Menackem E, French J. Treatment options for refractory epilepsy: New medications and vagal nerve stimulation. Epil Res 2001;47:17–25.


Cramer JA, Perrine K, Devinsky O, Bryant-Comstock L, Meador K, Hermann BP. Development and cross-cultural translation of a 31-item quality of life questionnaire (QOLIE-31). Epilepsia 1998;39:81–8.


Cramer JA, Perrine K, Devinsky O, Hays RD, Hermann B, Meador K.A brief questionnaire to screen for quality of life in epilepsy: the QOLIE-10. Epilepsia 1996;40:114–21.


Cramer JA for the ILAE Sub Commission on Outcome Measurement in Epilepsy (C. Camfield, H. Carpay, C. Helmstaedter, J. Langfitt, K.Malmgren, S.Wiebe). Principles of health-related quality of life: assessment in clinical trials. Epilepsia 2002;43:1084–95.

Joyce A.Cramer*
Department of Psychiatry
Yale University School of Medicine
West Haven, CT 06516-2770, USA
E-mail address:

* Fax: 1-203-937-3468

Authored Date: 
Wednesday, November 6, 2013