Children with epilepsy are at an increased risk for behavioral or psychiatric comorbidities.^1,2 Symptoms of depression, anxiety, and other behavioral difficulties (e.g., impulsivity, inattention) may be reported by the child, parent, teacher, or even the physician. It is increasingly evident that anxiety and depression are significant comorbidities among children with epilepsy.^3,4 If left unrecognized and untreated, psychiatric comorbidities may have an adverse psychosocial impact on the child in terms of academic and social development as well as family functioning as demonstrated in the general population. Psychiatric comorbidities in childhood can have long-term implications overflowing into adulthood impeding lifetime achievement and negatively impacting overall quality of life.

Contemporary psychiatric diagnostic systems (DSM [Diagnostic and Statistical Manual], ICD [International Classification of Diseases]) have only recently been used to comprehensively characterize the nature and type of these problems in children with epilepsy. There is minimal understanding of the additional complications caused by comorbid mental health disorders (e.g., cognitive problems, academic underachievement, increased health care utilization, adverse impact on family), and most striking is the lack of randomized controlled intervention trials to treat psychiatric comorbidities in youth with epilepsy with the exception of ADHD. Recently, research has indicated that epilepsy variables (i.e., seizure frequency, AEDs, and seizure type) are often not implicated in the occurrence of psychiatric comorbidities. This chapter will highlight the prevalence rates of anxiety and depression in children with epilepsy compared to children in the general population and review the current literature regarding recognition and treatment of anxiety and depression.

Among children and adolescents in the general population, depression and anxiety disorders appear to be the most common psychiatric disorders⁵ and represent a major public health problem.⁶ The prevalence rates range from 4% to 24% for major depression and around 20% for all anxiety disorders including specific phobias (8%), social phobias (5%), GAD (4%), and all other anxiety disorders (3%).⁵ Depression during childhood frequently occurs before, during, or after another psychiatric disorder;⁷ as a result, if a child presents with a depressive disorder, another psychiatric disorder may be lurking in the shadows. Anxiety disorders in childhood and adolescence are risk factors for depressive disorders later in life.⁸ Spady et al⁹ reported that children and adolescents with psychiatric disorders in general had greater medical service usage compared to children with no psychiatric disorders. Increased direct costs associated include clinic visits, counseling, hospitalizations, prescription medications, and emergency room care. Increased indirect costs are attributable to reduced productivity, absenteeism from work and school, and suicide.¹⁰ The majority of cost analyses have focused on adults. Greenberg et al¹⁰ reported that in the United States anxiety disorders costs totaled $42.3 billion in 1990 dollars and half of these costs were for nonpsychiatric medical treatment. Anxiety disorders have been linked to academic difficulties, low self-esteem, peer relationship problems, and depression.⁶ Anxiety and depression are significant disorders negatively impacting children and adolescents including those with epilepsy.

Among children with epilepsy, the prevalence of psychopathology reportedly ranges from 16% to 77%.^4,11,12 There are no published population-based surveys to determine the prevalence of psychiatric comorbidity in children and adolescents with epilepsy in the United States.² Two major investigations were conducted in the United Kingdom (Fig. 42–1). Rutter¹³ reported that 7% of the general population was identified with a mental health problem compared to 12% in children with nonneurological physical disorders, with significantly higher rates in children with epilepsy, specifically, 29% in uncomplicated and 58% in complicated epilepsy. More recently, Davies et al¹ reported strikingly similar findings. Psychiatric disorders were found in 9.3% of the general population (based on DSM-IV criteria), and again there were marked differences in rates of psychiatric disorders among those children with uncomplicated compared to complicated epilepsy (26% vs. 56%).

Additionally, in Norway as part of an unselected population-based sample of adolescents age 13–16 years, Lossius et al¹⁴ found higher rates of psychiatric symptoms in youth with epilepsy compared to adolescents without epilepsy. Among 10th graders with epilepsy, 40% reported borderline or abnormal scores on the Strength and Difficulties Questionnaire—Self-Report (SDQ-S)¹⁵ compared to 13% of controls. The SDQ is a brief questionnaire that assesses common behavioral problems based on the DSM-IV and ICD diagnostic criteria in children and adolescents and can be completed by parents, teachers, and children who are between 11 and 16 years of age. Importantly, it was reported that adolescents with epilepsy who did not endorse psychiatric symptoms continued to report difficulties coping with daily life.

In summary, epidemiological studies indicated that youth with epilepsy have higher rates of psychiatric comorbidity compared to the general population as well as those with other disabilities (e.g., diabetes). Notably, children with epilepsy have not been compared to children with other neurological disorders, and as a result, it is unclear if higher rates of anxiety and depression only occur in children with epilepsy when compared to children with other neurological disorders.

There is also a large literature using broad spectrum self-report or parent/teacher report behavioral inventories (e.g., Child Behavior Checklist).¹⁶ These studies have been consistent in indicating significantly more internalizing behavior problems (including anxiety and depression) than externalizing problems (e.g., ADHD, Conduct Disorder) in both observational and controlled study designs, the latter comparing children with epilepsy to healthy controls or other disease groups.^17,18 Rodenburg et al¹⁹ conducted a review of the literature from 1970 (after the Isle of Wight study) to 2003 that included children with epilepsy between 4 and 21 years of age and utilized broadband measures (i.e., CBCL parent, teacher, and self-report) to identify rates of psychopathology. A meta-analysis was conducted on 46 studies including 2434 children with epilepsy. The authors reported that youth with epilepsy had higher rates of psychopathology in general compared to healthy controls and children with nonneurological chronic illness. In addition, it appeared that children with epilepsy experienced more internalizing than externalizing behavior problems. This is the opposite of what is reported in the general literature that indicates higher rates of externalizing disorders compared to internalizing disorders (23.0% v. 15%).²⁰

Only a small number of studies have used contemporary research standard psychiatric interviews and diagnostic procedures to investigate rates of mental health problems in youth with epilepsy. Five studies, all quite recent, have demonstrated high rates of anxiety and mood disorders among children with epilepsy in selected populations (Table 42–1). Alwash et al¹¹ reported DSM-IV-based diagnoses in 101 Jordanian adolescents and young adults with epilepsy aged 14–24. They reported that 77.2% of the sample met criteria for depression and 48.5% met criteria for anxiety. Using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS), Thome-Souza et al²¹ reported that among 78 children with epilepsy in Brazil, 36.4% met criteria for depression. Using the Diagnostic Interview Schedule for Children-IV (DISC-IV), a study of adolescents in Nigeria reported that 28.4% of the sample met criteria for depression and a third of the sample met criteria for an anxiety disorder.²² Caplan et al³ administered the K-SADS and reported that among 100 children with generalized or localization-related epilepsy aged 5–16 years, 57 (33%) met DSM-IV criteria for a mood or anxiety disorder, with anxiety especially common (36%). Most recently, Jones et al,²³ using the K-SADS as well, found that among 53 children with recent onset epilepsy 22.6% meet criteria for a depressive disorder and 35.8% met criteria for an anxiety disorder. While advancing the field by using current psychiatric research methodology and careful characterization of pediatric epilepsy syndromes, these studies often lack information regarding specific depressive and anxiety disorders or rates of other comorbid psychiatric disorders.

Table 42–2 summarizes investigations that have used self-report inventories to quantify the degree of depression in children with epilepsy and Table 42–3 summarizes investigations that have used self-report measures to measure symptoms of anxiety in youth with epilepsy. These studies were either observational or controlled (comparing children with epilepsy to controls). Ettinger et al²⁴ found significantly elevated rates of depressive and anxiety symptoms based on the Children’s Depression Inventory (CDI) and Revised Child Manifest Anxiety Scale (RCMAS), respectively. Elevated rates of anxiety were also reported by Williams et al.²⁵ In a controlled study of anxiety, Margalit and Heiman²⁶ reported that significantly more children aged 8–14 years with epilepsy had higher levels of trait anxiety compared to healthy controls. In another sample of 35 children and adolescents with epilepsy aged 9–18 years, Oguz et al²⁷ reported symptoms of anxiety to be higher in the epilepsy group compared to controls. Additionally, more symptoms of depression were found in the childhood epilepsy group compared to the controls based on the CDI. Elevated rates of trait anxiety were also found by other investigators.^12,28 In summary, studies utilizing self-report measures consistently report significantly elevated rates of depression and anxiety in youth with epilepsy compared to healthy controls. Most of these studies utilized health controls, and there are no studies using children with other neurological disorders as controls and only a few studies using other illness groups as controls (i.e., asthma, diabetes).