Epilepsy is one of the most common chronic neurological disorders affecting individuals across all age groups worldwide. It is characterized by recurrent unprovoked seizures resulting from abnormal excessive neuronal discharges in the brain. Beyond the physical manifestations of seizures, epilepsy significantly affects psychological, social, occupational, and emotional functioning of affected individuals. In recent years, increasing attention has been directed toward psychiatric comorbidities associated with seizure disorders, particularly depression, anxiety, psychosis, and sexual dysfunction, as these conditions substantially worsen disease burden and negatively influence quality of life.[1] Psychiatric disorders in epilepsy are often underdiagnosed and undertreated despite their high prevalence and significant impact on patient outcomes. Studies have demonstrated that patients with epilepsy have nearly two to five times higher risk of developing psychiatric illnesses compared to the general population.[2] Depression and anxiety are the most frequently reported psychiatric disorders among epileptic patients and are associated with poor medication adherence, social isolation, increased stigma, reduced seizure control, and impaired quality of life.[3]

The relationship between epilepsy and psychiatric morbidity is considered bidirectional. Recurrent seizures, chronic use of antiepileptic drugs, social stigma, unemployment, fear of seizure recurrence, and impaired interpersonal relationships contribute to psychological distress among patients with epilepsy.[4] Additionally, underlying neurobiological mechanisms involving temporal and frontal lobe dysfunction, neurotransmitter abnormalities, and structural brain changes may predispose epileptic patients to psychiatric disorders.[5] Several studies conducted in recent years have highlighted the substantial prevalence of psychiatric comorbidities in epilepsy. Tsigebrhan et al. reported that mental health disorders in epilepsy are strongly associated with poor treatment outcomes and reduced quality of life.[1] Mula et al. observed that nearly one-third of patients with epilepsy experience psychiatric disorders during their lifetime, with depression and anxiety being the most common.[2] Similarly, Lu et al. demonstrated that psychiatric comorbidities complicate epilepsy management and significantly affect healthcare utilization and treatment adherence.[6]

Quality of life has emerged as an important outcome measure in epilepsy care. Traditionally, seizure control was considered the primary treatment goal; however, recent evidence suggests that psychosocial well-being and psychiatric status are equally important determinants of overall patient health.[7] Several studies have shown that quality of life in epileptic patients is influenced not only by seizure frequency but also by psychiatric morbidity, educational status, social support, and socioeconomic factors.[8] Anxiety and depression have been identified as major predictors of poor quality of life, often exerting greater impact than seizure severity itself.[3] Patients with frequent seizures and abnormal electroencephalographic findings are particularly vulnerable to emotional disturbances and psychosocial dysfunction.[9]

Although multiple international studies have evaluated psychiatric morbidity among epileptic patients, there remains limited literature from developing countries, especially from hospital-based Indian populations, assessing the combined burden of psychiatric morbidity and quality of life in seizure disorder patients. Furthermore, only few studies have explored the association between seizure characteristics such as seizure frequency, seizure duration, and EEG abnormalities with psychiatric manifestations and quality-of-life outcomes simultaneously. Existing studies have often focused predominantly on depression and anxiety, while relatively less emphasis has been given to psychosis and sexual dysfunction in epilepsy patients. There is therefore a significant research gap regarding comprehensive psychiatric assessment among patients with seizure disorders in tertiary care settings.

Considering the growing recognition of psychiatric comorbidities in epilepsy and their influence on patient well-being, the present study was undertaken to assess psychiatric morbidity and quality of life among patients with seizure disorder and to evaluate their association with seizure characteristics including seizure frequency and EEG abnormalities. The findings of this study may help in early identification of psychiatric manifestations and facilitate holistic multidisciplinary management of epilepsy patients.

MATERIALS AND METHODS

Study Design and Setting

The present study was a hospital-based cross-sectional observational study conducted in the Department of Neurology, Government Rajaji Hospital, Madurai. The study was carried out after obtaining approval from the Institutional Ethics Committee. Patients attending the epilepsy clinic with a confirmed diagnosis of seizure disorder were recruited for the study.

A total of 100 patients fulfilling the inclusion and exclusion criteria were included by random sampling method. The study was undertaken to evaluate psychiatric morbidity and quality of life among patients with seizure disorder and to assess their association with seizure-related clinical variables and EEG abnormalities.

Inclusion Criteria

1. Male and female patients diagnosed with seizure disorder based on clinical semiology, EEG findings, and neuroimaging.
2. Patients in the age group of 16–50 years.
3. Patients willing to provide written informed consent for participation in the study.
4. Patients whose last seizure episode occurred more than 7 days prior to assessment.

Exclusion Criteria

1. Patients with significant medical comorbidities such as diabetes mellitus, hypertension, ischemic heart disease, and hypothyroidism.
2. Patients with history of psychiatric illness prior to onset of seizure disorder.
3. Uncooperative patients who were unable to participate in psychiatric evaluation.
4. Patients refusing participation in the study.
5. Patients unwilling to provide informed consent for assessment.

Data Collection Procedure

After obtaining informed written consent, all participants were interviewed in detail using a semi-structured proforma. Sociodemographic details including age, sex, literacy status, occupation, marital status, family type, and socioeconomic status were collected. Clinical details such as seizure type, seizure duration, seizure frequency, EEG findings, family history, treatment details, and drug compliance were recorded. All participants subsequently underwent detailed psychiatric evaluation and mental status examination. Standardized psychiatric rating scales were administered to assess depression, anxiety, psychosis, sexual dysfunction, and quality of life.

Study Tools

1. Semi-Structured Proforma

A specially designed semi-structured proforma was used to collect sociodemographic and clinical information including seizure characteristics, EEG findings, treatment details, family history, and drug compliance.

2. MINI PLUS Neuropsychiatric Interview

The MINI PLUS Neuropsychiatric Interview developed by Sheehan et al. was used for diagnosing psychiatric disorders according to DSM-IV and ICD-10 criteria. It is a structured clinician-administered interview with good reliability and validity.

3. Hamilton Rating Scale for Depression (HAM-D)

HAM-D scale was used to assess the severity of depressive symptoms among patients. Based on scoring pattern, depression was categorized as mild, moderate, severe, and very severe.

4. Hamilton Rating Scale for Anxiety (HAM-A)

HAM-A was administered to assess anxiety symptoms and their severity. The scale evaluates both psychic and somatic symptoms of anxiety.

5. Brief Psychiatric Rating Scale (BPRS)

BPRS was used to assess psychotic symptoms and behavioral disturbances through clinician observation and patient interview.

6. Arizona Sexual Experience Scale (ASEX)

ASEX scale was used to evaluate sexual dysfunction among study participants. Higher scores indicated greater severity of sexual dysfunction.

7. WHO Quality of Life-BREF Scale (WHOQOL-BREF)

WHOQOL-BREF scale consisting of 26 items was used to assess quality of life under four domains including physical health, psychological health, social relationships, and environmental well-being.

Statistical Analysis

The collected data were entered and analyzed using appropriate statistical methods. Continuous variables were expressed as mean and standard deviation, whereas categorical variables were expressed as frequencies and percentages. Chi-square test was used for comparison of categorical variables. Student’s t-test and Analysis of Variance (ANOVA) were used for comparison of numerical variables between groups. A p-value less than 0.05 was considered statistically significant. Statistical analysis was performed to evaluate the association between psychiatric morbidity, seizure characteristics, EEG findings, and quality of life.

RESULTS

TABLE 1: Sociodemographic Profile of Study Participants (n = 100)

The majority of the study participants belonged to the 27–37 years age group (51%), followed by participants aged 38 years and above (25%). Males constituted 52% while females accounted for 48% of the study population. Most of the participants were married (77%), whereas 17% were unmarried and 6% were widowed. Nuclear family setup was more common, accounting for 65% of the study population, while 35% belonged to joint families. The findings indicate that seizure disorder predominantly affected middle-aged adults with nearly equal gender distribution. The predominance of married individuals and nuclear families reflects the sociocultural background of the study population.

TABLE 2: Clinical Characteristics of Patients with Seizure Disorder (n = 100)

Among the study participants, only 12% had a positive family history of seizure disorder, whereas 88% had no significant family history. Abnormal EEG findings were observed in 56% of patients, indicating a high prevalence of electrophysiological abnormalities. Good drug compliance was seen in 59% of patients, while 15% demonstrated poor compliance to antiepileptic medications. Regarding seizure frequency, 41% experienced seizures 2–5 times per year, 36% had less than one seizure per year, and 23% had more than five seizures annually. The findings suggest that abnormal EEG activity and increased seizure frequency are common among patients with seizure disorders. Drug compliance appeared satisfactory in the majority of participants.

Figure 1: Prevalence of Psychiatric Morbidity among Patients with Seizure Disorder (n = 100)

Depression was the most common psychiatric morbidity observed among patients with seizure disorder, affecting 54% of the study population. Anxiety was present in 40% of patients, while sexual dysfunction was identified in 29% of participants. Psychosis was relatively uncommon and noted in only 2% of cases. The findings demonstrate a substantial burden of psychiatric comorbidities among epileptic patients, particularly depression and anxiety. These psychiatric manifestations can adversely affect treatment compliance, social functioning, and quality of life. Early psychiatric evaluation and multidisciplinary management are therefore essential in seizure disorder patients. Identification of psychiatric symptoms at an early stage may improve overall treatment outcomes.

TABLE 3: Distribution of Psychiatric Morbidity According to Seizure Type

Depression was predominantly observed among patients with GTCS and CPSWSG seizure types. Anxiety was also more common among GTCS patients followed by CPSWSG and FMSWSG groups. Sexual dysfunction was most frequently associated with GTCS. Psychosis was relatively rare and noted only in isolated cases of CPSWSG and other seizure types. The results indicate that psychiatric morbidity is variably distributed across seizure phenotypes, with generalized tonic-clonic seizures demonstrating higher psychiatric burden. These findings highlight the importance of psychiatric screening across all seizure types. Early recognition and treatment of psychiatric symptoms may significantly improve patient quality of life.

TABLE 4: Association Between Seizure Frequency and Depression

Patients with seizure frequency greater than five episodes per year had the highest mean depression score (14.57 ± 5.29), whereas those with less than one seizure per year had the lowest mean score (6.44 ± 5.63). Participants experiencing 2–5 seizures annually had an intermediate mean depression score of 9.41 ± 6.04. The observed association between seizure frequency and depression was statistically significant (P < 0.05). The findings indicate that increasing seizure frequency is associated with worsening depressive symptoms. Frequent seizures may contribute to psychological distress, impaired social functioning, and reduced emotional well-being. Effective seizure control may therefore play an important role in reducing depressive morbidity.

TABLE 5: Association Between EEG Findings and Depression

Patients with abnormal EEG findings demonstrated significantly higher mean depression scores (11.30 ± 6.67) compared to patients with normal EEG findings (7.27 ± 5.42). The association between EEG abnormalities and depression was statistically significant (P < 0.05). The results suggest that electrophysiological abnormalities may be associated with greater psychiatric morbidity in seizure disorder patients. Persistent epileptiform activity may contribute to emotional dysregulation and depressive manifestations. The findings emphasize the importance of EEG evaluation not only for seizure diagnosis but also for identifying patients at risk for psychiatric complications. Early intervention may improve overall patient outcomes.

TABLE 6: Association Between Seizure Frequency and Anxiety

Patients experiencing more than five seizures annually had the highest mean anxiety score (16.22 ± 6.78), whereas those with less than one seizure per year had the lowest score (8.00 ± 5.77). Participants with seizure frequency between 2–5 episodes annually demonstrated moderate anxiety levels (10.37 ± 5.83). The observed association between seizure frequency and anxiety was statistically significant (P < 0.05). Increased seizure frequency may contribute to fear of recurrent attacks, social embarrassment, and uncertainty regarding daily functioning. The findings indicate that anxiety severity increases with worsening seizure control. Proper seizure management and psychiatric counseling are therefore important components of patient care.

TABLE 7: Association Between EEG Findings and Anxiety

Patients with abnormal EEG records demonstrated higher mean anxiety scores (11.30 ± 6.67) compared to those with normal EEG findings (7.27 ± 5.42). The difference was statistically significant (P < 0.05). The results indicate that abnormal EEG activity may be associated with increased anxiety among patients with seizure disorders. Patients with persistent EEG abnormalities may experience greater uncertainty regarding disease progression and seizure recurrence. Anxiety symptoms can negatively affect social interactions, occupational performance, and treatment adherence. The findings highlight the importance of routine psychological assessment in epileptic patients with abnormal EEG findings.

TABLE 8: Association Between Seizure Frequency and Quality of Life

Patients with seizure frequency below one episode per year demonstrated the highest quality-of-life score (71.11 ± 10.45), whereas patients experiencing more than five seizures annually had the lowest score (58.91 ± 17.68). Participants with seizure frequency between 2–5 episodes per year had an intermediate score of 64.51 ± 11.68. The association between seizure frequency and quality of life was statistically significant (P < 0.05). Increased seizure frequency appears to adversely affect physical, emotional, and social functioning. Frequent seizures may limit independence and reduce overall life satisfaction. Effective seizure control is therefore essential for improving quality of life in epileptic patients.

TABLE 9: Association Between Literacy Status and Quality of Life

Patients with degree-level education demonstrated the highest mean quality-of-life score (77.30 ± 13.11), whereas illiterate participants had the lowest score (59.13 ± 11.20). Participants educated up to HSC level also showed comparatively better quality-of-life scores. The association between literacy status and quality of life was statistically significant (P < 0.05). Higher educational status may improve disease awareness, treatment adherence, and coping strategies, thereby enhancing overall well-being. Conversely, lower literacy levels may contribute to poor understanding of illness and reduced healthcare utilization. The findings highlight the influence of educational status on psychosocial outcomes in seizure disorder patients.

DISCUSSION

The present hospital-based cross-sectional study was conducted to assess psychiatric morbidity and quality of life among patients with seizure disorder attending the Neurology Department of Government Rajaji Hospital, Madurai. Epilepsy is increasingly recognized as a chronic neurological condition associated not only with recurrent seizures but also with substantial psychiatric and psychosocial disturbances. The present study demonstrated a high prevalence of psychiatric morbidity among seizure disorder patients, with depression and anxiety being the most common psychiatric comorbidities. These findings are consistent with previous studies which reported that psychiatric illnesses are significantly more common among epileptic patients than in the general population.[11,12]

In the present study, the majority of patients belonged to the 27–37 years age group, accounting for 51% of the study population, with slight male predominance. Similar demographic patterns were reported by Engelhart et al., who observed that epilepsy commonly affects individuals in the productive age group, thereby adversely influencing occupational and social functioning.[13] Most participants in the present study were married and belonged to nuclear families, findings which are comparable with observations made by Siebenbrodt et al. in their quality-of-life study among epileptic patients.[14]

Depression was identified as the most common psychiatric morbidity in the current study and was observed in 54% of patients. Anxiety was present in 40% of patients, while psychosis and sexual dysfunction were noted in 2% and 29% respectively. Similar prevalence rates of depression and anxiety among epileptic patients have been reported in earlier studies. Scott et al. observed that depression and anxiety are highly prevalent among epilepsy patients and significantly contribute to impaired psychosocial functioning and poor treatment adherence.[9] Likewise, Gandy et al. emphasized that psychiatric symptoms in epilepsy are frequently underrecognized despite their substantial impact on patient well-being and seizure outcomes.[10] The findings of the present study therefore reinforce the growing evidence regarding the high burden of psychiatric comorbidities among patients with seizure disorder.[11]

The present study demonstrated that psychiatric morbidity varied according to seizure type. Depression and anxiety were more commonly observed among patients with generalized tonic-clonic seizures and complex partial seizures with secondary generalization. Similar findings were reported by Strzelczyk et al., who noted that generalized seizure disorders were associated with greater psychiatric burden and emotional disturbances compared to focal seizure disorders.[5] The increased prevalence of psychiatric manifestations among generalized seizure patients may be attributed to greater disease severity, social stigma, fear of recurrent seizures, and reduced social confidence.[15]

An important finding in the present study was the statistically significant association between seizure frequency and depression. Patients experiencing more than five seizures annually demonstrated significantly higher mean depression scores compared to patients with lower seizure frequency. Similar observations were made by Tsigebrhan et al., who concluded that frequent seizures are strongly associated with emotional disturbances and depressive symptoms among epileptic patients.[1] Recurrent seizures can contribute to helplessness, social isolation, unemployment, and fear of unpredictable attacks, thereby predisposing patients to depression.[16] The present findings therefore suggest that seizure frequency is an important determinant of psychiatric morbidity in epilepsy.

The current study also demonstrated a significant association between seizure frequency and anxiety. Patients with higher seizure frequency exhibited markedly elevated anxiety scores when compared to those with better seizure control. Comparable findings were reported by Clary et al., who observed that recurrent seizures substantially increase anticipatory anxiety, social fear, and psychological distress.[3] Anxiety among epilepsy patients may arise from fear of seizure recurrence, injury, embarrassment in public places, and uncertainty regarding future attacks. Persistent anxiety may further impair treatment adherence and seizure control, thereby worsening disease outcomes.[12]

Another significant observation in the present study was the association between abnormal EEG findings and psychiatric morbidity. Patients with abnormal EEG records demonstrated significantly higher depression and anxiety scores compared to patients with normal EEG findings. Similar findings were reported by Lu et al., who suggested that persistent epileptiform activity and cortical dysfunction may contribute to emotional dysregulation and psychiatric symptomatology.[6] EEG abnormalities may therefore serve as potential indicators of increased psychiatric vulnerability among epilepsy patients.[16]

Quality-of-life assessment in the present study revealed that patients with frequent seizures had significantly poorer quality-of-life scores compared to patients with lower seizure frequency. Patients with less than one seizure per year demonstrated the best quality-of-life outcomes, whereas those with frequent seizures had marked impairment in overall well-being. Similar findings were reported by Almarwani et al., who demonstrated that seizure frequency remains one of the strongest predictors of poor quality of life in epilepsy patients.[8] Frequent seizures adversely affect social interactions, employment, independence, and emotional health, thereby substantially reducing overall life satisfaction.[13]

The present study also observed that educational status significantly influenced quality of life. Patients with higher educational attainment demonstrated better quality-of-life scores compared to illiterate participants. Similar findings were reported by Siebenbrodt et al., who noted that education improves disease awareness, treatment compliance, coping mechanisms, and healthcare utilization.[14] Lower literacy levels may contribute to poor understanding of disease processes and increased social stigma, thereby negatively affecting psychosocial functioning and quality of life.[15]

Overall, the findings of the present study emphasize the importance of comprehensive psychiatric assessment in patients with seizure disorder. Depression, anxiety, and sexual dysfunction were highly prevalent and significantly associated with seizure frequency and EEG abnormalities. Early identification and multidisciplinary management of psychiatric morbidity may substantially improve treatment adherence, seizure control, psychosocial functioning, and overall quality of life among epileptic patients.[17]

The findings of the present study are further supported by a recent study conducted by Kumar VJ et al., who evaluated determinants of quality of life among epilepsy patients using WHOQOL-BREF and ASEX scales.[18] The authors reported that higher seizure frequency, lower educational status, and abnormal EEG findings were associated with poorer quality of life. They also observed sexual dysfunction in 29% of epilepsy patients, with significant association between sexual dysfunction and seizure frequency. These observations closely parallel the findings of the present study and further emphasize the importance of comprehensive psychosocial assessment in epilepsy management.

CONCLUSION

The present study demonstrated a high prevalence of psychiatric morbidity among patients with seizure disorder, with depression and anxiety being the most common psychiatric comorbidities. Increased seizure frequency and abnormal EEG findings were significantly associated with higher depression and anxiety scores. Quality of life was markedly impaired among patients with frequent seizures and lower educational status. The findings highlight the importance of routine psychiatric evaluation and integrated multidisciplinary care in epilepsy management. Early recognition and treatment of psychiatric comorbidities may significantly improve psychosocial functioning, treatment compliance, seizure outcomes, and overall quality of life among patients with seizure disorder.

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16. Lu E, Pyatka N, Burant CJ, et al. Psychiatric comorbidities in adults with epilepsy: A systematic review. Epilepsy Behav. 2021;118:107814. doi:10.1016/j.yebeh.2021.107814
17. Tsigebrhan R, Shibre T, Medhin G, et al. Comorbid mental disorders and quality of life among people with epilepsy. Brain Behav. 2021;11(1):e01929. doi:10.1002/brb3.1929
18. Kumar VJ. Living with epilepsy: a quantitative analysis of determinants of quality-of-life. Int J Med. 2026;8(2):587-593. doi:10.61336/im/26-2-12