Assessment of Depression, Anxiety, and Stress Among Epileptic Patients Utilizing the DASS-21 Scale: A Cross-Sectional Investigation

Assessment of Depression, Anxiety, and Stress Among Epileptic Patients Utilizing the DASS-21 Scale: A Cross-Sectional Investigation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of Depression, Anxiety, and Stress Among Epileptic Patients Utilizing the DASS-21 Scale: A Cross-Sectional Investigation Shani Vishwakarma, Abhishek Pathak, Anil Kumar Maurya, Nitish Kumar Singh, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5801920/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Introduction People with epilepsy frequently experience depression, Anxiety, and stress, which has a substantial negative impact on their quality of life and overall health-related satisfaction. This study aimed to identify psychiatric comorbidities in individuals with epilepsy, as assessed via the Depression, Anxiety, and Stress Scale, by comparing them with a healthy control group. Methodology This cross-sectional study was conducted in the XXXX, and patients were recruited from the Out-Patient Department of XXXX, from August 2022 to February 2024. The total number of participants was 388, including 194 Cases. 194 healthy controls were matched for age and sex, with participants under the age of 18 excluded. Psychiatric comorbidity was evaluated via the DASS-21 scale using Chi-square and one-way ANOVA. Results The study involved 194 patients and 194 healthy controls, with a mean age of 25.11 ± 10.28 years. Among the patients, 58.2% were female and 41.8% were male. A significant difference in depression levels was found between patients on monotherapy and polytherapy ( p = 0.003). However, no significant differences were found in anxiety ( p = 0.214) and stress ( p = 0.139). There are no significant links between depression, anxiety, stress and antiepileptic drugs. Patients with epilepsy had significantly higher levels of depression, anxiety, and stress compared to healthy controls, with all p = 0.00. Conclusion The study highlights the elevated levels of depression, anxiety, and stress among patients with epilepsy. Clinicians and healthcare practitioners should adopt comprehensive and holistic assessment methods to address and mitigate these psychiatric comorbidities in epilepsy patients. Epilepsy Antiepileptic drugs Depression Stress Anxiety DASS21 Figures Figure 1 Figure 2 Figure 3 Introduction Epilepsy is defined as a neurological condition that, by recurring seizures arising from improper electrical discharges in the brain, impacts millions of people worldwide [ 1 , 2 ]. Seizures can affect a person's quality of life differently and may range in severity. Epilepsy is a curable, non-contagious condition that can impact individuals of any age [ 3 ]. According to the World Health Organization (WHO), 50 million individuals worldwide suffer from epilepsy, and 80% of them are living in low-income nations [ 4 ]. Many studies revealed that a variety of factors, including low socioeconomic status, consumption of drugs, low education, multiple medications, perceived stigma, monthly seizure rate, and adverse AED negative effects, may contribute to these patients' non-adherence to antiepileptic drugs [ 5 – 8 ]. Patients with epilepsy require extensive care and management due to the high prevalence and increasing understanding of adverse effects caused by psychiatric comorbidities and non-adherence to medication [ 9 ]. Therefore, it is very critical to understand the psychological aspects that influence epilepsy patient’s medication adherence to design appropriate and successful techniques to increase adherence rates [ 10 ]. The primary therapeutic intervention for individuals with epilepsy is antiepileptic drugs (AEDs). Regular therapy is essential for achieving optimal seizure control following the successful implementation of a prescription; it is estimated that the occurrence of seizure is preventable in approximately 70% of patients with epilepsy [ 11 ]. Epilepsy patients frequently suffer from depression as a mental health problem, with estimates indicating that up to 50% experience symptoms of depression at some point in their lives [ 12 ]. A person's standard of living can be severely affected by depressive symptoms, which can also have an impact on their ability to work, interact with others, and carry out everyday responsibilities. Patients with epilepsy who show signs of depression should be promptly treated by healthcare experts to prevent adverse effects such as increased seizure frequency and decreased quality of life. An additional prevalent mental health concern among epilepsy patients is anxiety, which may impact up to 30% of people with epilepsy at some point in their lives [ 13 ]. Several signs of anxiety may arise, such as panic attacks, social anxiety, and obsessive-compulsive behaviours. Similar to depression, untreated anxiety adversely affects a person's quality of life by increasing the frequency of seizures and lowering their overall health. Anxiety appears to represent a variety of expressions rather than an overall comorbidity of epilepsy [ 14 ]. This range of symptoms illustrates several pathogenetic mechanisms, including direct neurobiological mechanisms involving brain structures implicated in the perception and regulation of emotions, preictal prodromes potentially indicating altered excitability, early ictal anxiety representing a loss of control, interictal anxiety, for example, in anticipation of different seizures, and social stigma expressing itself as nervous behaviour [ 15 ]. Stress is also an issue for persons who have epilepsy. Stress-related symptoms may emerge as a mental trauma of having a chronic illness, as well as the stigma and social stigma that many people with epilepsy experience [ 16 ]. Stress can show up as a variety of symptoms, including psychological ones like irritation and trouble concentrating, as well as physical ones like headaches and gastrointestinal issues [ 17 ]. The Depression Anxiety Stress Scale (DASS21) is a commonly used psychological diagnostic tool that assesses the severity of signs of these mental health disorders[ 18 ]. It consists of 21 questions, each of which is aimed at assessing the intensity of symptoms correlated to depression, anxiety, and stress. The DASS21 scale has been validated for use in a wide range of populations, including people with epilepsy [ 16 ]. The DASS21 scale may provide significant insight into how epileptic patients perceive themselves emotionally and psychologically. Healthcare providers can create personalized treatment programs to manage depression, anxiety, and stress-related symptoms and enhance patients' general well-being by evaluating the intensity of these symptoms [ 19 , 20 ]. However, patients with epilepsy have significant psychological problems that are still frequently disregarded. This study aimed to reduce the psychological impact of epilepsy and aid society and governments in developing effective solutions for individuals affected by the condition. By identifying the signs of depression, anxiety, and stress, medical practitioners can create specialized treatment programs to address these problems and enhance overall health. Methodology This cross-sectional study was conducted in the XXXX and patient was recruited from the Out-Patient XXXX, from August 2022, to February 2024. The total number of participants was 388, including 194 Cases, and 194 healthy controls were matched for age and sex. For control, the online survey was created using Google Forms, distributed through social media and emails to the group of XXXX students, and shared with friends who were above 18 age. A total number of individuals 201 control recruited. Where 7 individuals were excluded because they have a past history of epilepsy. We offer both the English and Hindi versions of the DASS21 questionnaire. Inclusion and Exclusion for Cases & Healthy Control Inclusion criteria We considered only those cases who were above the age of 18 had a clear diagnosis of epilepsy and were using at least one antiepileptic medication. All of the patients had an undetermined etiology. Control samples will include individuals without a history of epilepsy, aged between above18 years, and willing to participate voluntarily Exclusion criteria Exclusion criteria encompass patients with central nervous system infections and structural, metabolic, and neurodegenerative disorders. Additionally, epileptic patients undergoing acute illness or severe medical conditions that could independently affect their psychological state beyond epilepsy. Exclusion criteria involve individuals with a confirmed diagnosis of epilepsy, a past medical history of neurological disorders, psychiatric conditions, ongoing usage of psychotropic medications, who will not be included in the control group. Participants lacking a background of significant mental illnesses like schizophrenia or bipolar disorder may potentially complicate the evaluation of depression, anxiety, and stress are excluded. Sociodemographic characteristics of the study subject The questionnaire included the following socio-demographical data: age and gender as well as the clinical data related to the type of drugs taken, age of onset, family history of seizure, duration since diagnosis, clinical diagnosis of epilepsy, clinical diagnosis of depression, anxiety, stress, and clinical diagnosis of any other comorbidities. Ethical considerations The study received approval from the Institutional Medical Ethical Committee under reference number No. Dean/2022/EC/3413. Before participation, all participants were provided with comprehensive information concerning the study's objectives, methodology, their rights, and potential benefits. Each participant explicitly acknowledged their voluntary participation in the study and retained the right to withdraw at any time. Additionally, all participants completed informed consent forms. Depression, Anxiety, and Stress Scale (DASS-21) instrument The DASS-21 is a well-accepted scale for the quantification of depression, anxiety, and stress which consists of 21 items in the form of different questionnaires. The questionnaire included items related to depression (3, 5, 10, 13, 16, 17, and 21), anxiety (2, 4, 7, 9, 15, 19, and 20), and stress (1, 6, 8, 11, 12, 14, and 18)[ 21 ]. Evaluation of weightage of Each question, ranging from 0 to 3, which could have the following possible responses: a score of 0 meant that it did not apply to me at all; a score of 1 meant that it did apply to me to some extent or occasionally; a score of 2 meant that it applied to me to a significant extent or frequently; and a score of 3 meant that it applied to me heavily or frequently. The final score is an aggregate of all question scores based on every emotional state. The total score for the DASS-21 is calculated by doubling the scores of each subscale, given its abbreviated nature compared to the original 42-item DASS [ 22 ]. Based on this score, each participant is positioned on a spectrum from 'Normal' to 'Extremely Severe' shown in Table 1 . Table 1 The table represents the recommended cut-off scores for conventional severity labels in the DASS-21 (Depression, Anxiety, and Stress Scale-21) questionnaire. Severity Label Depression Score Anxiety Score Stress Score Normal 0–9 0–7 0–14 Mild 10–13 8–9 15–18 Moderate 14–20 10–14 19–25 Severe 21–27 15–19 26–33 Extremely Severe 28+ 20+ 34+ Statistical analysis Data were analysed using the IBM SPSS statistics version 20. Most of the data were reported as numbers and proportions to summarize the distribution of variables. The findings of the DASS-21 questionnaire are shown as the mean ± standard deviation for continuous variables along with the Kolmogorov-Smirnov (K-S) test for normal distribution and independent t-test to evaluate notable differences between the two groups but Significant differences between three groups were evaluated using one-way ANOVA. We performed the chi-square (χ²) test to investigate the association between gender and family history. The acceptable level for statistical significance was determined at P < 0.05. Results A total of 388 participants were examined, consisting of responses from 194 patients with epilepsy and 194 healthy controls. A description of the diverse main demographic and clinical variables included in the study was shown in Table 2 . There were no statistically significant differences in age, sex, cause, and family history. The study participants were predominantly females, 113 (58.2%). There was a significant difference in the measurable value of depression between males and females ( p = 0.002), but the differences in anxiety and stress were not significant. In depression ( p = 0.34), anxiety ( p = 0.547), and stress ( p = 0.231) among individuals with brain injury, epilepsy of unknown origin, and a family history of epilepsy showed no significant differences. There was no significant difference in the measurable values of depression ( p = 0.183), anxiety ( p = 0.373), and stress ( p = 0.812) (Table 3 ). Although among these patients, 11.9% had focal epilepsy, while 88.1% had generalized epilepsy. Another type of parameter for the same patients undergoing polytherapy (multidrug treatment) for depression scored significantly higher than those receiving monotherapy ( p = 0.003). There was no significant difference in the ratings for anxiety ( p = 0.214) and stress ( p = 0.139) shown in Fig. 3 . Table 2 Demographic and clinical characteristics of age, sex, type of therapy, cause and family history of patients with epilepsy and healthy controls. Demographic, Clinical, & Laboratory data of the study subject Parameter Epileptic Patients Control t value χ2 df p-value Sample Size N = 194(50%) N = 194(50%) Age (Year) Means ± SDs 25.11 ± 10.286 24.87 ± 10.52 0.409 386 0.683 Sex Male (%) 81(41.8) 72 (37.1) 0.874 1 0.203 Female (%) 113(58.2) 122(62.9) Types Of Therapy Monotherapy (%) 155 (79.9) Polytherapy (%) 39 (20.1) Cause Genetical (%) 60(30.9) Unknown (%) 126 (64.9) Brain Injury (%) 8(4.1) Family History Positive (%) 58(29.9) 3(1.5) 98.841 1 < 0.001 Negative (%) 136(70.1) 191(98.5) Note: N = No of sample, SD = Standard Deviation, t = t-test, χ2 = Chi-square, df = Degree of freedom, p = probability value. Table 3 The severity of symptoms of depression, anxiety, and stress in patients with epilepsy compared with age, sex, seizure types, medication (Treatment adherence), type of therapy, and cause. Parameter N (%) Depression Anxiety Stress Sample Size 194 Mean ± SD Mean ± SD Mean ± SD Age 18–38 174(89.7) 14.06 ± 5.74 11.28 ± 5.23 19.45 ± 4.81 39–58 14(7.21) 15.71 ± 5.37 14.86 ± 3.90 22.66 ± 6.78 < 59 6(3.09) 17.00 ± 4.15 15.00 ± 10.56 23.00 ± 6.89 p-value 0.284 0.018 0.016 Sex Male 81 (41.8) 12.79 ± 6.15 11.90 ± 5.92 19.80 ± 6.03 Female 113(58.2) 15.33 ± 5.11 11.47 ± 5.10 19.81 ± 4.38 p-value 0.002 0.587 0.997 Seizure Type Focal 23(11.9%) 12.78 ± 5.80 10.70 ± 6.39 19.57 ± 5.01 Generalized 171 (88.1) 14.47 ± 5.70 11.78 ± 5.31 19.84 ± 5.15 p-value 0.183 0.373 0.812 Medication Phenytoin 10 (5.2) 14.6 ± 7.12 9.80 ± 4.94 17.60 ± 3.30 Levetiracetam 55 (28.4) 13.27 ± 6.06 11.49 ± 6.35 20.00 ± 5.96 Oxocarbazepine 37 (19.1) 13.19 ± 5.76 11.24 ± 4.69 19.14 ± 5.04 Carbazepine 9 (4.6) 16.22 ± 5.51 11.56 ± 5.07 19.11 ± 3.88 Sodium Valproate 44 (22.7) 14.32 ± 4.39 11.82 ± 5.19 20.55 ± 4.25 p-value 0.529 0.886 0.457 Types Of Therapy Monotherapy 155(79.9) 13.59 ± 5.56 11.37 ± 5.24 19.50 ± 5.03 Polytherapy 39 (20.1) 16.38 ± 5.60 12.51 ± 6.02 20.77 ± 5.31 p-value 0.003 0.214 0.139 Cause Genetical 60 (30.9) 14.83 ± 5.62 11.17 ± 5.502 18.87 ± 4.91 Unknown 126(64.9) 13.87 ± 5.76 11.95 ± 5.52 20.21 ± 5.12 Brain Injury 8 (4.1) 16.25 ± 4.83 10.50 ± 3.50 20.50 ± 6.21 p-value 0.34 0.547 0.231 Note: N = No of the sample, SD = Standard Deviation, t = t-test, χ2 = Chi-square, df = Degree of freedom, p = probability value. One-way ANOVA or an independent sample t-test was used to compare the DASS-21 score means of the variable's categories. The mean ± standard deviation represents the depression, anxiety, and stress scores. P values are indicated in bold. On the subject of medication, the analysis of specific antiepileptic drugs showed that depression was not significantly associated with the use of Phenytoin (14.6 ± 7.12), Levetiracetam (13.27 ± 6.06), Oxcarbazepine (13.19 ± 5.76), Carbamazepine (16.22 ± 5.51), and Sodium Valproate (14.32 ± 4.39), with p > 0.529. No significant associations were found with anxiety for Phenytoin (9.80 ± 4.94), Levetiracetam (11.49 ± 6.35), Oxcarbazepine (11.24 ± 4.69), Carbamazepine (11.56 ± 5.07), and Sodium Valproate (11.82 ± 5.19), with p > 0.886. Additionally, there were no significant differences in stress with different types of drugs: Phenytoin (17.60 ± 3.30), Levetiracetam (20.00 ± 5.96), Oxcarbazepine (19.14 ± 5.04), Carbamazepine (19.11 ± 3.88), and Sodium Valproate (20.55 ± 4.25), with p > 0.457 (Table 3 & Fig. 2 ). Patients with epilepsy report moderate to extremely severe levels of depression (59.7%), anxiety (65.4%), and stress (53.6%) more frequently than the control group. These results are detailed in Table 4 . Table 4 Severity of Depression, Anxiety, and Stress. Level Depression Frequency (%) Anxiety Frequency (%) Stress Frequency (%) Normal 30 (15.5%) 42 (21.7%) 34 (17.5%) Mild 48 (24.8%) 25 (12.9%) 56 (28.9%) Moderate to Extremely Severe 116 (59.7%) 127 (65.4%) 104 (53.6%) The results show significant differences between the case and control groups for depression, anxiety, and stress, the statistical analysis (t-test) confirms that these differences was highly significant. Participate with a clinical diagnosis of epilepsy alone, the mean and standard deviation scores for depression, anxiety, and stress were 14.27 ± 5.69 ( p = 0.00), 11.65 ± 5.45( p = 0.00), and 19.80 ± 5.12 ( p = 0.00), shown in Table 5 & Fig. 1 . Table 5 Comparison of patients with epilepsy and healthy controls (Risk score on the DASS21) Variable Case Mean ± SD (N = 194) Control Mean ± SD (N = 194) t Value df p Value Depression 14.27 ± 5.69 8.87 ± 4.11 10.72 386 < 0.001 Anxiety 11.65 ± 5.45 7.02 ± 3.86 9.66 386 < 0.001 Stress 19.80 ± 5.12 14.02 ± 4.81 11.47 386 < 0.001 Note: N = No of sample, SD = Standard Deviation, t = t-test, χ2 = Chi-square, df = Degree of freedom, p = probability value Discussion Depression, anxiety, and stress are highly prevalent comorbidities with epilepsy. Our study aims to estimate the prevalence of these psychological symptoms in the Northern Indian population and explore their association with socio-demographic factors. In our study, out of 194 patients, mean ± SD 14.27 ± 5.69, 11.65 ± 5.45, and 19.80 ± 5.12 showed symptoms of depression, anxiety, and stress based on the DASS-21 scale (Table 5 & Fig. 1 ). The research outcomes indicate that among people with epilepsy, reported experiencing moderate to extremely severe levels of these psychiatric symptoms of depression (59.7%), anxiety (65.4%), and stress (53.6%) are relatively higher compared to control group Shown in Table 4 . In contrast to previous studies have highlighted a high prevalence of psychiatric symptoms, including depression, anxiety, and stress, among patients with epilepsy. The prevalence of depression in this study 59.7% among individuals with epilepsy varies significantly across different countries. Comparable rates were noted in the Emirates of Abu Dhabi (28.7%) [ 23 ], Egypt (25.5%) [ 24 ], Bosnia (34%) [ 25 ], and among Nigerian adolescents (28.43%)[ 26 ], Iran (9.5%)[ 27 ] and Thailand (20%) [ 28 ], while higher rates were reported in India (63.3%)[ 29 ], Pakistan (60%)[ 30 ], Korea (62%)[ 31 ], and Nigeria (85%)[ 26 ]. The prevalence of anxiety in this study was found to be 65.4%, which is higher than the rates reported in Canada (40%)[ 32 ], Brazil (39.4%)[ 33 ], the United Arab Emirates (43.5%)[ 34 ], Iran (24.5%)[ 27 ], Australia (20.2%)[ 35 ], India (11.0%)[ 36 ], Thailand (5.3%)[ 37 ], China (57.0%)[ 38 ], and Oman (47.8%)[ 39 ]. Similarly, the prevalence of stress in this study was 53.6%, higher than that observed in Germany (43%)[ 40 ] but lower than the rates reported in the U.S. (74%)[ 41 ], Pakistan (70%)[ 42 ], and India (35%)[ 43 ]. These differences are likely influenced by variations in study population diversity, study design, inclusion criteria, sample size, and the screening instruments used. There was a significant notable difference between depression and gender (41.8% of males, 88.1% of females) ( p < 0.002), but no significant difference in anxiety ( p < 0.587) and stress ( p < 0.812). A previous study found a significant association between gender and anxiety among epilepsy patients, with females demonstrating a higher frequency of anxiety compared to male. Biological factors, hormonal disparities, and psychosocial elements specific to each gender could potentially influence the differing levels of depression, anxiety, and stress seen in male and female epilepsy patients[ 44 ]. Significant sex differences in depression among epilepsy patients were observed, with females being 4.27 times more likely to experience depression compared to males[ 31 ]. The results showed that patients undergoing polytherapy (treatment with multiple drugs) for depression had notably higher scores compared to those receiving monotherapy ( p = 0.003). However, there were no significant differences in the ratings for anxiety ( p = 0.214) and stress ( p = 0.139). Multiple research demonstrates that monotherapy and polytherapy have a strong association with patients with epilepsy, with a mean of 75.8: 24.2, as well as a higher prevalence of depression[ 45 ]. Polytherapy has been recognized as an important factor, but definitive reports on the correlation between depression and the frequency of drug use are still lacking. Studies show significant variation, with some indicating a positive association while others find none. In previous studies, found no association between the use of multiple drugs and an increased risk of depression[ 46 ]. Similarly, other study found no significant link between depression and the frequency of drug use in their respective studies [ 12 ] [ 47 ]. The study revealed a significant correlation between drug frequency and depression, anxiety, and stress with individuals receiving polytherapy being 3.82 times more likely to experience depression compared to those on monotherapy [ 48 ]. Using several medications can increase the number of pills a person needs to take and reduce their adherence to the treatment. This often leads to poor seizure control and a higher risk of severe side effects. Patients under polytherapy face an elevated risk of drug-to-drug interactions and are more prone to medication errors. Thus, it is important to prioritize the right drug therapy, taking into account factors such as pill burden, tolerability, and potential interactions. Including education on medication regimens in epilepsy treatment guidelines and healthcare provider training is vital to ensure optimal management of patients [ 14 ]. In our analysis revealed no significant links between depression, anxiety, stress and antiepileptic drugs (Phenytoin, Levetiracetam, Oxcarbazepine, Carbamazepine and Sodium Valproate). We could not find any evidence of a significant relationship between medication adherence behavior and depression, anxiety, and the degree of stress (Table 3 ). Certain pervious research indicates that stress has a detrimental effect on medication adherence among epilepsy patients [ 49 ].The difference may arise from variations in the study's design, sample size, socio-cultural disparities, and participant demographics. In Ethiopia, the non-adherence rate to anti-epileptic medication among patients with psychiatric comorbidities was reported as 39 out of 77 cases [ 50 ]. The relevance of this issue is highlighted by the overall evidence showing that poor medication adherence is prevalent in people with epilepsy [ 51 ]. In epileptic patients, adherence to treatment was negatively impacted by co-occurring symptoms of depression, anxiety, and stress. These overlapping mental health issues can cause feelings of hopelessness, disinterest, and a breakdown in communication with healthcare providers, which in turn complicates medication adherence and heightens the risk of not following treatment plans [ 52 ]. Individuals with epilepsy who suffer from antiepileptic drug-related side effects are 2.5 times more likely to experience anxiety compared to those without such side effects (AOR = 2.547 [1.242, 5.224]). This finding is consistent with multiple studies conducted in Canada and Ethiopia [ 50 ] [ 53 ]. This association could be due to depression, anxiety, and stress being physiological responses, with antiepileptic drugs potentially disrupting daily tasks and causing anxiety [ 54 ]. Another potential explanation is that individuals with untreated beliefs may restrict their social interactions, experience lowered self-esteem due to their psychiatric illness, and limit social activities such as marriage and education. They may perceive themselves as weak, dependent, and incapable. Thus, these issues are increasingly being discussed in people's minds. They may feel stressed as a result [ 55 ]. In epilepsy patients, poor medication adherence was significantly predicted by higher levels of depression, anxiety, and stress. The adherence to anti-epileptic medication hinges significantly on preventing, detecting early, and managing comorbid mental illnesses and pharmaceutical side effects effectively[ 56 ]. Individuals with epilepsy in low-income and middle-income countries experience a notable treatment disparity[ 57 ], influenced by how their psychological well-being is shaped by sociocultural and economic factors in their respective countries [ 58 ]. The research indicates that the prevalence of co-occurring mood problems among epileptic patients is significantly higher in developing nations [ 59 ]. Several advantages of the study; Wide Coverage and Inclusive Sample: The study covers a broad demographic and clinical spectrum of epilepsy patients, enhancing the generalizability of its findings within the Northern Indian population. The inclusion of both hospital-based patients and healthy controls via an online survey adds depth to the comparative analysis. The DASS-21 is a validated instrument used to assess depression, anxiety, and stress, providing reliable and standardized evaluations of psychological distress. This includes sociodemographic and clinical characteristics enabling a detailed analysis of factors potentially influencing psychological outcomes in epilepsy patients. Disadvantages of the study, Cross-Sectional Design while effective for determining prevalence, the cross-sectional design cannot establish causality between epilepsy and psychological distress and the effect of treatment adherence on psychological outcomes. Bias of self-response relying on self-reported data for the DASS-21 and sociodemographic information may introduce response biases, affecting the accuracy of the reported psychological states and adherence levels. Moreover, only one question was used to assess some of the independent factors, including the presence of thoughts of suicide, sexual or physical abuse, and medication adherence. This might cause some patients to answer inappropriately. Lack of Longitudinal Follow up regional specificity: While the study offers valuable insights into the Northern Indian population, its findings may not be universally applicable to other regions and populations due to variations in culture, socioeconomic status, and healthcare systems. Last but not least, the study mentions the impact of psychiatric comorbidities on treatment adherence but does not delve deeply into adherence rates and factors affecting adherence, which are crucial for understanding and improving epilepsy management. Future investigations must use longitudinal studies to assess the dynamic changes in psychological flexibility in epilepsy patients. Subsequently, in the context of epilepsy, future studies might assess the significance of psychological flexibility in predicting outcomes including treatment compliance, medication response, and mental health state. Conclusion The prevalence of depression, anxiety, and stress among epilepsy patients exceeded that of healthy controls. Significant associations were found among those who perceived epilepsy as untreatable, experienced anxiety, and faced stigma. Factors contributing to these findings included an elevated likelihood of stress-related symptoms, highlighting the importance for clinicians and healthcare providers to be vigilant. Therefore, comprehensive and systemic assessment approaches are necessary to mitigate the levels of depression, anxiety, and stress in epilepsy patients. Declarations Author Contribution S.V., A.P., R.S. conceived and designed the research. A.K.M and S.V. performed all operations. A.K.M. and S.V. analyzed the data and drew the figures. S.V., R.S., A.K.M., N.K.S., and A.P. wrote the manuscript. All authors contributed to the article and approved the submitted version. Acknowledgement We want to extend our sincere gratitude to the Department of Anatomy, Department of Neurology, Multi-Disciplinary Research Units (MRUs) Laboratory, Institute of Medical Sciences, Banaras Hindu University References Safeer V S M, Sahu JK, Madaan P, et al (2024) Estimating the active and lifetime prevalence and incidence of epilepsy in Asian Countries: A systematic review and meta-analysis. Epilepsy Behav 154:. https://doi.org/10.1016/j.yebeh.2024.109739 Blixen C, Ogede D, Briggs F, et al (2020) Correlates of stigma in people with epilepsy. J Clin Neurol 16:423–432. https://doi.org/10.3988/jcn.2020.16.3.423 Ranjan LK, Panday R, Kiran M (2016) Stress, anxiety, and depression among individuals with epilepsy. Open Jour of Psych & Allied Scie 7:129. https://doi.org/10.5958/2394-2061.2016.00020.3 Adamu A, Chen R, Li A, Xue G (2023) Epilepsy in Asian countries. Acta Epileptologica 5:25. https://doi.org/10.1186/s42494-023-00136-1 Bala A, Olejnik A, Kułak M, et al (2024) Determinants of the Quality of Life in Patients with Drug-Resistant Temporal Lobe Epilepsy: A Comparison of the Results before and after Surgery. Brain Sci 14:. https://doi.org/10.3390/brainsci14030241 Tan X, Pharm B, Makmor-Bakry M, et al (2015) Factors affecting adherence to antiepileptic drugs therapy in Malaysia. Neurology Asia Park KM, Kim SE, Lee BI (2019) Antiepileptic Drug Therapy in Patients with Drug-Resistant Epilepsy. J Epilepsy Res 9:14–26. https://doi.org/10.14581/jer.19002 Espinosa-Jovel C, Toledano R, Aledo-Serrano Á, et al (2018) Epidemiological profile of epilepsy in low income populations. Seizure 56:67–72. https://doi.org/10.1016/j.seizure.2018.02.002 Davoudi M, Lundgren T, Jansson-Fröjmark M, et al (2022) The Psychological Flexibility in Epilepsy Questionnaire (PFEQ): Psychometric properties of the Persian version. Epilepsy & Behavior 130:108672. https://doi.org/10.1016/j.yebeh.2022.108672 Siarava E, Markoula S, Pelidou S-H, et al (2020) Psychological distress symptoms and illness perception in patients with epilepsy in Northwest Greece. Epilepsy Behav 102:. https://doi.org/10.1016/j.yebeh.2019.106647 Keskin Guler S, Aytac B, Durak ZE, et al (2016) Antioxidative–oxidative balance in epilepsy patients on antiepileptic therapy: a prospective case–control study. Neurol Sci 37:763–767. https://doi.org/10.1007/s10072-016-2494-0 Engidaw NA, Bacha L, Kenea A (2020) Prevalence of depression and associated factors among epileptic patients at Ilu Ababore zone hospitals, South West Ethiopia, 2017: a cross–sectional study. Ann Gen Psychiatry 19:19. https://doi.org/10.1186/s12991-020-00268-5 Rauh R, Schulze-Bonhage A, Metternich B (2022) Assessment of Anxiety in Patients With Epilepsy: A Literature Review. Front Neurol 13:836321. https://doi.org/10.3389/fneur.2022.836321 Asadi-Pooya A, Sperling M (2011) Depression and Anxiety in Patients with Epilepsy, With or Without Other Chronic Disorders. 13: Shadid AM, Alsaber N, Aldawish RA, et al (2024) Depression and anxiety among patients with epilepsy: A cross-sectional study from Riyadh, Saudi Arabia. Journal of Family Medicine and Primary Care 13:549–555. https://doi.org/10.4103/jfmpc.jfmpc_834_23 Thapa DK, Visentin D, Kornhaber R, Cleary M (2022) Psychometric properties of the Nepali language version of the Depression Anxiety Stress Scales (DASS-21). Nursing Open 9:2608–2617. https://doi.org/10.1002/nop2.959 Huang S, Wu C, Jia Y, et al (2020) COVID-19 outbreak: The impact of stress on seizures in patients with epilepsy. Epilepsia 61:1884–1893. https://doi.org/10.1111/epi.16635 Wittayapun Y, Summart U, Polpanadham P, et al (2023) Validation of depression, anxiety, and stress scales (DASS-21) among Thai nursing students in an online learning environment during the COVID-19 outbreak: A multi-center study. PLoS ONE 18:e0288041. https://doi.org/10.1371/journal.pone.0288041 Farnia V, Afshari D, Abdoli N, et al (2021) The effect of substance abuse on depression, anxiety, and stress (DASS-21) in epileptic patients. Clinical Epidemiology and Global Health 9:128–131. https://doi.org/10.1016/j.cegh.2020.08.001 Parsons ALM, Bucknor EMV, Castroflorio E, et al (2022) The Interconnected Mechanisms of Oxidative Stress and Neuroinflammation in Epilepsy. Antioxidants 11:157. https://doi.org/10.3390/antiox11010157 Kim RH, Paulino YC, Kawabata Y (2024) Validating Constructs of the Depression, Anxiety, and Stress Scale-21 and Exploring Health Indicators to Predict the Psychological Outcomes of Students Enrolled in the Pacific Islands Cohort of College Students. IJERPH 21:509. https://doi.org/10.3390/ijerph21040509 Okunola OP, Ikhurionan PE (2022) Depression, Anxiety and Stress Disorders among Mothers of Children with Chronic Neurologic Disorder seen at the University of Benin Teaching Hospital, Nigeria: A Cross-sectional Study. Trop J Health Sci 29:21–26. https://doi.org/10.4314/tjhc.v29i3.4 Alsaadi T, El Hammasi K, Shahrour TM, et al (2015) Depression and Anxiety among Patients with Epilepsy and Multiple Sclerosis: UAE Comparative Study. Behavioural Neurology 2015:1–4. https://doi.org/10.1155/2015/196373 Shehata GA, Mahran DG (2013) Egyptian students’ guardians knowledge, attitude and predictors of negative attitude of epilepsy in Assiut city. JEGH 4:87. https://doi.org/10.1016/j.jegh.2013.09.006 Bagić A, Bagić D, Živković I (2009) First population study of the general public awareness and perception of epilepsy in Bosnia and Herzegovina. Epilepsy & Behavior 14:154–161. https://doi.org/10.1016/j.yebeh.2008.10.007 Adewuya AO, Ola BA (2005) Prevalence of and risk factors for anxiety and depressive disorders in Nigerian adolescents with epilepsy. Epilepsy & Behavior 6:342–347. https://doi.org/10.1016/j.yebeh.2004.12.011 Asadi-Pooya AA, Sperling MR (2011) Depression and anxiety in patients with epilepsy, with or without other chronic disorders. Iran Red Crescent MedJ 13:112–116 Phabphal K, Sattawatcharawanich S, Sathirapunya P, Limapichart K (2007) Anxiety and depression in Thai epileptic patients. J Med Assoc Thailand 90:2010–2015 Sah SK, Rai N, Sah MK, et al (2020) Comorbid depression and its associated factors in patients with epilepsy treated with single and multiple drug therapy: A cross-sectional study from Himalayan country. Epilepsy & Behavior 112:107455. https://doi.org/10.1016/j.yebeh.2020.107455 Yousafzai AU, Yousafzai AW, Taj R (2009) Frequency of depression in epilepsy: a hospital based study. J Ayub Med Coll Abbottabad 21:73–75 Lee S-A, Lee S-M, No Y-J (2010) Factors contributing to depression in patients with epilepsy. Epilepsia 51:1305–1308. https://doi.org/10.1111/j.1528-1167.2009.02387.x Pham T, Sauro KM, Patten SB, et al (2017) The prevalence of anxiety and associated factors in persons with epilepsy. Epilepsia 58:. https://doi.org/10.1111/epi.13817 Stefanello S, Marín-Léon L, Fernandes PT, et al (2011) Depression and anxiety in a community sample with epilepsy in Brazil. Arq Neuro-Psiquiatr 69:342–348. https://doi.org/10.1590/S0004-282X2011000300015 Alsaadi T, El Hammasi K, Shahrour TM, et al (2015) Prevalence of depression and anxiety among patients with epilepsy attending the epilepsy clinic at Sheikh Khalifa Medical City, UAE: A cross-sectional study. Epilepsy Behav 52:194–199. https://doi.org/10.1016/j.yebeh.2015.09.008 Scott AJ, Sharpe L, Hunt C, Gandy M (2017) Anxiety and depressive disorders in people with epilepsy: A meta-analysis. Epilepsia 58:973–982. https://doi.org/10.1111/epi.13769 Rehman S, Kalita KK, Baruah A (2017) A hospital based cross sectional study on comorbid psychiatric problems in persons with epilepsy from north eastern part of India. Int J Epilepsy 4:31–35. https://doi.org/10.1016/j.ijep.2017.01.004 Kuladee S, Prachason T, Srisopit P, et al (2019) Prevalence of psychiatric disorders in Thai patients with epilepsy. Epilepsy Behav 90:20–24. https://doi.org/10.1016/j.yebeh.2018.11.004 Yang H, Feng Y, Zhu Z, et al (2020) Evaluation of anxiety, depression, and sleep quality among parents of children with epilepsy in Southern China. Epilepsy Behav 112:. https://doi.org/10.1016/j.yebeh.2020.107340 T T, B A (2018) Prevalence and Factors Associated to Depression and Anxiety among People with Epilepsy on Follow up at Hospitals in West Shewa Zone, Oromia Regional State, Central Ethiopia: Institutional Based Cross- Sectional Study. J Psychiatry Ment Health 3:. https://doi.org/10.16966/2474-7769.124 Grajewski RS, Boelke AC, Adler W, et al (2020) Perceived Stress Levels in Adult Patients With Uveitis. Front Psychiatry 10:916. https://doi.org/10.3389/fpsyt.2019.00916 Zhang M, A. Simon M, Dong X, 1 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL 60701, USA; (2014) The Prevalence of Perceived Stress among U.S. Chinese Older Adults. AIMS Medical Science 1:40–56. https://doi.org/10.3934/medsci.2014.1.40 Sahar N (2012) Assessment of Psychological Distress in Epilepsy: Perspective from Pakistan. Epilepsy Research and Treatment 2012:1–7. https://doi.org/10.1155/2012/171725 Sendhilkumar M, Tripathy J, Harries A, et al (2017) Factors associated with high stress levels in adults with diabetes mellitus attending a tertiary diabetes care center, Chennai, Tamil Nadu, India. Indian J Endocrinol Metab 21:56–63. https://doi.org/10.4103/2230-8210.196006 Guo W, Li Y, Zhang Y, et al (2023) Risk analysis of depression among adult patients with epilepsy of different sex: a retrospective single-center study from China. Front Psychiatry 14:1283983. https://doi.org/10.3389/fpsyt.2023.1283983 Athira SB, Pal P, Nair PP, et al (2024) Influence of sleep disturbance, depression, anxiety, and stress on quality of life in people with epilepsy. Epileptic Disord 26:69–78. https://doi.org/10.1002/epd2.20169 Chandrasekharan SC, Menon V, Wadwekar V, Nair PP (2017) High Frequency of Depressive Symptoms among Adults with Epilepsy: Results from a Hospital-based Study. Journal of Neurosciences in Rural Practice 08:S013–S019. https://doi.org/10.4103/jnrp.jnrp_21_17 Nidhinandana S, Chinvarun Y, Sithinamsuwan P, et al (2007) Prevalence of Depression among Epileptic Patients at Phramongkutklao Hospital. 90: Zegeye A, Dessie G, Wagnew F, et al (2019) Prevalence and determinants of anti-tuberculosis treatment non-adherence in Ethiopia: A systematic review and meta-analysis. PLoS ONE 14:e0210422. https://doi.org/10.1371/journal.pone.0210422 Jalihal V, Shankar R, Henley W, et al (2018) Eslicarbazepine acetate as a replacement for levetiracetam in people with epilepsy developing behavioral adverse events. Epilepsy Behav 80:365–369. https://doi.org/10.1016/j.yebeh.2018.01.020 Seid J, Mebrahtu K, Andualem F (2022) Prevalence and associated factors of anxiety disorder symptoms among people with epilepsy in Mekelle, Ethiopia, 2019: Institutional-based cross‐sectional study. Nursing Open 9:1731–1743. https://doi.org/10.1002/nop2.1198 Seid J, Mebrahtu K (2022) Prevalence and associated factors of depression among people with epilepsy in Ethiopia: a cross-sectional study. Egypt J Neurol, Psychiatr Neurosurg 58:. https://doi.org/10.1186/s41983-022-00534-1 Khatooni M, Rahimi S, Bahrami M (2024) The relationship between stress, anxiety, depression and medication adherence behavior in patients with epilepsy: A cross-sectional study. Epilepsy Behav 151:. https://doi.org/10.1016/j.yebeh.2023.109616 Jalihal V, Shankar R, Henley W, et al (2018) Eslicarbazepine acetate as a replacement for levetiracetam in people with epilepsy developing behavioral adverse events. Epilepsy & Behavior 80:365–369. https://doi.org/10.1016/j.yebeh.2018.01.020 Meador KJ, Cohen MJ, Loring DW, et al (2021) Two-Year-Old Cognitive Outcomes in Children of Pregnant Women with Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 78:927–936. https://doi.org/10.1001/jamaneurol.2021.1583 Campbell C, McCormack M, Patel S, et al (2022) A pharmacogenomic assessment of psychiatric adverse drug reactions to levetiracetam. Epilepsia 63:1563–1570. https://doi.org/10.1111/epi.17228 Plöthner M, Ribbentrop D, Hartman J-P, Frank M (2016) Cost-Effectiveness of Pharmacogenomic and Pharmacogenetic Test-Guided Personalized Therapies: A Systematic Review of the Approved Active Substances for Personalized Medicine in Germany. Adv Ther 33:1461–1480. https://doi.org/10.1007/s12325-016-0376-8 Shafiyev J, Karadaş Ö (2024) The assessment of the impact of antiepileptic drugs on cognitive functions via N-200/P-300 potentials and neuropsychological measures. Neurol Sci. https://doi.org/10.1007/s10072-024-07606-5 Al-Hayani M, AboTaleb H, Bazi A, Alghamdi B (2023) Depression, anxiety and stress in Saudi migraine patients using DASS-21: local population-based cross-sectional survey. International Journal of Neuroscience 133:248–256. https://doi.org/10.1080/00207454.2021.1909011 Othman A, Razak SA, Nasir A, et al (2023) Depressive, Anxiety, and Stress Symptoms in Parents of Children Being Admitted for Febrile Seizures in a Tertiary Hospital in the East Coast of Malaysia. EJIHPE 13:1015–1025. https://doi.org/10.3390/ejihpe13060077 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5801920","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":400351012,"identity":"ba05c49a-db11-4ae0-bb01-dfd84240219d","order_by":0,"name":"Shani Vishwakarma","email":"","orcid":"","institution":"Institute of Medical Science, Banaras Hindu University, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Shani","middleName":"","lastName":"Vishwakarma","suffix":""},{"id":400351013,"identity":"5108f2b3-a1ed-4eb2-8625-19836832aaa2","order_by":1,"name":"Abhishek Pathak","email":"","orcid":"","institution":"Institute of Medical Science, Banaras Hindu University, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Abhishek","middleName":"","lastName":"Pathak","suffix":""},{"id":400351014,"identity":"e44eedce-3fb0-48ef-8cbe-6e0b3b134433","order_by":2,"name":"Anil Kumar Maurya","email":"","orcid":"","institution":"Institute of Medical Science, Banaras Hindu University, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Anil","middleName":"Kumar","lastName":"Maurya","suffix":""},{"id":400351015,"identity":"2f08200b-37da-4d6c-bdc7-302e497ae697","order_by":3,"name":"Nitish Kumar Singh","email":"","orcid":"","institution":"Institute of Medical Science, Banaras Hindu University, Varanasi, India","correspondingAuthor":false,"prefix":"","firstName":"Nitish","middleName":"Kumar","lastName":"Singh","suffix":""},{"id":400351016,"identity":"3ef896ee-1b45-4957-ab9b-667dc09c501f","order_by":4,"name":"Royana Singh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBADHiBifMzYAOEdIFYLszFJWkC62KRhWvAC8/Yew88FNXUy5vxrj1UX7jjMwN9+gPFwAR4tMmfOGEvPOHaYx3LGu7TbM88cZpA4k8BweAYeLRISOQbSPGwHeAxunDG7zdt2mIHhBgPDYR78Wox/8/yrA2spBmmRJ0KLmTRvGzOPwfkeM2aQFgOCWniOlVnz9h0G2sJjLD2zLZ3H8ExiA34t7M2bb/N8q7M3OH/G8HNhm7Wc3PHDhz/j08LAwGEA1ZwApoCKCcYO+wMIzX+AgMJRMApGwSgYsQAAOXVJXoKJVPUAAAAASUVORK5CYII=","orcid":"","institution":"Institute of Medical Science, Banaras Hindu University, Varanasi, India","correspondingAuthor":true,"prefix":"","firstName":"Royana","middleName":"","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2025-01-10 08:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5801920/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5801920/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":74073409,"identity":"fbde2eeb-1bb4-4472-8154-1c0b643cf7a8","added_by":"auto","created_at":"2025-01-17 13:20:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":338767,"visible":true,"origin":"","legend":"\u003cp\u003eStress, anxiety, and depression prevalence in epileptic patients with healthy control.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5801920/v1/85b7627907f70befc2ce30cd.png"},{"id":74073404,"identity":"539baed6-9482-4d91-abac-a23273103be3","added_by":"auto","created_at":"2025-01-17 13:20:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44512,"visible":true,"origin":"","legend":"\u003cp\u003eCompare of antiepileptic drugs with DASS21\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5801920/v1/8b0d49cf9f226470202c086b.png"},{"id":74075358,"identity":"1018b3b3-1434-4dab-985a-261940f0d8df","added_by":"auto","created_at":"2025-01-17 13:36:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38910,"visible":true,"origin":"","legend":"\u003cp\u003eCompare of types of therapy (Monotherapy and Polytherapy) with DASS21.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5801920/v1/f9b792125f557a96945b1d24.png"},{"id":74076914,"identity":"76d90a9c-b3cf-4454-98d6-4c170dd01d16","added_by":"auto","created_at":"2025-01-17 13:44:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1376821,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5801920/v1/50450cf4-7bee-4c66-a8b4-d43ead6ebef7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAssessment of Depression, Anxiety, and Stress Among Epileptic Patients Utilizing the DASS-21 Scale: A Cross-Sectional Investigation\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpilepsy is defined as a neurological condition that, by recurring seizures arising from improper electrical discharges in the brain, impacts millions of people worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Seizures can affect a person's quality of life differently and may range in severity. Epilepsy is a curable, non-contagious condition that can impact individuals of any age [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to the World Health Organization (WHO), 50\u0026nbsp;million individuals worldwide suffer from epilepsy, and 80% of them are living in low-income nations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Many studies revealed that a variety of factors, including low socioeconomic status, consumption of drugs, low education, multiple medications, perceived stigma, monthly seizure rate, and adverse AED negative effects, may contribute to these patients' non-adherence to antiepileptic drugs [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patients with epilepsy require extensive care and management due to the high prevalence and increasing understanding of adverse effects caused by psychiatric comorbidities and non-adherence to medication [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, it is very critical to understand the psychological aspects that influence epilepsy patient\u0026rsquo;s medication adherence to design appropriate and successful techniques to increase adherence rates [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The primary therapeutic intervention for individuals with epilepsy is antiepileptic drugs (AEDs). Regular therapy is essential for achieving optimal seizure control following the successful implementation of a prescription; it is estimated that the occurrence of seizure is preventable in approximately 70% of patients with epilepsy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Epilepsy patients frequently suffer from depression as a mental health problem, with estimates indicating that up to 50% experience symptoms of depression at some point in their lives [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A person's standard of living can be severely affected by depressive symptoms, which can also have an impact on their ability to work, interact with others, and carry out everyday responsibilities. Patients with epilepsy who show signs of depression should be promptly treated by healthcare experts to prevent adverse effects such as increased seizure frequency and decreased quality of life. An additional prevalent mental health concern among epilepsy patients is anxiety, which may impact up to 30% of people with epilepsy at some point in their lives [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Several signs of anxiety may arise, such as panic attacks, social anxiety, and obsessive-compulsive behaviours. Similar to depression, untreated anxiety adversely affects a person's quality of life by increasing the frequency of seizures and lowering their overall health. Anxiety appears to represent a variety of expressions rather than an overall comorbidity of epilepsy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This range of symptoms illustrates several pathogenetic mechanisms, including direct neurobiological mechanisms involving brain structures implicated in the perception and regulation of emotions, preictal prodromes potentially indicating altered excitability, early ictal anxiety representing a loss of control, interictal anxiety, for example, in anticipation of different seizures, and social stigma expressing itself as nervous behaviour [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStress is also an issue for persons who have epilepsy. Stress-related symptoms may emerge as a mental trauma of having a chronic illness, as well as the stigma and social stigma that many people with epilepsy experience [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Stress can show up as a variety of symptoms, including psychological ones like irritation and trouble concentrating, as well as physical ones like headaches and gastrointestinal issues [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The Depression Anxiety Stress Scale (DASS21) is a commonly used psychological diagnostic tool that assesses the severity of signs of these mental health disorders[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It consists of 21 questions, each of which is aimed at assessing the intensity of symptoms correlated to depression, anxiety, and stress. The DASS21 scale has been validated for use in a wide range of populations, including people with epilepsy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The DASS21 scale may provide significant insight into how epileptic patients perceive themselves emotionally and psychologically. Healthcare providers can create personalized treatment programs to manage depression, anxiety, and stress-related symptoms and enhance patients' general well-being by evaluating the intensity of these symptoms [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, patients with epilepsy have significant psychological problems that are still frequently disregarded. This study aimed to reduce the psychological impact of epilepsy and aid society and governments in developing effective solutions for individuals affected by the condition. By identifying the signs of depression, anxiety, and stress, medical practitioners can create specialized treatment programs to address these problems and enhance overall health.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis cross-sectional study was conducted in the XXXX and patient was recruited from the Out-Patient XXXX, from August 2022, to February 2024. The total number of participants was 388, including 194 Cases, and 194 healthy controls were matched for age and sex. For control, the online survey was created using Google Forms, distributed through social media and emails to the group of XXXX students, and shared with friends who were above 18 age. A total number of individuals 201 control recruited. Where 7 individuals were excluded because they have a past history of epilepsy. We offer both the English and Hindi versions of the DASS21 questionnaire.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion for Cases \u0026amp; Healthy Control\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003eWe considered only those cases who were above the age of 18 had a clear diagnosis of epilepsy and were using at least one antiepileptic medication. All of the patients had an undetermined etiology. Control samples will include individuals without a history of epilepsy, aged between above18 years, and willing to participate voluntarily\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eExclusion criteria encompass patients with central nervous system infections and structural, metabolic, and neurodegenerative disorders. Additionally, epileptic patients undergoing acute illness or severe medical conditions that could independently affect their psychological state beyond epilepsy. Exclusion criteria involve individuals with a confirmed diagnosis of epilepsy, a past medical history of neurological disorders, psychiatric conditions, ongoing usage of psychotropic medications, who will not be included in the control group. Participants lacking a background of significant mental illnesses like schizophrenia or bipolar disorder may potentially complicate the evaluation of depression, anxiety, and stress are excluded.\u003c/p\u003e\n\u003ch3\u003eSociodemographic characteristics of the study subject\u003c/h3\u003e\n\u003cp\u003eThe questionnaire included the following socio-demographical data: age and gender as well as the clinical data related to the type of drugs taken, age of onset, family history of seizure, duration since diagnosis, clinical diagnosis of epilepsy, clinical diagnosis of depression, anxiety, stress, and clinical diagnosis of any other comorbidities.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe study received approval from the Institutional Medical Ethical Committee under reference number No. Dean/2022/EC/3413. Before participation, all participants were provided with comprehensive information concerning the study's objectives, methodology, their rights, and potential benefits. Each participant explicitly acknowledged their voluntary participation in the study and retained the right to withdraw at any time. Additionally, all participants completed informed consent forms.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDepression, Anxiety, and Stress Scale (DASS-21) instrument\u003c/h2\u003e \u003cp\u003eThe DASS-21 is a well-accepted scale for the quantification of depression, anxiety, and stress which consists of 21 items in the form of different questionnaires.\u003c/p\u003e \u003cp\u003eThe questionnaire included items related to depression (3, 5, 10, 13, 16, 17, and 21), anxiety (2, 4, 7, 9, 15, 19, and 20), and stress (1, 6, 8, 11, 12, 14, and 18)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Evaluation of weightage of Each question, ranging from 0 to 3, which could have the following possible responses: a score of 0 meant that it did not apply to me at all; a score of 1 meant that it did apply to me to some extent or occasionally; a score of 2 meant that it applied to me to a significant extent or frequently; and a score of 3 meant that it applied to me heavily or frequently. The final score is an aggregate of all question scores based on every emotional state. The total score for the DASS-21 is calculated by doubling the scores of each subscale, given its abbreviated nature compared to the original 42-item DASS [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Based on this score, each participant is positioned on a spectrum from 'Normal' to 'Extremely Severe' shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe table represents the recommended cut-off scores for conventional severity labels in the DASS-21 (Depression, Anxiety, and Stress Scale-21) questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeverity Label\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStress Score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u0026ndash;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u0026ndash;33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analysed using the IBM SPSS statistics version 20. Most of the data were reported as numbers and proportions to summarize the distribution of variables. The findings of the DASS-21 questionnaire are shown as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables along with the Kolmogorov-Smirnov (K-S) test for normal distribution and independent t-test to evaluate notable differences between the two groups but Significant differences between three groups were evaluated using one-way ANOVA. We performed the chi-square (χ\u0026sup2;) test to investigate the association between gender and family history. The acceptable level for statistical significance was determined at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 388 participants were examined, consisting of responses from 194 patients with epilepsy and 194 healthy controls. A description of the diverse main demographic and clinical variables included in the study was shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There were no statistically significant differences in age, sex, cause, and family history. The study participants were predominantly females, 113 (58.2%). There was a significant difference in the measurable value of depression between males and females (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), but the differences in anxiety and stress were not significant. In depression (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.34), anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.547), and stress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.231) among individuals with brain injury, epilepsy of unknown origin, and a family history of epilepsy showed no significant differences. There was no significant difference in the measurable values of depression (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.183), anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.373), and stress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.812) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Although among these patients, 11.9% had focal epilepsy, while 88.1% had generalized epilepsy. Another type of parameter for the same patients undergoing polytherapy (multidrug treatment) for depression scored significantly higher than those receiving monotherapy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). There was no significant difference in the ratings for anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.214) and stress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.139) shown in \u003cb\u003eFig.\u0026nbsp;3\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics of age, sex, type of therapy, cause and family history of patients with epilepsy and healthy controls.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eDemographic, Clinical, \u0026amp; Laboratory data of the study subject\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEpileptic Patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003et value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eχ2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003edf\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;194(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;194(50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeans\u0026thinsp;\u0026plusmn;\u0026thinsp;SDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.11\u0026thinsp;\u0026plusmn;\u0026thinsp;10.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.87\u0026thinsp;\u0026plusmn;\u0026thinsp;10.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.683\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81(41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113(58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122(62.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTypes Of Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonotherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155 (79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolytherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGenetical (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60(30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrain Injury (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFamily History\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58(29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136(70.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e191(98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eNote: N\u0026thinsp;=\u0026thinsp;No of sample, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, t\u0026thinsp;=\u0026thinsp;t-test, χ2\u0026thinsp;=\u0026thinsp;Chi-square, df\u0026thinsp;=\u0026thinsp;Degree of freedom, p\u0026thinsp;=\u0026thinsp;probability value.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe severity of symptoms of depression, anxiety, and stress in patients with epilepsy compared with age, sex, seizure types, medication (Treatment adherence), type of therapy, and cause.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174(89.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.45\u0026thinsp;\u0026plusmn;\u0026thinsp;4.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39\u0026ndash;58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(7.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.66\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(3.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.284\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.79\u0026thinsp;\u0026plusmn;\u0026thinsp;6.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.90\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.80\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113(58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.587\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.997\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizure Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(11.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171 (88.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.183\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.373\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.812\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenytoin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevetiracetam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.49\u0026thinsp;\u0026plusmn;\u0026thinsp;6.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxocarbazepine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.24\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbazepine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium Valproate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.55\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.529\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.886\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.457\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes Of Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155(79.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.59\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (20.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.51\u0026thinsp;\u0026plusmn;\u0026thinsp;6.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.214\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.139\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.17\u0026thinsp;\u0026plusmn;\u0026thinsp;5.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.87\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126(64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.95\u0026thinsp;\u0026plusmn;\u0026thinsp;5.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrain Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.25 \u0026plusmn; 4.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.50 \u0026plusmn; 3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.50 \u0026plusmn; 6.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.547\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.231\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNote: N\u0026thinsp;=\u0026thinsp;No of the sample, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, t\u0026thinsp;=\u0026thinsp;t-test, χ2\u0026thinsp;=\u0026thinsp;Chi-square, df\u0026thinsp;=\u0026thinsp;Degree of freedom, p\u0026thinsp;=\u0026thinsp;probability value. One-way ANOVA or an independent sample t-test was used to compare the DASS-21 score means of the variable's categories. The mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation represents the depression, anxiety, and stress scores. P values are indicated in bold.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn the subject of medication, the analysis of specific antiepileptic drugs showed that depression was not significantly associated with the use of Phenytoin (14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12), Levetiracetam (13.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.06), Oxcarbazepine (13.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76), Carbamazepine (16.22\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51), and Sodium Valproate (14.32\u0026thinsp;\u0026plusmn;\u0026thinsp;4.39), with p\u0026thinsp;\u0026gt;\u0026thinsp;0.529. No significant associations were found with anxiety for Phenytoin (9.80\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94), Levetiracetam (11.49\u0026thinsp;\u0026plusmn;\u0026thinsp;6.35), Oxcarbazepine (11.24\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69), Carbamazepine (11.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.07), and Sodium Valproate (11.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19), with p\u0026thinsp;\u0026gt;\u0026thinsp;0.886. Additionally, there were no significant differences in stress with different types of drugs: Phenytoin (17.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.30), Levetiracetam (20.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96), Oxcarbazepine (19.14\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04), Carbamazepine (19.11\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88), and Sodium Valproate (20.55\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25), with p\u0026thinsp;\u0026gt;\u0026thinsp;0.457 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cb\u003e\u0026amp;\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients with epilepsy report moderate to extremely severe levels of depression (59.7%), anxiety (65.4%), and stress (53.6%) more frequently than the control group. These results are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSeverity of Depression, Anxiety, and Stress.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStress Frequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (17.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (24.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to Extremely Severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (65.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e104 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results show significant differences between the case and control groups for depression, anxiety, and stress, the statistical analysis (t-test) confirms that these differences was highly significant. Participate with a clinical diagnosis of epilepsy alone, the mean and standard deviation scores for depression, anxiety, and stress were 14.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00), 11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45(\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00), and 19.80\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.00), shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cb\u003e\u0026amp;\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patients with epilepsy and healthy controls \u003cb\u003e(Risk score on the DASS21)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.80\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: N\u0026thinsp;=\u0026thinsp;No of sample, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, t\u0026thinsp;=\u0026thinsp;t-test, χ2\u0026thinsp;=\u0026thinsp;Chi-square, df\u0026thinsp;=\u0026thinsp;Degree of freedom, p\u0026thinsp;=\u0026thinsp;probability value\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDepression, anxiety, and stress are highly prevalent comorbidities with epilepsy. Our study aims to estimate the prevalence of these psychological symptoms in the Northern Indian population and explore their association with socio-demographic factors.\u003c/p\u003e \u003cp\u003eIn our study, out of 194 patients, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD 14.27\u0026thinsp;\u0026plusmn;\u0026thinsp;5.69, 11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45, and 19.80\u0026thinsp;\u0026plusmn;\u0026thinsp;5.12 showed symptoms of depression, anxiety, and stress based on the DASS-21 scale (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cb\u003e\u0026amp;\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The research outcomes indicate that among people with epilepsy, reported experiencing moderate to extremely severe levels of these psychiatric symptoms of depression (59.7%), anxiety (65.4%), and stress (53.6%) are relatively higher compared to control group Shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In contrast to previous studies have highlighted a high prevalence of psychiatric symptoms, including depression, anxiety, and stress, among patients with epilepsy.\u003c/p\u003e \u003cp\u003eThe prevalence of depression in this study 59.7% among individuals with epilepsy varies significantly across different countries. Comparable rates were noted in the Emirates of Abu Dhabi (28.7%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Egypt (25.5%) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Bosnia (34%) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and among Nigerian adolescents (28.43%)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], Iran (9.5%)[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and Thailand (20%) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], while higher rates were reported in India (63.3%)[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], Pakistan (60%)[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], Korea (62%)[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and Nigeria (85%)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of anxiety in this study was found to be 65.4%, which is higher than the rates reported in Canada (40%)[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], Brazil (39.4%)[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], the United Arab Emirates (43.5%)[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Iran (24.5%)[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Australia (20.2%)[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], India (11.0%)[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], Thailand (5.3%)[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], China (57.0%)[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and Oman (47.8%)[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Similarly, the prevalence of stress in this study was 53.6%, higher than that observed in Germany (43%)[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] but lower than the rates reported in the U.S. (74%)[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], Pakistan (70%)[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], and India (35%)[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. These differences are likely influenced by variations in study population diversity, study design, inclusion criteria, sample size, and the screening instruments used. There was a significant notable difference between depression and gender (41.8% of males, 88.1% of females) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.002), but no significant difference in anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.587) and stress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.812). A previous study found a significant association between gender and anxiety among epilepsy patients, with females demonstrating a higher frequency of anxiety compared to male. Biological factors, hormonal disparities, and psychosocial elements specific to each gender could potentially influence the differing levels of depression, anxiety, and stress seen in male and female epilepsy patients[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Significant sex differences in depression among epilepsy patients were observed, with females being 4.27 times more likely to experience depression compared to males[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results showed that patients undergoing polytherapy (treatment with multiple drugs) for depression had notably higher scores compared to those receiving monotherapy (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). However, there were no significant differences in the ratings for anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.214) and stress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.139). Multiple research demonstrates that monotherapy and polytherapy have a strong association with patients with epilepsy, with a mean of 75.8: 24.2, as well as a higher prevalence of depression[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Polytherapy has been recognized as an important factor, but definitive reports on the correlation between depression and the frequency of drug use are still lacking. Studies show significant variation, with some indicating a positive association while others find none. In previous studies, found no association between the use of multiple drugs and an increased risk of depression[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Similarly, other study found no significant link between depression and the frequency of drug use in their respective studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The study revealed a significant correlation between drug frequency and depression, anxiety, and stress with individuals receiving polytherapy being 3.82 times more likely to experience depression compared to those on monotherapy [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Using several medications can increase the number of pills a person needs to take and reduce their adherence to the treatment. This often leads to poor seizure control and a higher risk of severe side effects. Patients under polytherapy face an elevated risk of drug-to-drug interactions and are more prone to medication errors. Thus, it is important to prioritize the right drug therapy, taking into account factors such as pill burden, tolerability, and potential interactions. Including education on medication regimens in epilepsy treatment guidelines and healthcare provider training is vital to ensure optimal management of patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our analysis revealed no significant links between depression, anxiety, stress and antiepileptic drugs (Phenytoin, Levetiracetam, Oxcarbazepine, Carbamazepine and Sodium Valproate). We could not find any evidence of a significant relationship between medication adherence behavior and depression, anxiety, and the degree of stress (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Certain pervious research indicates that stress has a detrimental effect on medication adherence among epilepsy patients [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].The difference may arise from variations in the study's design, sample size, socio-cultural disparities, and participant demographics. In Ethiopia, the non-adherence rate to anti-epileptic medication among patients with psychiatric comorbidities was reported as 39 out of 77 cases [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The relevance of this issue is highlighted by the overall evidence showing that poor medication adherence is prevalent in people with epilepsy [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In epileptic patients, adherence to treatment was negatively impacted by co-occurring symptoms of depression, anxiety, and stress. These overlapping mental health issues can cause feelings of hopelessness, disinterest, and a breakdown in communication with healthcare providers, which in turn complicates medication adherence and heightens the risk of not following treatment plans [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Individuals with epilepsy who suffer from antiepileptic drug-related side effects are 2.5 times more likely to experience anxiety compared to those without such side effects (AOR\u0026thinsp;=\u0026thinsp;2.547 [1.242, 5.224]). This finding is consistent with multiple studies conducted in Canada and Ethiopia [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. This association could be due to depression, anxiety, and stress being physiological responses, with antiepileptic drugs potentially disrupting daily tasks and causing anxiety [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Another potential explanation is that individuals with untreated beliefs may restrict their social interactions, experience lowered self-esteem due to their psychiatric illness, and limit social activities such as marriage and education. They may perceive themselves as weak, dependent, and incapable. Thus, these issues are increasingly being discussed in people's minds. They may feel stressed as a result [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In epilepsy patients, poor medication adherence was significantly predicted by higher levels of depression, anxiety, and stress. The adherence to anti-epileptic medication hinges significantly on preventing, detecting early, and managing comorbid mental illnesses and pharmaceutical side effects effectively[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Individuals with epilepsy in low-income and middle-income countries experience a notable treatment disparity[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], influenced by how their psychological well-being is shaped by sociocultural and economic factors in their respective countries [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The research indicates that the prevalence of co-occurring mood problems among epileptic patients is significantly higher in developing nations [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral advantages of the study; Wide Coverage and Inclusive Sample: The study covers a broad demographic and clinical spectrum of epilepsy patients, enhancing the generalizability of its findings within the Northern Indian population. The inclusion of both hospital-based patients and healthy controls via an online survey adds depth to the comparative analysis. The DASS-21 is a validated instrument used to assess depression, anxiety, and stress, providing reliable and standardized evaluations of psychological distress. This includes sociodemographic and clinical characteristics enabling a detailed analysis of factors potentially influencing psychological outcomes in epilepsy patients.\u003c/p\u003e \u003cp\u003eDisadvantages of the study, Cross-Sectional Design while effective for determining prevalence, the cross-sectional design cannot establish causality between epilepsy and psychological distress and the effect of treatment adherence on psychological outcomes. Bias of self-response relying on self-reported data for the DASS-21 and sociodemographic information may introduce response biases, affecting the accuracy of the reported psychological states and adherence levels. Moreover, only one question was used to assess some of the independent factors, including the presence of thoughts of suicide, sexual or physical abuse, and medication adherence. This might cause some patients to answer inappropriately. Lack of Longitudinal Follow up regional specificity: While the study offers valuable insights into the Northern Indian population, its findings may not be universally applicable to other regions and populations due to variations in culture, socioeconomic status, and healthcare systems. Last but not least, the study mentions the impact of psychiatric comorbidities on treatment adherence but does not delve deeply into adherence rates and factors affecting adherence, which are crucial for understanding and improving epilepsy management.\u003c/p\u003e \u003cp\u003eFuture investigations must use longitudinal studies to assess the dynamic changes in psychological flexibility in epilepsy patients. Subsequently, in the context of epilepsy, future studies might assess the significance of psychological flexibility in predicting outcomes including treatment compliance, medication response, and mental health state.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe prevalence of depression, anxiety, and stress among epilepsy patients exceeded that of healthy controls. Significant associations were found among those who perceived epilepsy as untreatable, experienced anxiety, and faced stigma. Factors contributing to these findings included an elevated likelihood of stress-related symptoms, highlighting the importance for clinicians and healthcare providers to be vigilant. Therefore, comprehensive and systemic assessment approaches are necessary to mitigate the levels of depression, anxiety, and stress in epilepsy patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.V., A.P., R.S. conceived and designed the research. A.K.M and S.V. performed all operations. A.K.M. and S.V. analyzed the data and drew the figures. S.V., R.S., A.K.M., N.K.S., and A.P. wrote the manuscript. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe want to extend our sincere gratitude to the Department of Anatomy, Department of Neurology, Multi-Disciplinary Research Units (MRUs) Laboratory, Institute of Medical Sciences, Banaras Hindu University\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSafeer V S M, Sahu JK, Madaan P, et al (2024) Estimating the active and lifetime prevalence and incidence of epilepsy in Asian Countries: A systematic review and meta-analysis. Epilepsy Behav 154:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2024.109739\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2024.109739\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlixen C, Ogede D, Briggs F, et al (2020) Correlates of stigma in people with epilepsy. J Clin Neurol 16:423\u0026ndash;432. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3988/jcn.2020.16.3.423\u003c/span\u003e\u003cspan address=\"10.3988/jcn.2020.16.3.423\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRanjan LK, Panday R, Kiran M (2016) Stress, anxiety, and depression among individuals with epilepsy. Open Jour of Psych \u0026amp; Allied Scie 7:129. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5958/2394-2061.2016.00020.3\u003c/span\u003e\u003cspan address=\"10.5958/2394-2061.2016.00020.3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamu A, Chen R, Li A, Xue G (2023) Epilepsy in Asian countries. Acta Epileptologica 5:25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s42494-023-00136-1\u003c/span\u003e\u003cspan address=\"10.1186/s42494-023-00136-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBala A, Olejnik A, Kułak M, et al (2024) Determinants of the Quality of Life in Patients with Drug-Resistant Temporal Lobe Epilepsy: A Comparison of the Results before and after Surgery. Brain Sci 14:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/brainsci14030241\u003c/span\u003e\u003cspan address=\"10.3390/brainsci14030241\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan X, Pharm B, Makmor-Bakry M, et al (2015) Factors affecting adherence to antiepileptic drugs therapy in Malaysia. Neurology Asia\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark KM, Kim SE, Lee BI (2019) Antiepileptic Drug Therapy in Patients with Drug-Resistant Epilepsy. J Epilepsy Res 9:14\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.14581/jer.19002\u003c/span\u003e\u003cspan address=\"10.14581/jer.19002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEspinosa-Jovel C, Toledano R, Aledo-Serrano \u0026Aacute;, et al (2018) Epidemiological profile of epilepsy in low income populations. Seizure 56:67\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.seizure.2018.02.002\u003c/span\u003e\u003cspan address=\"10.1016/j.seizure.2018.02.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavoudi M, Lundgren T, Jansson-Fr\u0026ouml;jmark M, et al (2022) The Psychological Flexibility in Epilepsy Questionnaire (PFEQ): Psychometric properties of the Persian version. Epilepsy \u0026amp; Behavior 130:108672. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2022.108672\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2022.108672\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiarava E, Markoula S, Pelidou S-H, et al (2020) Psychological distress symptoms and illness perception in patients with epilepsy in Northwest Greece. Epilepsy Behav 102:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2019.106647\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2019.106647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeskin Guler S, Aytac B, Durak ZE, et al (2016) Antioxidative\u0026ndash;oxidative balance in epilepsy patients on antiepileptic therapy: a prospective case\u0026ndash;control study. Neurol Sci 37:763\u0026ndash;767. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10072-016-2494-0\u003c/span\u003e\u003cspan address=\"10.1007/s10072-016-2494-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngidaw NA, Bacha L, Kenea A (2020) Prevalence of depression and associated factors among epileptic patients at Ilu Ababore zone hospitals, South West Ethiopia, 2017: a cross\u0026ndash;sectional study. Ann Gen Psychiatry 19:19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12991-020-00268-5\u003c/span\u003e\u003cspan address=\"10.1186/s12991-020-00268-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRauh R, Schulze-Bonhage A, Metternich B (2022) Assessment of Anxiety in Patients With Epilepsy: A Literature Review. Front Neurol 13:836321. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fneur.2022.836321\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2022.836321\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsadi-Pooya A, Sperling M (2011) Depression and Anxiety in Patients with Epilepsy, With or Without Other Chronic Disorders. 13:\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShadid AM, Alsaber N, Aldawish RA, et al (2024) Depression and anxiety among patients with epilepsy: A cross-sectional study from Riyadh, Saudi Arabia. Journal of Family Medicine and Primary Care 13:549\u0026ndash;555. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/jfmpc.jfmpc_834_23\u003c/span\u003e\u003cspan address=\"10.4103/jfmpc.jfmpc_834_23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThapa DK, Visentin D, Kornhaber R, Cleary M (2022) Psychometric properties of the Nepali language version of the Depression Anxiety Stress Scales (DASS-21). Nursing Open 9:2608\u0026ndash;2617. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nop2.959\u003c/span\u003e\u003cspan address=\"10.1002/nop2.959\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang S, Wu C, Jia Y, et al (2020) COVID-19 outbreak: The impact of stress on seizures in patients with epilepsy. Epilepsia 61:1884\u0026ndash;1893. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/epi.16635\u003c/span\u003e\u003cspan address=\"10.1111/epi.16635\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWittayapun Y, Summart U, Polpanadham P, et al (2023) Validation of depression, anxiety, and stress scales (DASS-21) among Thai nursing students in an online learning environment during the COVID-19 outbreak: A multi-center study. PLoS ONE 18:e0288041. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0288041\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0288041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarnia V, Afshari D, Abdoli N, et al (2021) The effect of substance abuse on depression, anxiety, and stress (DASS-21) in epileptic patients. Clinical Epidemiology and Global Health 9:128\u0026ndash;131. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cegh.2020.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.cegh.2020.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParsons ALM, Bucknor EMV, Castroflorio E, et al (2022) The Interconnected Mechanisms of Oxidative Stress and Neuroinflammation in Epilepsy. Antioxidants 11:157. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/antiox11010157\u003c/span\u003e\u003cspan address=\"10.3390/antiox11010157\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim RH, Paulino YC, Kawabata Y (2024) Validating Constructs of the Depression, Anxiety, and Stress Scale-21 and Exploring Health Indicators to Predict the Psychological Outcomes of Students Enrolled in the Pacific Islands Cohort of College Students. IJERPH 21:509. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph21040509\u003c/span\u003e\u003cspan address=\"10.3390/ijerph21040509\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkunola OP, Ikhurionan PE (2022) Depression, Anxiety and Stress Disorders among Mothers of Children with Chronic Neurologic Disorder seen at the University of Benin Teaching Hospital, Nigeria: A Cross-sectional Study. Trop J Health Sci 29:21\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4314/tjhc.v29i3.4\u003c/span\u003e\u003cspan address=\"10.4314/tjhc.v29i3.4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsaadi T, El Hammasi K, Shahrour TM, et al (2015) Depression and Anxiety among Patients with Epilepsy and Multiple Sclerosis: UAE Comparative Study. Behavioural Neurology 2015:1\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2015/196373\u003c/span\u003e\u003cspan address=\"10.1155/2015/196373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShehata GA, Mahran DG (2013) Egyptian students\u0026rsquo; guardians knowledge, attitude and predictors of negative attitude of epilepsy in Assiut city. JEGH 4:87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jegh.2013.09.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jegh.2013.09.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagić A, Bagić D, Živković I (2009) First population study of the general public awareness and perception of epilepsy in Bosnia and Herzegovina. Epilepsy \u0026amp; Behavior 14:154\u0026ndash;161. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2008.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2008.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdewuya AO, Ola BA (2005) Prevalence of and risk factors for anxiety and depressive disorders in Nigerian adolescents with epilepsy. Epilepsy \u0026amp; Behavior 6:342\u0026ndash;347. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2004.12.011\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2004.12.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsadi-Pooya AA, Sperling MR (2011) Depression and anxiety in patients with epilepsy, with or without other chronic disorders. Iran Red Crescent MedJ 13:112\u0026ndash;116\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhabphal K, Sattawatcharawanich S, Sathirapunya P, Limapichart K (2007) Anxiety and depression in Thai epileptic patients. J Med Assoc Thailand 90:2010\u0026ndash;2015\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSah SK, Rai N, Sah MK, et al (2020) Comorbid depression and its associated factors in patients with epilepsy treated with single and multiple drug therapy: A cross-sectional study from Himalayan country. Epilepsy \u0026amp; Behavior 112:107455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2020.107455\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2020.107455\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYousafzai AU, Yousafzai AW, Taj R (2009) Frequency of depression in epilepsy: a hospital based study. J Ayub Med Coll Abbottabad 21:73\u0026ndash;75\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee S-A, Lee S-M, No Y-J (2010) Factors contributing to depression in patients with epilepsy. Epilepsia 51:1305\u0026ndash;1308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1528-1167.2009.02387.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1528-1167.2009.02387.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePham T, Sauro KM, Patten SB, et al (2017) The prevalence of anxiety and associated factors in persons with epilepsy. Epilepsia 58:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/epi.13817\u003c/span\u003e\u003cspan address=\"10.1111/epi.13817\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStefanello S, Mar\u0026iacute;n-L\u0026eacute;on L, Fernandes PT, et al (2011) Depression and anxiety in a community sample with epilepsy in Brazil. Arq Neuro-Psiquiatr 69:342\u0026ndash;348. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S0004-282X2011000300015\u003c/span\u003e\u003cspan address=\"10.1590/S0004-282X2011000300015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsaadi T, El Hammasi K, Shahrour TM, et al (2015) Prevalence of depression and anxiety among patients with epilepsy attending the epilepsy clinic at Sheikh Khalifa Medical City, UAE: A cross-sectional study. Epilepsy Behav 52:194\u0026ndash;199. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2015.09.008\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2015.09.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott AJ, Sharpe L, Hunt C, Gandy M (2017) Anxiety and depressive disorders in people with epilepsy: A meta-analysis. Epilepsia 58:973\u0026ndash;982. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/epi.13769\u003c/span\u003e\u003cspan address=\"10.1111/epi.13769\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRehman S, Kalita KK, Baruah A (2017) A hospital based cross sectional study on comorbid psychiatric problems in persons with epilepsy from north eastern part of India. Int J Epilepsy 4:31\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijep.2017.01.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ijep.2017.01.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuladee S, Prachason T, Srisopit P, et al (2019) Prevalence of psychiatric disorders in Thai patients with epilepsy. Epilepsy Behav 90:20\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2018.11.004\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2018.11.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang H, Feng Y, Zhu Z, et al (2020) Evaluation of anxiety, depression, and sleep quality among parents of children with epilepsy in Southern China. Epilepsy Behav 112:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2020.107340\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2020.107340\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT T, B A (2018) Prevalence and Factors Associated to Depression and Anxiety among People with Epilepsy on Follow up at Hospitals in West Shewa Zone, Oromia Regional State, Central Ethiopia: Institutional Based Cross- Sectional Study. J Psychiatry Ment Health 3:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.16966/2474-7769.124\u003c/span\u003e\u003cspan address=\"10.16966/2474-7769.124\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrajewski RS, Boelke AC, Adler W, et al (2020) Perceived Stress Levels in Adult Patients With Uveitis. Front Psychiatry 10:916. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyt.2019.00916\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2019.00916\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang M, A. Simon M, Dong X, 1 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, IL 60701, USA; (2014) The Prevalence of Perceived Stress among U.S. Chinese Older Adults. AIMS Medical Science 1:40\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3934/medsci.2014.1.40\u003c/span\u003e\u003cspan address=\"10.3934/medsci.2014.1.40\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahar N (2012) Assessment of Psychological Distress in Epilepsy: Perspective from Pakistan. Epilepsy Research and Treatment 2012:1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2012/171725\u003c/span\u003e\u003cspan address=\"10.1155/2012/171725\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSendhilkumar M, Tripathy J, Harries A, et al (2017) Factors associated with high stress levels in adults with diabetes mellitus attending a tertiary diabetes care center, Chennai, Tamil Nadu, India. Indian J Endocrinol Metab 21:56\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/2230-8210.196006\u003c/span\u003e\u003cspan address=\"10.4103/2230-8210.196006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo W, Li Y, Zhang Y, et al (2023) Risk analysis of depression among adult patients with epilepsy of different sex: a retrospective single-center study from China. Front Psychiatry 14:1283983. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyt.2023.1283983\u003c/span\u003e\u003cspan address=\"10.3389/fpsyt.2023.1283983\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAthira SB, Pal P, Nair PP, et al (2024) Influence of sleep disturbance, depression, anxiety, and stress on quality of life in people with epilepsy. Epileptic Disord 26:69\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/epd2.20169\u003c/span\u003e\u003cspan address=\"10.1002/epd2.20169\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandrasekharan SC, Menon V, Wadwekar V, Nair PP (2017) High Frequency of Depressive Symptoms among Adults with Epilepsy: Results from a Hospital-based Study. Journal of Neurosciences in Rural Practice 08:S013\u0026ndash;S019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/jnrp.jnrp_21_17\u003c/span\u003e\u003cspan address=\"10.4103/jnrp.jnrp_21_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNidhinandana S, Chinvarun Y, Sithinamsuwan P, et al (2007) Prevalence of Depression among Epileptic Patients at Phramongkutklao Hospital. 90:\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZegeye A, Dessie G, Wagnew F, et al (2019) Prevalence and determinants of anti-tuberculosis treatment non-adherence in Ethiopia: A systematic review and meta-analysis. PLoS ONE 14:e0210422. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0210422\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0210422\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJalihal V, Shankar R, Henley W, et al (2018) Eslicarbazepine acetate as a replacement for levetiracetam in people with epilepsy developing behavioral adverse events. Epilepsy Behav 80:365\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2018.01.020\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2018.01.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeid J, Mebrahtu K, Andualem F (2022) Prevalence and associated factors of anxiety disorder symptoms among people with epilepsy in Mekelle, Ethiopia, 2019: Institutional-based cross‐sectional study. Nursing Open 9:1731\u0026ndash;1743. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/nop2.1198\u003c/span\u003e\u003cspan address=\"10.1002/nop2.1198\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeid J, Mebrahtu K (2022) Prevalence and associated factors of depression among people with epilepsy in Ethiopia: a cross-sectional study. Egypt J Neurol, Psychiatr Neurosurg 58:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s41983-022-00534-1\u003c/span\u003e\u003cspan address=\"10.1186/s41983-022-00534-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhatooni M, Rahimi S, Bahrami M (2024) The relationship between stress, anxiety, depression and medication adherence behavior in patients with epilepsy: A cross-sectional study. Epilepsy Behav 151:. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2023.109616\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2023.109616\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJalihal V, Shankar R, Henley W, et al (2018) Eslicarbazepine acetate as a replacement for levetiracetam in people with epilepsy developing behavioral adverse events. Epilepsy \u0026amp; Behavior 80:365\u0026ndash;369. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.yebeh.2018.01.020\u003c/span\u003e\u003cspan address=\"10.1016/j.yebeh.2018.01.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeador KJ, Cohen MJ, Loring DW, et al (2021) Two-Year-Old Cognitive Outcomes in Children of Pregnant Women with Epilepsy in the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs Study. JAMA Neurol 78:927\u0026ndash;936. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamaneurol.2021.1583\u003c/span\u003e\u003cspan address=\"10.1001/jamaneurol.2021.1583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell C, McCormack M, Patel S, et al (2022) A pharmacogenomic assessment of psychiatric adverse drug reactions to levetiracetam. Epilepsia 63:1563\u0026ndash;1570. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/epi.17228\u003c/span\u003e\u003cspan address=\"10.1111/epi.17228\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePl\u0026ouml;thner M, Ribbentrop D, Hartman J-P, Frank M (2016) Cost-Effectiveness of Pharmacogenomic and Pharmacogenetic Test-Guided Personalized Therapies: A Systematic Review of the Approved Active Substances for Personalized Medicine in Germany. Adv Ther 33:1461\u0026ndash;1480. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12325-016-0376-8\u003c/span\u003e\u003cspan address=\"10.1007/s12325-016-0376-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShafiyev J, Karadaş \u0026Ouml; (2024) The assessment of the impact of antiepileptic drugs on cognitive functions via N-200/P-300 potentials and neuropsychological measures. Neurol Sci. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10072-024-07606-5\u003c/span\u003e\u003cspan address=\"10.1007/s10072-024-07606-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Hayani M, AboTaleb H, Bazi A, Alghamdi B (2023) Depression, anxiety and stress in Saudi migraine patients using DASS-21: local population-based cross-sectional survey. International Journal of Neuroscience 133:248\u0026ndash;256. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00207454.2021.1909011\u003c/span\u003e\u003cspan address=\"10.1080/00207454.2021.1909011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOthman A, Razak SA, Nasir A, et al (2023) Depressive, Anxiety, and Stress Symptoms in Parents of Children Being Admitted for Febrile Seizures in a Tertiary Hospital in the East Coast of Malaysia. EJIHPE 13:1015\u0026ndash;1025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ejihpe13060077\u003c/span\u003e\u003cspan address=\"10.3390/ejihpe13060077\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Epilepsy, Antiepileptic drugs, Depression, Stress, Anxiety, DASS21","lastPublishedDoi":"10.21203/rs.3.rs-5801920/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5801920/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeople with epilepsy frequently experience depression, Anxiety, and stress, which has a substantial negative impact on their quality of life and overall health-related satisfaction. This study aimed to identify psychiatric comorbidities in individuals with epilepsy, as assessed via the Depression, Anxiety, and Stress Scale, by comparing them with a healthy control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted in the XXXX, and patients were recruited from the Out-Patient Department of XXXX, from August 2022 to February 2024. The total number of participants was 388, including 194 Cases. 194 healthy controls were matched for age and sex, with participants under the age of 18 excluded. Psychiatric comorbidity was evaluated via the DASS-21 scale using Chi-square and one-way ANOVA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involved 194 patients and 194 healthy controls, with a mean age of 25.11 ± 10.28 years. Among the patients, 58.2% were female and 41.8% were male. A significant difference in depression levels was found between patients on monotherapy and polytherapy (\u003cem\u003ep\u003c/em\u003e = 0.003). However, no significant differences were found in anxiety (\u003cem\u003ep\u003c/em\u003e = 0.214) and stress (\u003cem\u003ep\u003c/em\u003e = 0.139). There are no significant links between depression, anxiety, stress and antiepileptic drugs. Patients with epilepsy had significantly higher levels of depression, anxiety, and stress compared to healthy controls, with all \u003cem\u003ep\u003c/em\u003e = 0.00.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study highlights the elevated levels of depression, anxiety, and stress among patients with epilepsy. Clinicians and healthcare practitioners should adopt comprehensive and holistic assessment methods to address and mitigate these psychiatric comorbidities in epilepsy patients.\u003c/p\u003e","manuscriptTitle":"Assessment of Depression, Anxiety, and Stress Among Epileptic Patients Utilizing the DASS-21 Scale: A Cross-Sectional Investigation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-17 13:20:06","doi":"10.21203/rs.3.rs-5801920/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-27T18:47:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-25T19:59:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70213371942422408805367851638138741681","date":"2025-02-20T06:46:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-16T03:22:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208655125145805020143427508737182990740","date":"2025-02-16T02:15:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-09T04:11:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173315673501701567085579460396563718536","date":"2025-02-05T13:37:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-05T13:17:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-31T13:05:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-25T11:46:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Psychology","date":"2025-01-10T08:23:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2588f4e1-20a1-4fac-97be-f0bdd1d166aa","owner":[],"postedDate":"January 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T06:53:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-17 13:20:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5801920","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5801920","identity":"rs-5801920","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}