studies have reported the prevalence of psychological distress and psychiatric comorbidity in patients with epilepsy [ 14 ] .
seizure activity , poor seizure control , and kindling - like phenomena may be causes of depression .
sometimes depression may be a side effect of anticonvulsant medication [ 5 , 6 ] .
psychosocial factors predisposing to depression in people with epilepsy include adjustment difficulties , limitations and restrictions in social settings which the disorder imposes , as well as the unpredictable nature of the seizures and the associated feelings of helplessness and loss of control over one 's life .
the unpredictability limits mobility , hinders the work and education , and may lead towards the psychological disorders .
these issues gain more importance when there is limited knowledge about the disorder especially in the case of developing countries with low level of education and poor health care system .
three quarters of the 50 million people with epilepsy live in developing countries and 94% of them are untreated .
this large percentage raises many questions related to the treatment facilities as well as the societal attitude towards the disorder .
several studies from developing countries have reported more negative attitudes and stigma about epilepsy as compared to the developed countries [ 810 ] .
overall prevalence of epilepsy is estimated to be 9.99 per 1000 population with the highest rate in young adulthood . here
the burden of epilepsy is twice as high in rural areas ( 14.8/1000 ) as compared to urban areas ( 7.4/1000 ) .
this high rate of pwe in rural areas increases the need to investigate more about the disorder with a focus on cultural variation and psychosocial variables to help in the treatment and management .
factors associated with depression include lack of occupation , the presence of an underlying disabling condition ( with treatment ) , and the severity of epilepsy [ 1417 ] . in one study by the authors of [ 18 , 19 ]
it was found that women with epilepsy of childbearing age are at high risk of depression .
sometimes depression may be a side effect of anticonvulsant medication or from combinations [ 5 , 6 ] .  
a number of researches have reported the comorbidity of anxiety along with depression in patients with epilepsy [ 2022 ] .
the most common emotional responses of people with epilepsy include fear of the unexpected seizure , humiliation after a seizure , particularly if incontinence occurs , and feelings of alienation at work and social situations .
these emotional responses are not limited to cognitive impairments , but also affect the social domain of functioning . since the person who has seizures has no control over other people 's reactions during a seizure , therefore they prefer solitary activities or reduce their social contacts .
it has been reported that people with epilepsy have feelings of low life satisfaction in the areas of employment , peace of mind , and social relationships . in one study
it was found that the family dysfunction contributes to psychiatric , emotional , and behavioral problems , to be worse in those with epilepsy than in the control group of patients with other chronic diseases .
a research conducted by aziz , akthar , and hasan   from pakistan reported that pwe face difficulty performing activities of daily living and find it hard to make decisions about whether to marry or to have children .
it is therefore important to consider the above - mentioned clinical ( seizure frequency ) and demographic variables ( gender , education , occupation ) in assessment of psychological and social well - being in epilepsy .
the existing literature suggests that in pakistan studies on epilepsy are mainly limited to distribution , prevalence , etiology , and biological aspect of the disease .
therefore it is necessary to assess the psychological , social , and behavioral aspects of epilepsy so the improvement can be made in the management plan keeping in consideration the cultural aspects .
based on the above - mentioned literature the following hypotheses have been formulated . there exists a significant relationship between seizure frequency and psychological distress .
in this study , a total 50 individuals ( 31 males and 19 females ) with epilepsy were selected as participants .
patients with a confirmed diagnosis of epilepsy were included with the help of psychiatrists or neurophysicians .
patients who had a diagnosis of epilepsy for more than 1 year were included in the sampling frame .
participants with tonic - clonic seizures and partial complex seizure were selected because these types are common among adults with epilepsy in pakistan .
patients were excluded from the sampling frame if they had serious physical or mental limitations that did not allow them to complete the questionnaire .
in addition , patients with psychiatric or neurological disorders that would impair judgment or impact quality of life beyond the effects caused by epilepsy , including mental retardation , stroke , head injury , brain tumor , and cerebral palsy , were excluded from the sampling frame .
participants were divided into three categories : mild , moderate , and severe which is based on the number of seizures over the past 6 months .
individuals who had only one or no seizure in the past 6 months were categorized as being in the mild seizure state .
patients with one seizure in the past 3 months were included in the moderate state .
patients who had one or more seizures during the past month were categorized as being in the severe or uncontrolled state .
the demographic information included name ( optional ) , age , gender , education , occupation , area of residence , and monthly income ( personal or family ) .
the epilepsy - related variables included current medications and number of seizures during the last 6 months .
general health questionnarie-28 ( ghq-28 ) developed by goldberg and hillier in 1979 is wildly used instrument in detecting the psychological distress among clinical and nonclinical population . in pakistan
this questionnaire has been translated in urdu and this urdu version has found to be valid and reliable .
there are four dimensions in assessing the psychological distress . these are 
 each item has four response choices ranging from 
the scoring of ghq-28 followed the test manual recommendations ( 0 , 0 , 1 , 1 ) using the binary scale method .
a cut - point of 5 is used to detect psychological distress . higher score on ghq-28 subscales
the scale is a valid and reliable instrument ; in the present study the alpha reliability coefficient was computed to be  0.80 .
the internal consistency reliability levels for the subscales is reported to be 0.74 ( somatic complaints ) , 0.75 ( anxiety / insomnia ) , 0.72 ( social function ) , and 0.76 ( depression ) in this research .
the data was collected from outdoor patients department at neurology and psychiatry departments of three government hospitals from rawalpindi and islamabad .
further questions related to day - time activity , seizure effects , medication effect , and treatment options tried before were also catered .
after the data collection results were analyzed by using statistical product for social sciences ( spss v.17 ) .
descriptive ( mean , standard deviation , cross - tabulation ) and inferential statistics ( independent sample t - test , multiple regression analysis ) were computed and will be discussed in section 3 .
the sample comprises of 50 adults including 31 men ( 62% ) and 19 women ( 38% ) .
majority of the participant had education up to matriculation ( n = 23 , 46% ) .
thirty - eight percent of patients were in mild seizure category , 26% fall in moderate seizure category , and 36% had severe seizures . 

furthermore no significant differences are present in seizure frequency , mean age , marital status and education . 

so epilepsy patients did not show the symptoms of anxiety like insomnia , sleep disturbances , and irritability as reported by the participants .
there is need to assess anxiety particularly related with epilepsy , its characteristics and medication side effects . in regression
seizure frequency is found to be a significant predictor of psychological distress ( b = 1.20 , p = .001 ) accounting for 42% variance in psychological distress ( table 4 ) .
the results further indicate that education is also found to be predictor for psychological distress ( b = 1.19 , p = .01 ) .
gender , occupation , and age are found to be non - significant in predicting psychological distress among patients with epilepsy . in order to identify gender differences
a further analysis comprising cross - tabulation was also computed to see gender differences ( see table 7 ) , and results show that 68% female and 71% males with epilepsy experience psychological distress .
furthermore a descriptive analysis of mean scores was also computed to see the gender differences in psychological distress and the subscales of ghq-28 .  

as the table shows females have higher mean score on the total as well as all subscales except somatic complaints .
the highest difference is reported on social dysfunction subscale which indicates high level of psychological distress in females as compared to males .
the demographic profile of the participants has revealed that most of them were experiencing severe or uncontrolled epilepsy ( n = 18 , 36% ) .
it has also been identified that none of female participant was employed ( table 2 ) .
this condition is cultural specific because in pakistan it is preferable for women to stay in their homes , so they are totally depending on their families for financial support and long - term treatment of the disorder .
it is also evident from the results of table 6 where female as compared to males had high mean scores in social dysfunction .
the social dysfunction in people with epilepsy has increased the risk of accidents and unexpected sudden death especially in the communities where a great deal of social activities takes place around the fire .
it is further reported that pwe face difficulty in performing activities of daily living and find it hard to make decisions about whether to marry or to have children .
this social dysfunction is further linked to psychological morbidity , that is , presence of psychological disorders .
factors associated with depression include lack of occupation , antiepileptic medications , and the severity of epilepsy .
psychosocial factors predisposing to depression in pwe include adjustment difficulties , the limitations and restrictions which the disorder imposes , as well as the unpredictable nature of the seizures and the associated feelings of helplessness and loss of control over one 's life .
the present research has also investigated the relationship between these clinical and demographic variables with psychological distress including depression and anxiety ( tables 3 and 4 ) which has supported the first hypothesis . in the present study participants
have reported that they experience severe headache , drowsiness and lethargy for one to two days after a seizure .
society 's lack of understanding of epilepsy is a psychosocial burden that is strongly felt , and many people with epilepsy try to keep their condition a secret .
feelings of anger , frustration , embarrassment , and vulnerability may develop as a result of society 's attitude towards the illness .
other demographic variables leading to psychological distress include lack of education , unemployment , and age .
the present study has also included regression analysis for these variables and the results indicate that education has inverse relation with psychological distress ( table 4 ) .
patients with epilepsy in pakistan do not appear to be highly stigmatized , but their education and grades are affected by the disorder .
they have difficulty performing activities of daily living and find it hard to make decisions about whether to marry or to have children .
previous researches have reported that employment is a significant predictor of psychological distress [ 24 , 29 ] .  
table 1 also shows that even though 46% of the participants have education up to matriculation , however the unemployment rate is high ( 42% ) .
there are number of factors related to this high unemployment rate . in one research by chung et al .  
31% of respondents from the community believed that pwe should not be employed in jobs as other persons are .
depression is also affected by a number of demographic variables . in one study by beghi et al .  
it was found that women with epilepsy of childbearing age are at high risk of depression .
the similar finding has been generated in the present research in which 13 out of 19 females with epilepsy have reported to suffer from psychological distress .
it was also found that none of these women was employed ( a cultural specific phenomenon ) with a slightly high number of unmarried females ( 74% ) as compared to males ( 71% ) .
these gender differences reveal that women carry with themselves not only a diagnosis of epilepsy but relatively low position in the society especially with reference to decision making in major life events . in pakistan
it is also evident from the present research where 42% unemployed participants are solely dependent on their families for maintenance and treatment expenditures .
it has also been reported in one community - based research in karachi , pakistan that pwe do not appear to be highly stigmatized .
the results further indicate that seizure frequency is the most significant predictor in epilepsy ( table 4 ) .
furthermore it is also reported that quality of life can be improved by controlling seizure frequency [ 15 , 32 ] .
it has also been reported that treating comorbid depression in epilepsy increases psychological well - being .
therefore it is important to assess psychological distress in epilepsy and to incorporate this component in treatment plan .
on the basis of present study findings it can be concluded that seizure frequency is a significant predictor of psychological distress .
increase in seizure can also increase psychological problems such as depression and anxiety . furthermore the social dysfunction and somatic complaints are also reported .
it can be better understood in realm of physical as well as in psychological , social , and behavioral domains .
this finding may help in management and rehabilitation of patients with epilepsy in developing countries .
the finding can be used by health care providers and policy makers to propose interventions such as improved access to mental health care , job training , and self - management programs to improve health outcomes in people with epilepsy especially by using the knowledge of indigenous practices and social structure .
so by understanding the relationship between clinical and psychosocial variables in epilepsy a good management plan can be devised for the patients with epilepsy with a focus on social and gender differences .
the present research can also help to increase the awareness and to lower the stigmatization related to epilepsy .
this is a small - scale research focusing on four major domains of psychological well - being .
it is therefore suggested to conduct research on larger sample for result generalization and to cooperate other factors such as age at onset of illness , treatment mode , and perceived social support .
the issues highlighted by this research are the gender differences especially in terms of work status and difference in depression .
an in - depth analysis is required to see the economic hardships faced by the patient and its correlate with their social status .  
moreover this research will be beneficial for health professionals to consider the societal attitude with reference to stigmatization , as this present research has included only those patients coming to hospitals not the traditional healers .
 the unpredictable nature & elongated course of epilepsy affect all dimensions ( physical , psychological , and social ) of an individual 's life . 
 people with the diagnosis of epilepsy are a high - risk group for different psychiatric problems that is anxiety , depression as well as social problems ( marriage , education , and daily activities ) . 
 the findings of present research revealed high rate ( 70% ) of psychological distress among fifty adult individuals with epilepsy . 
 it was also found that people with uncontrolled epilepsy experience high level of psychological distress ( 100% ) as compared to those with controlled ( 42% ) . 
 demographic and clinical factors associated with distress include lack of occupation , the presence of an underlying disabling condition ( with treatment ) , and the severity of epilepsy . 
 the finding generated here showed that 13 out of 19 females with epilepsy reported psychological distress . 
 it was also found that none of these women was employed ( a cultural specific phenomenon ) with a slightly high number of unmarried females ( 74% ) . 
 so by understanding the relationship between clinical and psychosocial variables , a good management plan can be devised with a focus on social and gender differences . 
 the present research can also help to increase the awareness and to lower the stigmatization related to epilepsy . 
 