Seizure 40 (2016) 133–135
Psychiatric disorders comorbid with epilepsy in a prison sample

Ali Ercan Altınöz a,*, Olcay Tosun Meriç b, Ş engül Tosun Altınöz c, Altan Eş sizoğlu a,
Behçet Coş ar d

a Department of Psychiatry, Faculty of Medicine, Eskiş ehir Osmangazi University, Eskiş ehir, Turkey
b Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
c Eskiş ehir State Hospital, Psychiatry, Eskiş ehir, Turkey
d Department of Psychiatry, Faculty of Medicine, Gazi University, Ankara, Turkey

A R T I C L E I N F O

Article history:

Received 18 April 2016

Received in revised form 20 June 2016

Accepted 22 June 2016

Keywords:

Epilepsy

Mental health

Prisoner

Comorbidity

A B S T R A C T

Purpose: Epilepsy is an extremely widespread and serious neurological disease. Although comorbidities

of psychiatric disorders are prevalent in epilepsy patients, quite often this coexistence could be

overlooked. Studies in this area demonstrated that depression, anxiety disorders and schizophrenia are

the most common psychiatric disorders accompanying epilepsy. Mental health problems are known to

be more common in prisoners compared to general population. The present study aims to demonstrate

the psychiatric comorbidities in prisoners diagnosed with epilepsy.

Method: In this study, demographic data and the psychiatric comorbidity of 200 patients who were

diagnosed with epilepsy by a neurologist at Ankara Penal Institution Campus State Hospital between

January 2013 and January 2014 were analyzed retrospectively.

Results: The mean age of study population was 32.6 � 10.1 years. 181 of these patients were male (90.5%).

81 of 200 patients (40.5%) had a comorbid psychiatric disorder. The most common comorbid psychiatric

disorders were depression (18.5%), anxiety (11%), and personality disorders (11%), respectively.

Conclusion: The most common psychiatric comorbid disorders among prisoners diagnosed with

epilepsy were depression and anxiety as general population with epilepsy whereas some disorders,

personality disorder, substance dependence and bipolar affective disorders, were found to be more

common among prisoners compared to the general population with epilepsy. It is crucial to question

psychiatric symptoms and comorbidities while evaluating the patients with epilepsy, especially among

prisoners.

� 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Seizure

jou r nal h o mep age: w ww.els evier . co m/lo c ate /ys eiz
Introduction

Epilepsy is an extremely widespread and serious neurological
disease [1]. Psychiatric disorders have been observed in epilepsy
patients, decreasing their quality of life and negatively affecting
the course of illness [2]. Although comorbidities of psychiatric
disorders are prevalent in epilepsy patients, quite often, this
coexistence can be overlooked [1,2]. Studies in this field have
demonstrated that depression, anxiety disorders and schizophre-
nia are the most common psychiatric disorders comorbid with
epilepsy [3]. The prevalence of psychiatric disorders has been
found to be higher in epilepsy patients than in the general
* Corresponding author at: ESOGU Tip Fakultesi Hastanesi, Psikiyatri Anabilim

Dali, Meselik Kampüsü, Odunpazari, Eskisehir, Turkey. Tel.: +90 2222392979.

E-mail address: ercanaltinoz@hotmail.com (A.E. Altınöz).

http://dx.doi.org/10.1016/j.seizure.2016.06.016

1059-1311/� 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights re
population, but the rates vary in most studies. This variation in
prevalence may have originated from methodological differences,
such as type of seizure, response to treatment, duration of disease,
scales used for evaluating the psychiatric disorder and patient
group from which the study sample was selected [4]. Contrary to
the widespread belief that epilepsy patients are more prone to
violence and crime, prison studies have demonstrated that
epilepsy prevalence in prisons is similar to that in the general
population [5,6]. On the other hand, in terms of mental health, it
has been known for a long time that psychiatric problems are more
frequent in prison samples [7]. Previous studies have reported that
one out of every seven people was found to have a serious mental
illness, and one out of every two prisoners was reported to have a
personality disorder. This implies two to four times more
prevalence for serious mental illnesses and ten times more
prevalence for personality disorders than those in the general
population [8]. It has also been documented that the point
served.

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Table 2
Numbers and percentages of epilepsy patients with psychiatric disorders.

Comorbid psychiatric disorder(s) n %

Depressive episode & recurrent depressive disorder (F32–F33) 37 18.5

Other anxiety disorders (F41) 22 11

Disorders of adult personality and behaviour (F60–F69) 22 11

Mental and behavioural disorders due to psychoactive

substance use (F10–F19)

18 9

Dissociative [conversion] disorders (F44) 12 6

Non-organic sleep disorders (F51) 12 6

Manic episode & bipolar affective disorder (F30–F31) 11 5.5

Schizophrenia, schizotypal and delusional disorders (F20–F29) 9 4.5

Conduct disorders & mixed disorders of conduct and emotions

(F91–F92)

8 4

Reaction to severe stress and adjustment disorders (F43) 6 3

Obsessive compulsive disorder (F42) 2 1

A.E. Altınöz et al. / Seizure 40 (2016) 133–135134
prevalence of psychiatric disorders is almost 63% in arrestees and
prisoners [9]. A study conducted in Brazil in 2014 has found that
the most common mental illnesses among arrestees and prisoners
were depression and anxiety disorders [10].

The present study aimed to demonstrate psychiatric disorders
comorbid with epilepsy in a prison sample.

Method

This study was conducted in Ankara Penal Institution Campus
State Hospital (APICSH), the only hospital providing health services
for approximately 4000 prisoners settled in Ankara Penal
Institution Campus (APIC). APIC contains seven different prisons.
All prisoners in APIC apply to APICSH for their health problems. For
our study, the medical files of all prisoners aged between 18 and
65 years and diagnosed with epilepsy between January 2013 and
January 2014 at APICSH were extracted. The diagnosis of epilepsy
was based on both the patient’s clinical history and electroen-
cephalogram results. Epilepsy patients not diagnosed by a
neurologist were excluded. Demographic data, psychiatric appli-
cations and comorbid diagnoses of the remaining patients were
retrospectively investigated. In the evaluation of psychiatric
comorbidities, only the diagnoses made by a psychiatrist based
on Chapter V-Mental and behavioral disorders (F00–F99) in the
International Statistical Classification of Diseases and Related
Health Problems, 10th Revision (ICD-10)-WHO Version were taken
into consideration. Psychiatric diagnosis was independent of
epilepsy diagnosis. Psychiatric diagnostic entries made by
emergency physicians, neurologists and internists were excluded.
When there were multiple psychiatric diagnoses for a patient, each
diagnosis was included. This retrospective study was conducted
with the permission of the ethical commission, in accordance with
the Declaration of Helsinki.

Results

The investigation of records taken during January 2013–January
2014 at APICSH revealed that 213 patients were diagnosed with
epilepsy, of which 13 were excluded because their diagnosis was
not made by a neurologist. Data of the remaining 200 patients were
included. Among these, 181 were men (90.5%). The mean age of the
patients was 32.6 � 10.1 years. The mean age of the men and women
was 32.3 � 10.0 and 35.3 � 11.2 years, respectively.

Psychiatric comorbidity was found in 90 patients. Nine of them
were not included because their diagnoses were made by an
emergency physician or internist. Of these nine patients, four had a
diagnosis of conversion disorder and five were diagnosed with
depression. Thus, psychiatric comorbidity was found in 81 of 200
patients (40.5%). The mean age of the patients with psychiatric
comorbidity was 32.4 � 8.8 years. In this group, there were 76 males
(94.0%) and 5 females (6.0%). The number of patients and gender
distribution are shown in Table 1.

It was found that, within a year, these 81 patients applied 523
times to the psychiatry outpatient clinic (average, 6.46/year) and
received 181 (average, 2.23/year) different ICD-10 diagnoses.
When these diagnoses were rearranged according to the diagnostic
Table 1
Distribution of mean age and sex of the study sample and the group with psychiatric

comorbidity.

Male Female

Number of patients 181 19

Mean age (years) 32.3 � 10.0 35.3 � 11.2

Number of psychiatric comorbidity patients 76 5

Mean age (years) 32.4 � 9.3 32.8 � 9.6
groups, it was observed that they received diagnoses for 159
different diagnostic groups.

The patients’ ICD-10-based psychiatric diagnoses were evalu-
ated in the diagnostic groups, and the most prevalent diagnosis
was found to be depressive disorders (n = 37, 18.5%). Anxiety
disorders (n = 22, 18.0%), personality disorders (n = 22, 18.0%) and
substance abuse disorders (n = 18, 9.0%) were also prevalent in
epilepsy patients. Table 2 lists all psychiatric comorbidities.

Conclusion

Although two studies did not found any significant difference in
the prevalence of psychiatric disorders between epilepsy patients
and healthy controls [11,12], more recent studies have shown a
higher prevalence of psychiatric disorders in epilepsy patients than
in the general population [13]. Population-based studies have
indicated comorbidity rates of between 32% and 35.5% [14,15].
Here we found a comorbidity rate of 40.5%. This higher rate may be
due to our sample, which consisted of arrestees and prisoners. The
prevalence of psychiatric disorders in prison samples is known to
be higher than that in the general population [14]. In addition, this
comorbidity rate is consistent with the those in referral epilepsy
centres, particularly those that serve indigent populations with a
comorbidity rate of between 25% and 50% [16]. Our study
demonstrated that prisoners who have a psychiatric disorder as
well as an epilepsy diagnosis frequently applied to the psychiatry
outpatient clinic. The average time between psychiatric follow-ups
of the patients with epilepsy was less than 60 days. This duration is
quite short for standard psychiatric controls. This situation could
stem from the dual diagnosis per patient as well as conditions of
the prison environment that may lead to more applications to the
psychiatric outpatient clinic.

Some studies have also indicated that the frequency of dual
diagnosis increases with age and is particularly higher in people
aged above 40 years. In our study, although this age group was a
minority (n = 51, 25.0%), the frequency of dual diagnosis was
higher than that reported in the literature. Once again, this may be
due to the characteristics of the sample [14,17].

In the literature, studies have reported the prevalence rates of
depression to be 6%–19% for the general population and 9%–37% for
epilepsy patients [15,18–20]. The present study found the
prevalence of depression in epilepsy patients to be 18.5%, which
is compatible with that in the existing literature. Compatible
results with the existing literature are important to demonstrate
that epilepsy patients in prisons have similar rates of depression
comorbidity in comparison to the general population because
depression as a mood disorder is one of the most frequent and
leading psychiatric disorders in prisoners [10].



A.E. Altınöz et al. / Seizure 40 (2016) 133–135 135
The prevalence rates of anxiety disorders have been reported to
be 7%–11% in the general population and 11%–25% in epilepsy
patients. The present study obtained similar results, with a
comorbidity prevalence of 11.0% [15,19,20], which is compatible
with that in the existing literature.

A diagnosis of bipolar affective disorder is rare in epilepsy
patients, with a frequency reported to be 1.3–2.8% [21]. In our
study, we found a frequency of 5.5%, which is consistent with
studies that report a diagnosis of bipolar affective disorder to be
seven times more frequent in prison populations than in the
general population [22].

A recent meta-analysis reported the prevalence of comorbidity
of psychosis in epilepsy to be 5.6% [23]. The present study is
important because it provides parallel results, indicating that
psychiatric disorders comorbid with epilepsy were not affected by
imprisonment.

The prevalence rates of personality disorders have been
reported to be 5.9%–13.4% in the general population and 4%–
38% in epilepsy patients [24]. The 11% prevalence in this study was
consistent with that reported in the literature. However, consid-
ering that the prevalence of personality disorders is 10-times
higher than that in the general population, a higher ratio could
have been expected [8]. The lower-than-expected results could be
due to multiple diagnoses of the patients in our sample because
this could complicate the evaluation of personality disorders.
Another point is that the diagnoses of mental disorders due to
known physiological condition were missing. These findings
suggest that the psychiatric evaluation of prisoners is not
sufficiently detailed to determine the personality disorder; in
addition, it seems to be oriented to results against causality.

In a prison sample, most prevalent psychiatric disorders
comorbid with epilepsy are depression and anxiety disorders,
similar to that in the general population; it was also found that
psychiatric disorders, such as personality, substance abuse and
bipolar mood disorders, were more prevalent in epilepsy patients
in the prison sample. This draws attention to the importance of a
detailed evaluation of psychiatric symptoms in the treatment of
arrestees and prisoners with epilepsy.

The present study has some limitations. Our study is not a
prevalence study. Instead of epileptic seizure and epilepsy
syndrome classifications, our study used existing data of patients
under regular evaluation. In addition, the retrospective nature of
the study resulted in the exclusion of some epilepsy-related
variables such as epilepsy type, intractability rates and medication
use. In the existing literature, age at onset, number of seizure types,
lateralisation and medication type have been reported to affect the
prevalence of psychiatric comorbidity [4]. Another limitation of
the present study was the lack of information about the duration of
imprisonment. Controversial results exist in the literature with
regard to the negative effects of imprisonment. While some studies
did not find a relationship between imprisonment duration and
mental state, others have stated that the mental state deteriorates
in the acute phase after the first admission to prison but that it gets
better after a while. Among these studies, some that the largest
deterioration of mental health occurs in the first 3 days after
admission to prison, while others found that this duration is as long
as 12 weeks [25]. Because this was a retrospective survey study,
such information could not be accessed.

The present study has a special importance among all other
studies that investigated psychiatric comorbidity in epilepsy
patients because it is the only one that included arrestees and
prisoners in the sample.
Conflicts of Interest

The authors have no conflict of interests to disclose

Acknowledgement

The authors would like to thank Yusuf Sevim and Elif Okan
Gezmiş for translation and language editing. The preliminary
results of this study were presented as a poster report on 27 March
2015 at 12th National Congress of Consultation and Liaison
Psychiatry and Psychosomatic Medicine.

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	Psychiatric disorders comorbid with epilepsy in a prison sample
	Introduction
	Method
	Results
	Conclusion
	Conflicts of Interest
	Acknowledgement
	References