It comes as no surprise that disorders of mood are linked to health-related quality of life (HRQOL) for people with epilepsy. The report by Au et al.[1] in a recent issue of Epilepsy & Behavior confirms previous findings that depressed mood is closely associated with poor HRQOL among adult epilepsy patients.Perrine et al.[2] noted this association during the validation of the QOLIE-89 [3] comparing mood scores with QOLIE-89 scores.Bot h Perrine et al. [2] and Au et al.[1] pursued this hypothesis based on numerous reports suggesting an association between behavior and psychosocial function (Hermann, Dodrill, etc.). A review of the literature reveals that although depression and HRQOL are negatively correlated in epilepsy, it has not been possible to determine which is the driver. As such, we cannot state whether depressed mood causes low HRQOL in epilepsy or whether poor seizure control leads to depressed mood.

An interesting addition to the literature is the finding by Au et al.[1] that a feeling of lack of control is also correlated with low HRQOL.The concept of "locus of control" is based on understanding a patient's feeling of control over health status.In this observational cohort study, patients whose responses indicated that they perceived that their health (or seizure control) was beyond their control were more likely to have low HRQOL. This finding can logically be explained as a feeling of despair in which patients whose seizures cannot be well managed come to feel that their lives are not controllable.This despair may be expressed as low HRQOL. An associated finding was that satisfaction with social support was moderately correlated with QOLIE-89 domains, but availability of social support was not associated. It is likely that satisfaction and chance locus of control also were significantly correlated with mood, although this correlation was not described in the Au report.

A review of the early literature on psychosocial and behavioral problems among epilepsy patients provides abundant information about mood states. These assessments often used traditional psychosocial or neuropsychological tests [4–6]. The development of HRQOL instruments in recent years has provided a different approach to the assessment of patient perceptions [7]. The difference is the integration of psychological, social,

physical, and epilepsy-related domains into a single instrument. Analyses performed on subscales within the QOLIE-89 also have demonstrated that mood items were negatively correlated with overall HRQOL [2].The report by Au et al. [1] advances the concept that depressed mood spreads to or is impacted by other psychosocial functions.Their patients felt that they had no control over their health (i.e., seizures) and were dissatisfied with social support.

Although the high incidence of depression among epilepsy patients has been documented, the number of patients treated for depression is low. The apparent reluctance of neurologists to document a diagnosis of comorbid depression or to prescribe an antidepressant is difficult to interpret. Of course, treatment with an optimum combination of antiepileptic drugs is the primary goal. Nonetheless, these reports and others in the literature show that depression associated with poor seizure control has far-reaching effects. These data provide support for modification of antiepileptic drug therapy to reduce the burden of drugs that might be exacerbating the dysphoria. Despite the higher cost of second-generation drugs, their lesser adverse effect impact could be an important advantage for patients whose uncontrolled seizures cause an intolerable psychosocial burden [8].

1. Clinical importance

The message to health care providers is that poor seizure control is associated with a cascade of pervasive psychosocial problems that often are neglected as part of the patient's overall care. The lack of an index to guide treatment decisions has resulted in a purgatory of life experience for the many thousands of people with uncontrolled seizures. Ideally, clinicians would like to have a measure similar to a hemoglobin test that could relate low test levels with low energy, and need for intervention. In fact, we have HRQOL instruments that can be used as clinical measures of patient perceptions. Rather than using instinct in addition to seizure frequency to decide when to change or add a medication, HRQOL scores can be a simple guide to neurologists that define individual patient's status and (more importantly) changes in status.