Depressive symptoms and difficulties in emotion regulation in adult patients with epilepsy: Association with quality of life and stigma Mario Tombini a, ⁎, Giovanni Assenza a , Livia Quintiliani b , Lorenzo Ricci a , Jacopo Lanzone a , Martina Ulivi a , Vincenzo Di Lazzaro a a Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico, via Álvaro del Portillo 21, 00128 Rome, Italy b Psicologia Clinica, Università Campus Bio-Medico, via Álvaro del Portillo 21, 00128 Roma, Italy abstract article info Article history: Received 19 November 2019 Revised 12 March 2020 Accepted 23 March 2020 Available online xxxx Objective: The objective of the study was to assess depressive symptoms (DS) and difficulties in emotion regula- tion (ER) in adult people with epilepsy (PWE) and their correlation with quality of life and stigmatization feelings of patients. Materials and methods: We enrolled consecutively 110 PWE who completed the Beck Depression Inventory-II (BDI-II) questionnaire and, for the first time, the Italian translation of Difficulties in Emotion Regulation Scale (DERS) to evaluate DS and ER. They also fulfilled the Italian version of the Stigma Scale of Epilepsy (SSE), which allowed the quantification of the stigma perception by our cohort of patients and a 3-item Jacoby's Stigma Scale (JSS) and QOLIE-31 (Q31) for the evaluation of stigma and the quality of life. The results of BDI-II and DERS were correlated with clinical details of PWE, as well as the Q31 and SSE scores. Finally, a multiple stepwise regres- sion analysis was applied to identify the main factors affecting DS and ER difficulties in these patients. Results: About 30% of PWE evidenced DS, of which 17.3% showed a BDI-II score higher than 19, suggestive of mod- erate to severe DS. Several factors related to epilepsy (seizure frequency, number of antiepileptic drugs (AEDs)) as well as ER and quality of life/stigmatization perception resulted significantly correlated with DS. As a new find- ing, the main factors affecting DS in PWE turned out to be the difficulties in ER and quality of life and stigma per- ception (as evaluated through Q31 and JSS scores). Conclusions: Our findings evidenced that DS in PWE are highly prevalent and strongly correlated with ER difficul- ties that mostly influence DS together with quality of life and stigma perception. Depressive symptoms and emo- tion dysregulation are linked by a bidirectional relationship and are significantly associated with worse quality of life and higher stigmatization feelings. © 2020 Elsevier Inc. All rights reserved. Keywords: Epilepsy Depressive symptoms Emotion regulation Quality of life Stigma 1. Introduction Psychiatric comorbidities have higher prevalence rates in people with epilepsy (PWE) than in people with other chronic medical disor- ders and the general population [1]. Population-based studies demon- strate that one of every three PWE experiences a psychiatric disorder in the course of life, with mood and anxiety disorders being the most frequently documented comorbidities in adults and children [2]. In a recent paper, the point prevalence of major depression disorder (MDD) is estimated at 21.9% among PWE in epilepsy clinics and is higher in females than in males [3]. Death by suicide accounts for ap- proximately 12% of all deaths in PWE, being ten times more frequent than in the general population [4]. The relationship between epilepsy and mood disorders has been rec- ognized for a long time. The ancient physicians were already aware of a bidirectional etiological relationship and shared pathophysiology of de- pression and epilepsy [5]. In his famous quotations, Hippocrates, or more precisely, the group of Alexandrian physicians who supposedly composed the 53 single writings of the “Corpus Hippocraticum” during the Ptolemaic age from the 5th century B.C. to the 1st century A.D. [6] stated that “melancholics ordinarily become epileptics, and epileptics, mel- ancholics: what determines the preference is the direction the malady takes; if it bears upon the body, epilepsy, if upon the intelligence, melan- choly”— as quoted by Lewis [5]. Nowadays, in the latest definition from International League Against Epilepsy (ILAE) official report [7], ep- ilepsy is recognized as “a disorder of the brain characterized by an endur- ing predisposition to generate epileptic seizures” but also “by the neurobiologic, cognitive, psychological, and social consequences of this con- dition”. However, there is evidence that psychiatric comorbidities are not only the consequence of epilepsy, but often precede the onset of the seizure disorder. Several population-based studies have Epilepsy & Behavior 107 (2020) 107073 ⁎ Corresponding author at: Neurology, Campus Bio-Medico University, Via Alvaro del Portillo 200, Trigoria, 00128 Roma, Italy. E-mail address: m.tombini@unicampus.it (M. Tombini). YEBEH-107073; No of Pages 7 https://doi.org/10.1016/j.yebeh.2020.107073 1525-5050/© 2020 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh