The epileptic patients in this study were less likely to be married, more likely to be unemployed, and with a lower income as compared to the control group. This is consistent with other studies which found that people with epilepsy appear at greater risk of problems in relation to marriage, employment, and socio-economic status.26
The present study highlights the impact of epilepsy on the QOL of epileptic patients in Basrah. When compared with the epilepsy-free control group, patients with epilepsy reported a significantly lower QOL across all domains. Such a result is consistent with many previous studies that have been done in Iran, the Arabian Gulf, the Near East, Thailand, Norway, the UK, Russia, and Tunisia.14
The epileptic patients’ rather poor QOL may be explained by the disease’s chronicity (the mean duration of patients’ illness in this study was 10.6 years), a result which was reported by Sillanpää et al.,
or because most of the epileptic patients in this study (78.4%) had not been seizure-free in the last year. Seizure frequency was described as one of the most relevant determinants of poor QOL.33
Similar to other studies, higher QOL scores in epileptic patients were associated with youth, and higher levels of education and family income.35
It is reasonable to suggest that these factors increase the potential for social support, positive coping methods, and awareness of the disease.14
Elderly people may have more difficulty in coping with epilepsy than do younger patients who have more physiological reserves and fewer responsibilities.39
Education is an important indicator that may directly or indirectly influence QOL through its association with employment, higher social class, and economic status, or because well-educated patients are more aware of self-management practices and are better educated about the disease and also know that regular treatment can help patients avoid seizures and hence lead a normal life.40
Economic status was recognised as an important predictor of QOL in epileptic patients.41
Having enough money is important to QOL not only to meet people’s basic needs, but also to allow participation in society and in holidays and hobbies, and to allow people to enjoy luxuries and be prepared for unexpected expenses and emergencies.
In univariate analysis, patients living in rural areas had significantly lower QOL scores as compared to those living in urban areas, but this association disappeared in multivariate analysis. The role of residence may have been confounded by the effect of the social and economic levels. It was reported that epilepsy and its sequelae were more prevalent in patients with low social and economic levels.42
Current seizure activity was an independent clinical predictor of QOL. Even patients with infrequent seizures, who would generally be regarded as having good control, had a relatively compromised QOL as compared with those who were seizure-free. Guekht et al.,
reported that patients with frequent seizures had low social contact and feelings of stigmatisation.32
Considerable emphasis has been placed on the desirability of monotherapy. Many studies have shown that the prescription of multiple drugs can result in multiple adverse side effects and have a negative effect on QOL.14
In the present study, no significant association was found between the number of drugs and QOL. However, epileptic patients who were taking one antiepileptic drug had a slightly higher QOL score than those on multiple drugs.
In contrast to some earlier reports, patients’ gender, marital status, and duration of the disease did not have a significant association with total QOL in this study.43
The association between duration of epilepsy and QOL which was identified in univariate analysis was no longer significant after multiple regression analysis. A possible explanation of this discrepancy in significance might be related to age as a potential confounder.
A few limitations must be addressed in our study. To generalise our results to all epileptic patients, a random sample of patients with epilepsy would have been suitable. But it has been reported that obtaining a random sample of people with epilepsy is complex and labour-intensive.14
Furthermore, with this being a case-control study, certain limitations such as recall bias, the problem of selection and non-response bias may have been encountered. Recall bias can exist in obtaining information, as by asking the study population by the mean of the SF-36 instrument whether their work or other regular daily activities, during a previous period, were affected by their physical health. The recall bias in this study was at least reduced by asking respondents to specify the type of effect and limiting the recall period in the questionnaire form to the present time, except in one question about seizure frequency, in which the recall period extended to one year before.
Another source of possible bias is the non-response bias, but in this study the response rate was 100% because all the cases and controls were willing to participate in the study and the data were obtained by means of an interview. Age, sex, and educational level as strong confounders were removed by the process of matching. The problem of selection was unlikely to have been eliminated totally.
We accept that this study may have had biased sampling as patients with serious physical or mental limitations were excluded from the study. Therefore, the results may be biased towards the opinions of people with slightly better general health. In addition, the availability of free antiepileptic drugs should have helped in the inclusion of many patients with a lower socio-economic status, but this assumption may not be true because Basrah General Hospital is a secondary referral hospital, so it receives people from different socio-economic levels. The control group cannot be claimed to be totally representative of the general population. They were selected in a random manner which is valuable within the framework of a case-control study, but does not allow the generalisability of the SF-36 results to the whole population. A final limitation of this study was that data concerning the type of epilepsy were not collected. Despite these limitations, the results are valuable in providing insights into how the QOL of people with epilepsy can be improved.