Comorbidity of Epilepsy and Depression in Al Husseini Teaching Hospital in Holy Kerbala /Iraq in 2018
DOI:
https://doi.org/10.70863/karbalajm.v13i1.778Keywords:
Epilepsy, Depression, Family history, duration of disease, PHQ-9Abstract
Background: Epilepsy comorbidity with depression is well known in clinical practice. The impact of depression state is bidirectional, and similarly seizure might be causal or result of depressive state.
Material and methods: a cross-sectional study among sixty patients with epilepsy investigated the prevalence and predictors of depression among these patients. A validated well known questionnaire form (PHQ-9) was used to assess depressive state.
Results: Very high prevalence, exceeding 80%, of depression was found and this might be related to the unstable security and economic state in the country. Significant predictors were gender, duration of disease and positive video EEG findings. While patients’ age, family history of epilepsy, type of fit, the type of therapy and compliance were all not significantly associated with depression.
Conclusions: a high majority of epileptic patients suffer from depression and this might affects their response to treatment and their prognosis.
References
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6. Forsgren L, Beghi E, Oun A, Sillanpää M. The epidemiology of epilepsy in Europe–a systematic review. European Journal of neurology. 2005;12(4):245-53.
7. Boylan L, Flint L, Labovitz D, Jackson S, Starner K, Devinsky O. Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy. Neurology. 2004;62(2):258-61.
8. Kanner AM. Management of psychiatric and neurological comorbidities in epilepsy. Nature Reviews Neurology. 2016;12(2):106.
9. Keezer MR, Sisodiya SM, Sander JW. Comorbidities of epilepsy: current concepts and future perspectives. The Lancet Neurology. 2016;15(1):106-15.
10. Elger CE, Johnston SA, Hoppe C. Diagnosing and treating depression in epilepsy. Seizure. 2017;44:184-93.
11. Group WHOQoL. What is quality of life? World Health Organization Quality of Life Assessment. World Health Forum. 1996;17:354-6.
12. Shakir M, Al-Asadi JN. Quality of life and its determinants in people with epilepsy in basrah, iraq. Sultan Qaboos University medical journal. 2012;12(4):449-57.
13. Brown KL. The connection between post-traumatic stress disorder and suicide behavior: what links post-traumatic stress disorder to suicide? : University of Toledo; 2013.
14. Nielsen H, Kristensen O. Personality correlates of sphenoidal EEG‐foci in temporal lobe epilepsy. Acta Neurologica Scandinavica. 1981;64(4):289-300.
15. Fisher RS vEB, Blume W, Elger C, Genton P, Lee P, et al. Epileptic seizures and epilepsy: Definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005:470-2.
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17. Bosak M, Turaj W, Dudek D, Siwek M, Szczudlik A. Depressogenic medications and other risk factors for depression among Polish patients with epilepsy. Neuropsychiatric disease and treatment. 2015;11:2509-17.
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19. Jacoby A, Baker GA, Steen N, Potts P, Chadwick DW. The clinical course of epilepsy and its psychosocial correlates: findings from a UK community study. Epilepsia. 1996;37(2):148-61.
20. Ettinger A, Reed M, Cramer J. Depression and comorbidity in community-based patients with epilepsy or asthma. Neurology. 2004;63(6):1008-14.
21. Gaitatzis A, Trimble M, Sander JW. The psychiatric comorbidity of epilepsy. Acta Neurologica Scandinavica. 2004;110(4):207-20.
22. Tellez‐Zenteno JF, Patten SB, Jetté N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: a population‐based analysis. Epilepsia. 2007;48(12):2336-44.
23. Gaitatzis A, Carroll K, Majeed A, Sander JW. The epidemiology of the comorbidity of epilepsy in the general population. Epilepsia. 2004;45(12):1613-22.
24. Perini G, Tosin C, Carraro C, Bernasconi G, Canevini M, Canger R, et al. Interictal mood and personality disorders in temporal lobe epilepsy and juvenile myoclonic epilepsy. Journal of Neurology, Neurosurgery & Psychiatry. 1996;61(6):601-5.
25. Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, et al. The NIMH Epidemiologic Catchment Area program: historical context, major objectives, and study population characteristics. Archives of general psychiatry. 1984;41(10):934-41.
26. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of general psychiatry. 1993;50(2):85-94.
27. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of general psychiatry. 1994;51(1):8-19.
28. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry. 2005;62(6):617-27.
29. Chang H-J, Liao C-C, Hu C-J, Shen WW, Chen T-L. Psychiatric disorders after epilepsy diagnosis: a population-based retrospective cohort study. PloS one. 2013;8(4):e59999.
30. Fiest KM, Dykeman J, Patten SB, Wiebe S, Kaplan GG, Maxwell CJ, et al. Depression in epilepsy: a systematic review and meta-analysis. Neurology. 2013;80(6):590-9.
31. Kanner AM. Depression and epilepsy: a new perspective on two closely related disorders. Epilepsy currents. 2006;6(5):141-6.
32. Bifftu BB, Dachew BA, Tiruneh BT, Birhan Tebeje N. Depression among people with epilepsy in Northwest Ethiopia: a cross-sectional institution based study. BMC research notes. 2015;8:585-.
33. Hoppe C. Citing Hippocrates on depression in epilepsy. Epilepsy & behavior : E&B. 2018;90:31-6.
34. Wiegartz P, Seidenberg M, Woodard A, Gidal B, Hermann B. Co-morbid psychiatric disorder in chronic epilepsy: recognition and etiology of depression. Neurology. 1999.
35. Kanner AM. Depression in neurologic disorders: why should neurologists care? Depression in neurologic disorders: diagnosis and management. 2012:1-9.
36. Fiest KM, Patten SB, Altura KC, Bulloch AG, Maxwell CJ, Wiebe S, et al. Patterns and frequency of the treatment of depression in persons with epilepsy. Epilepsy & Behavior. 2014;39:59-64.
37. Kondziella D, Asztely F. Don’t be afraid to treat depression in patients with epilepsy! Acta Neurologica Scandinavica. 2009;119(2):75-80.
38. Ettinger AB, Weisbrot DM, Nolan EE, Gadow KD, Vitale SA, Andriola MR, et al. Symptoms of depression and anxiety in pediatric epilepsy patients. Epilepsia. 1998;39(6):595-9.
39. Barry JJ. Idiopathic depressive disorders: basic principles. Depression in Neurologic Disorders: Diagnosis and Management. 2012:28-38.
40. Organization WH. http://www. who. int/mediacentre/factsheets/fs340/en. url> http://www who int/mediacentre/factsheets/fs241/en/</url. 2014.
41. Murray CJ, Lopez AD, Organization WH. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020: summary. 1996.
42. Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub; 2013.
43. Atlantis E, Sullivan T. Bidirectional Association Between Depression and Sexual Dysfunction: A Systematic Review and Meta-Analysis2012. 1497-507 p.
44. Hoppe C, Elger CE. Depression in epilepsy: a critical review from a clinical perspective. Nature Reviews Neurology. 2011;7(8):462.
45. Leah E, Sarah M. Manuscript Pilot Study: Evaluation of Changes in Depressive Symptoms After One Year in Patients with Refractory Epilepsy Treated with Vagus Nerve Stimulation. 2016.
46. Mula M. The interictal dysphoric disorder of epilepsy: Legend or reality? Epilepsy & Behavior. 2016;58:7-10.
47. Mori Y, Kanemoto K, Onuma T, Tanaka M, Oshima T, Kato H, et al. Anger is a distinctive feature of epilepsy patients with depression. The Tohoku journal of experimental medicine. 2014;232(2):123-8.
48. Amiri M, Hansen CP. The interictal dysphoric disorder in patients with epilepsy: a doubtful disorder lacking diagnostic tools. Seizure. 2015;24:70-6.
49. Bogren M, Brådvik L, Holmstrand C, Nöbbelin L, Mattisson C. Gender differences in subtypes of depression by first incidence and age of onset: a follow-up of the Lundby population. European archives of psychiatry and clinical neuroscience. 2018;268(2):179-89.
50. Wang X, Chen Y, Lei L, Zhiyi H. Factors associated with quality of life in epileptics in northen China and the variations between men and women. Chinese Journal of Neurology. 2017;50(1):34-9.
51. Alanis-Guevara I, Pena E, Corona T, Lopez-Ayala T, Lopez-Meza E, Lopez-Gomez M. Sleep disturbances, socioeconomic status, and seizure control as main predictors of quality of life in epilepsy. Epilepsy & Behavior. 2005;7(3):481-5.
52. Buck D, Jacoby A, Baker GA, Ley H, Steen N. Cross-cultural differences in health-related quality of life of people with epilepsy: findings from a European study. Quality of Life Research. 1999;8(8):675-85.
53. Shetty PH, Naik RK, Saroja A, Punith K. Quality of life in patients with epilepsy in India. Journal of neurosciences in rural practice. 2011;2(1):33.
54. Hirsch L, Arif H. Neuroimaging in the evaluation of seizures and epilepsy. UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA Accessed. 2017;10:12.
55. Qassim Hadi A-A, Ala Khalil A-B. The significance of EEG recording in confirming the diagnosis of epilepsy in cases referred for the 1st time. Mustansiriya Medical Journal. 2006;6(1):77-85.
56. Brown E, Clark D, Bogess M, Widge A, Ramasubbu R, Protzner A, et al. Oscillation Changes in EEG Measured in the On and Off DBS State in Patients with Treatment Resistant Depression. Biological Psychiatry. 2017;81(10):S401.
57. Stafstrom CE, Carmant L. Seizures and epilepsy: an overview for neuroscientists. Cold Spring Harbor perspectives in medicine. 2015;5(6):a022426.
58. Northoff G. How do resting state changes in depression translate into psychopathological symptoms? From ‘Spatiotemporal correspondence’to ‘Spatiotemporal Psychopathology’. Current opinion in psychiatry. 2016;29(1):18-24.
59. Kroenke K, Spitzer RL, Williams JB. The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine. 2001;16(9):606-13.
60. Davison K. EEG activation after intravenous amitriptyline. Electroencephalography and clinical neurophysiology. 1965;19(3):298-300.
61. Wiegartz P, Seidenberg M, Woodard A, Gidal B, Hermann B. Co-morbid psychiatric disorder in chronic epilepsy: recognition and etiology of depression. Neurology. 1999;53(5 Suppl 2):S3-8.
62. Alexander HB, Broshek DK, Quigg M. Quality of life in adults with epilepsy is associated with anticonvulsant polypharmacy independent of seizure status. Epilepsy & Behavior. 2018;78:96-9.
63. Sabah Abdullah J. Quality Of Life For Patients With Epilepsy In Baghdad City. kufa Journal for Nursing sciences. 2014;4(2):1-9.
64. Ulrich G, Renfordt E, Zeller G, Frick K. Interrelation between changes in the EEG and psychopathology under pharmacotherapy for endogenous depression. Pharmacopsychiatry. 1984;17(06):178-
2. Spitzer RL, Williams JB, Kroenke K, Linzer M, Verloin deGruy F, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. Jama. 1994;272(22):1749-56.
3. Brodie MJ, French JA. Management of epilepsy in adolescents and adults. The Lancet. 2000;356(9226):323-9.
4. Shih C-C, Su Y-C, Liao C-C, Lin J-G. Patterns of medical pluralism among adults: results from the 2001 National Health Interview Survey in Taiwan. BMC health services research. 2010;10(1):191.
5. Prevots DR, Burr RK, Sutter RW, Murphy TV. Poliomyelitis Prevention in the United States: Updated Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report: Recommendations and Reports. 2000:i-22.
6. Forsgren L, Beghi E, Oun A, Sillanpää M. The epidemiology of epilepsy in Europe–a systematic review. European Journal of neurology. 2005;12(4):245-53.
7. Boylan L, Flint L, Labovitz D, Jackson S, Starner K, Devinsky O. Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy. Neurology. 2004;62(2):258-61.
8. Kanner AM. Management of psychiatric and neurological comorbidities in epilepsy. Nature Reviews Neurology. 2016;12(2):106.
9. Keezer MR, Sisodiya SM, Sander JW. Comorbidities of epilepsy: current concepts and future perspectives. The Lancet Neurology. 2016;15(1):106-15.
10. Elger CE, Johnston SA, Hoppe C. Diagnosing and treating depression in epilepsy. Seizure. 2017;44:184-93.
11. Group WHOQoL. What is quality of life? World Health Organization Quality of Life Assessment. World Health Forum. 1996;17:354-6.
12. Shakir M, Al-Asadi JN. Quality of life and its determinants in people with epilepsy in basrah, iraq. Sultan Qaboos University medical journal. 2012;12(4):449-57.
13. Brown KL. The connection between post-traumatic stress disorder and suicide behavior: what links post-traumatic stress disorder to suicide? : University of Toledo; 2013.
14. Nielsen H, Kristensen O. Personality correlates of sphenoidal EEG‐foci in temporal lobe epilepsy. Acta Neurologica Scandinavica. 1981;64(4):289-300.
15. Fisher RS vEB, Blume W, Elger C, Genton P, Lee P, et al. Epileptic seizures and epilepsy: Definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005:470-2.
16. Domínguez-Aguilera MC, Muñiz-Landeros CE. Prevalence of psychiatric disorders in patients with epilepsy in a tertiary level care hospital: Detection through the MINI PLUS International Structured Interview. Medicina Universitaria. 2017;19(74):3-6.
17. Bosak M, Turaj W, Dudek D, Siwek M, Szczudlik A. Depressogenic medications and other risk factors for depression among Polish patients with epilepsy. Neuropsychiatric disease and treatment. 2015;11:2509-17.
18. Ottman R, Lipton RB, Ettinger AB, Cramer JA, Reed ML, Morrison A, et al. Comorbidities of epilepsy: results from the Epilepsy Comorbidities and Health (EPIC) survey. Epilepsia. 2011;52(2):308-15.
19. Jacoby A, Baker GA, Steen N, Potts P, Chadwick DW. The clinical course of epilepsy and its psychosocial correlates: findings from a UK community study. Epilepsia. 1996;37(2):148-61.
20. Ettinger A, Reed M, Cramer J. Depression and comorbidity in community-based patients with epilepsy or asthma. Neurology. 2004;63(6):1008-14.
21. Gaitatzis A, Trimble M, Sander JW. The psychiatric comorbidity of epilepsy. Acta Neurologica Scandinavica. 2004;110(4):207-20.
22. Tellez‐Zenteno JF, Patten SB, Jetté N, Williams J, Wiebe S. Psychiatric comorbidity in epilepsy: a population‐based analysis. Epilepsia. 2007;48(12):2336-44.
23. Gaitatzis A, Carroll K, Majeed A, Sander JW. The epidemiology of the comorbidity of epilepsy in the general population. Epilepsia. 2004;45(12):1613-22.
24. Perini G, Tosin C, Carraro C, Bernasconi G, Canevini M, Canger R, et al. Interictal mood and personality disorders in temporal lobe epilepsy and juvenile myoclonic epilepsy. Journal of Neurology, Neurosurgery & Psychiatry. 1996;61(6):601-5.
25. Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, et al. The NIMH Epidemiologic Catchment Area program: historical context, major objectives, and study population characteristics. Archives of general psychiatry. 1984;41(10):934-41.
26. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of general psychiatry. 1993;50(2):85-94.
27. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of general psychiatry. 1994;51(1):8-19.
28. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry. 2005;62(6):617-27.
29. Chang H-J, Liao C-C, Hu C-J, Shen WW, Chen T-L. Psychiatric disorders after epilepsy diagnosis: a population-based retrospective cohort study. PloS one. 2013;8(4):e59999.
30. Fiest KM, Dykeman J, Patten SB, Wiebe S, Kaplan GG, Maxwell CJ, et al. Depression in epilepsy: a systematic review and meta-analysis. Neurology. 2013;80(6):590-9.
31. Kanner AM. Depression and epilepsy: a new perspective on two closely related disorders. Epilepsy currents. 2006;6(5):141-6.
32. Bifftu BB, Dachew BA, Tiruneh BT, Birhan Tebeje N. Depression among people with epilepsy in Northwest Ethiopia: a cross-sectional institution based study. BMC research notes. 2015;8:585-.
33. Hoppe C. Citing Hippocrates on depression in epilepsy. Epilepsy & behavior : E&B. 2018;90:31-6.
34. Wiegartz P, Seidenberg M, Woodard A, Gidal B, Hermann B. Co-morbid psychiatric disorder in chronic epilepsy: recognition and etiology of depression. Neurology. 1999.
35. Kanner AM. Depression in neurologic disorders: why should neurologists care? Depression in neurologic disorders: diagnosis and management. 2012:1-9.
36. Fiest KM, Patten SB, Altura KC, Bulloch AG, Maxwell CJ, Wiebe S, et al. Patterns and frequency of the treatment of depression in persons with epilepsy. Epilepsy & Behavior. 2014;39:59-64.
37. Kondziella D, Asztely F. Don’t be afraid to treat depression in patients with epilepsy! Acta Neurologica Scandinavica. 2009;119(2):75-80.
38. Ettinger AB, Weisbrot DM, Nolan EE, Gadow KD, Vitale SA, Andriola MR, et al. Symptoms of depression and anxiety in pediatric epilepsy patients. Epilepsia. 1998;39(6):595-9.
39. Barry JJ. Idiopathic depressive disorders: basic principles. Depression in Neurologic Disorders: Diagnosis and Management. 2012:28-38.
40. Organization WH. http://www. who. int/mediacentre/factsheets/fs340/en. url> http://www who int/mediacentre/factsheets/fs241/en/</url. 2014.
41. Murray CJ, Lopez AD, Organization WH. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020: summary. 1996.
42. Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub; 2013.
43. Atlantis E, Sullivan T. Bidirectional Association Between Depression and Sexual Dysfunction: A Systematic Review and Meta-Analysis2012. 1497-507 p.
44. Hoppe C, Elger CE. Depression in epilepsy: a critical review from a clinical perspective. Nature Reviews Neurology. 2011;7(8):462.
45. Leah E, Sarah M. Manuscript Pilot Study: Evaluation of Changes in Depressive Symptoms After One Year in Patients with Refractory Epilepsy Treated with Vagus Nerve Stimulation. 2016.
46. Mula M. The interictal dysphoric disorder of epilepsy: Legend or reality? Epilepsy & Behavior. 2016;58:7-10.
47. Mori Y, Kanemoto K, Onuma T, Tanaka M, Oshima T, Kato H, et al. Anger is a distinctive feature of epilepsy patients with depression. The Tohoku journal of experimental medicine. 2014;232(2):123-8.
48. Amiri M, Hansen CP. The interictal dysphoric disorder in patients with epilepsy: a doubtful disorder lacking diagnostic tools. Seizure. 2015;24:70-6.
49. Bogren M, Brådvik L, Holmstrand C, Nöbbelin L, Mattisson C. Gender differences in subtypes of depression by first incidence and age of onset: a follow-up of the Lundby population. European archives of psychiatry and clinical neuroscience. 2018;268(2):179-89.
50. Wang X, Chen Y, Lei L, Zhiyi H. Factors associated with quality of life in epileptics in northen China and the variations between men and women. Chinese Journal of Neurology. 2017;50(1):34-9.
51. Alanis-Guevara I, Pena E, Corona T, Lopez-Ayala T, Lopez-Meza E, Lopez-Gomez M. Sleep disturbances, socioeconomic status, and seizure control as main predictors of quality of life in epilepsy. Epilepsy & Behavior. 2005;7(3):481-5.
52. Buck D, Jacoby A, Baker GA, Ley H, Steen N. Cross-cultural differences in health-related quality of life of people with epilepsy: findings from a European study. Quality of Life Research. 1999;8(8):675-85.
53. Shetty PH, Naik RK, Saroja A, Punith K. Quality of life in patients with epilepsy in India. Journal of neurosciences in rural practice. 2011;2(1):33.
54. Hirsch L, Arif H. Neuroimaging in the evaluation of seizures and epilepsy. UpToDate, Pedley, TA (Ed), UpToDate, Waltham, MA Accessed. 2017;10:12.
55. Qassim Hadi A-A, Ala Khalil A-B. The significance of EEG recording in confirming the diagnosis of epilepsy in cases referred for the 1st time. Mustansiriya Medical Journal. 2006;6(1):77-85.
56. Brown E, Clark D, Bogess M, Widge A, Ramasubbu R, Protzner A, et al. Oscillation Changes in EEG Measured in the On and Off DBS State in Patients with Treatment Resistant Depression. Biological Psychiatry. 2017;81(10):S401.
57. Stafstrom CE, Carmant L. Seizures and epilepsy: an overview for neuroscientists. Cold Spring Harbor perspectives in medicine. 2015;5(6):a022426.
58. Northoff G. How do resting state changes in depression translate into psychopathological symptoms? From ‘Spatiotemporal correspondence’to ‘Spatiotemporal Psychopathology’. Current opinion in psychiatry. 2016;29(1):18-24.
59. Kroenke K, Spitzer RL, Williams JB. The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine. 2001;16(9):606-13.
60. Davison K. EEG activation after intravenous amitriptyline. Electroencephalography and clinical neurophysiology. 1965;19(3):298-300.
61. Wiegartz P, Seidenberg M, Woodard A, Gidal B, Hermann B. Co-morbid psychiatric disorder in chronic epilepsy: recognition and etiology of depression. Neurology. 1999;53(5 Suppl 2):S3-8.
62. Alexander HB, Broshek DK, Quigg M. Quality of life in adults with epilepsy is associated with anticonvulsant polypharmacy independent of seizure status. Epilepsy & Behavior. 2018;78:96-9.
63. Sabah Abdullah J. Quality Of Life For Patients With Epilepsy In Baghdad City. kufa Journal for Nursing sciences. 2014;4(2):1-9.
64. Ulrich G, Renfordt E, Zeller G, Frick K. Interrelation between changes in the EEG and psychopathology under pharmacotherapy for endogenous depression. Pharmacopsychiatry. 1984;17(06):178-
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Published
2020-06-18
How to Cite
Al Mousawi, A. M. (2020). Comorbidity of Epilepsy and Depression in Al Husseini Teaching Hospital in Holy Kerbala /Iraq in 2018. Karbala Journal of Medicine, 13(1), 2310–2318. https://doi.org/10.70863/karbalajm.v13i1.778
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