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Anxiety, Epilepsy, Depression, Transcranial direct current stimulation, What&,rsquo s Known Transcranial direct current stimulation is an effective intervention in treating the symptoms of depression, anxiety, and stress. This safe and efficient method can be used in patients with epilepsy for the reduction of seizures. What&,rsquo s New For the first time, we evaluated the effects of transcranial direct current stimulation on the psychological profile of patients with temporal lobe epilepsy. The low current rate and the lack of sensitivity make this method a noninvasive technique thus, its use in patients with epilepsy is unrestricted. IntroductionAccording to the World Health Organization (WHO), neurological disorders affect the nervous system cause some structural, biochemical, and electrical abnormalities in the central nervous system and produce a series of symptoms. Epilepsy is a chronic and neurological disease with its own features. Seizures are its main characteristic and can stem from systematic, metabolic, or toxic factors. 1, In addition to physical disabilities, this disorder causes some psychological problems. Elger and others demonstrated that psychological neuropathy had high comorbidity with chronic epilepsy. 2, These patients&,rsquo psychological profiles should be examined to understand their psychological problems. The psychological profile is used for studying depression, anxiety, and stress.Depression is one of the most common psychiatric disorders that affect individuals with epilepsy. Nonetheless, patients do not pay much attention to this disorder and usually do not receive treatment. 3, In these patients, failure to receive treatment or inappropriate treatment can result in suicide. 4, In recent years, numerous studies have reported a bidirectional relationship between depression and epilepsy. In other words, patients with epilepsy are more likely to be depressed. Likewise, the risk of epilepsy in depressed individuals is three to seven times higher than the normal population. 5, Thapar and colleagues indicated that, in the treatment of epilepsy, the management of depression was very important, since it controlled seizures, stress, and anxiety indirectly. 6, Anxiety is one of the adjustment disorders experienced by patients upon diagnosis with depression. It is increased by the exacerbation of seizures. 4, The results of a study by Tellez-Zenteno and others showed that the risk of anxiety and depression (suicidal thoughts) in patients with epilepsy was 2.4 and 2.2 higher than that in healthy individuals. 7, The results of a meta-analysis performed by Scott and colleagues indicated that in patients with epilepsy, the prevalence of anxiety and depression was 20.2% and 22.9%, respectively. 8, Among the psychological problems experienced by these patients, stress is a vague factor, because it still is not clear whether stress is the cause or the effect of the disease. Since stress is an integral part of everyday life, its examination as a trigger for seizure attacks is important. Gelisse and colleagues demonstrated that in some patients with epilepsy (5 in 1000), seizures began after stressful events. 9, It is clear that in these patients, the psychological profile undergoes some changes interventions are, thus, required to improve it in patients, who suffer from epilepsy. In the present study, transcranial direct current stimulation (tDCS) was selected from among various interventions. San-Juan and others in a meta-analysis demonstrated that this method was safe and efficient in patients and animals with epilepsy. 10, Narita and Yokoi examined the effects of tDCS on cognition and depression among individuals with Alzheimer&,rsquo s disease. They placed the anode in the left dorsolateral prefrontal cortex (DLPFC) and the cathode in the F3 and FP2 regions. Individuals received 2 mA for 30 minutes. The findings represented an improvement in the quality of life. 11, Liu and colleagues studied patients with temporal lobe epilepsy and demonstrated that the tDCS intervention with 2 mA and for 20 minutes improved depression. 12, Brunoni and others used tDCS to improve emotional processing in the DLPFC of patients with major depressive disorders. They found that even one session of tDCS might cause potential changes in emotional processing. 13, Ironside and others used the tDCS method to treat anxiety. They placed the anode in the left DLPFC and the cathode in the right DLPFC. The results indicated a reduction in vigilance against threats. 14, Bishop and colleagues concluded that the activity of the DLPFC was negatively correlated with trait anxiety. The result of their study highlighted the fact that working in the DLPFC area could be useful and practical. 15, Brunoni and others showed that tDCS could lower cortisol levels and augment vagal activation through anodal stimulation, leading to the management of stress. 16, Moradi Kelardeh and colleagues investigated the effects of DLPFC stimulation on cigarette craving and stress and found tDCS useful in reducing cigarette cravings and stress. 17, These studies highlight the gap in research, especially in the field of anxiety and stress. The aforementioned studies have not examined epileptic patients. Consequently, the present study endeavored to survey the effects of tDCS on depression, anxiety, and stress in patients with epilepsy.Patients and MethodsThe present study was a randomized clinical trial with a pretest-posttest and a control group. It was conducted in the private clinic of Dr. Hasani Kia in Urmia in 2019. The first step was participant selection. The target population consisted of 30 participants, who suffered from temporal lobe epilepsy. Delavar stated that in intervention studies and controlled conditions, researchers could accommodate 15 individuals in each group. 18, In the current investigation, the participants were selected by convenience sampling and were divided by simple randomizatoion into an intervention group and a control group by using a random number table. The reason for using convenience sampling and 15 participants in each group was the limited availability of these patients. The inclusion criteria encompassed willingness to participate, having temporal lobe epilepsy according to the medical record, age range between 15 and 50 years, a minimum mid-school qualification, not being pregnant, not being in the menstrual period, having a shower before the intervention so that the electrical current was not interrupted by greasy hair, having any prosthesis in the skull, having no battery in the heart, having received no psychological treatment in the past year, and having no other medical illnesses. The exclusion criteria were comprised of non-cooperation during the intervention and research, the decision to discontinue participation, any sensitivity to tDCS, and receiving any psychological interventions or psychiatric drugs.In the second step, the participants completed the Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire. After the administration of the pretest, tDCS was applied, followed by the posttest. In this technique, electrodes are placed in sponge pads, which are soaked in a conductive solution. The current passes through different areas, before it reaches the surface of the cerebral cortex. The current that reaches this area causes neurons to have an electric charge and creates positive and negative poles, leading to a change in the activity of that area. In the current research, during the intervention, a total of 15 patients, who were in the intervention group received 1.5 mA for 20 minutes over the left DLPFC. The anode was placed in the left hemisphere over the F3 region, while the cathode was placed over the F4 region in the right hemisphere. The intervention was implemented for 10 sessions. The first five sessions were held consecutively, and the last five sessions were held every other day. The control group did not receive any stimulation despite the placement of electrodes.Ethical ApprovalThe present study was approved by Urmia University of Medical Sciences (Ethical Code, IR.UMSU.REC.1398.140 and was registered with the Clinical Trials Code of, IRCT20190803044417N1). The researchers explained the process of the study to the participants, who completed the written informed consent under reassurance that they were free to leave the study at any time.Measurement InstrumentThe depression, anxiety, and stress scale consisted of 21 items and was the short version of the questionnaire developed by Lovibond and Lovibond.19 Each subscale (depression, anxiety, and stress) was measured through seven items. The participants expressed agreement or disagreement on a four-point Likert-type scale, ranging from zero (i.e., Never) to three (i.e., Often). Items 3, 5, 10, 13, 16, 17, and 21 were related to depression. Items 2, 4, 7, 9, 15, 19, and 20 were related to anxiety. Finally, items 1, 6, 8, 11, 12, 14, and 18 were linked to the stress subscale. Lovibond calculated the Cronbach&,rsquo s alpha coefficients of reliability for the three mentioned subscales and reported 0.91, 0.84, and 0.9 for depression, anxiety, and stress, respectively. 19, Sahebi and colleagues reported that the Cronbach&,rsquo s alpha coefficients of reliability for depression, anxiety, and stress were 0.77, 0.79, and 0.78, respectively. 20, In the present study, the reliability index was 0.69 for depression, 0.64 for anxiety, and 0.71 for stress. Statistical AnalysisThe SPSS software, version 23, was used to analyze the data from the perspective of descriptive and inferential statistics. The comparisons of the DASS-21 scores before and after the intervention were done using the analysis of covariance (ANCOVA), which is a general method best suited to examine the between-group differences of pretest to posttest. Nonetheless, prior to the analysis, the hypotheses of ANCOVA were examined. The Levene&,rsquo s test was utilized to investigate the equality of variance between the two groups, and the Kolmogorov&,ndash Smirnov test was employed to check the distribution. A P value of less than 0.05 was considered statistically significant.ResultsThe present study initially selected 52 patients, of whom 22 were excluded. Ultimately, 30 participants were assigned to intervention and control groups ( figure 1,). The demographic characteristics of the participants in both groups are compared in table 1, (P&,le 0.001).Figure 1. CONSORT diagram shows the flow of the participants through each stage of this randomized clinical trial.Variables Intervention Group (n, %)Control Group (n, %)P value(n=15)(n=15)Marital StatusSingle4 (26.60%)3 (20%)&,gt 0.999Married7 (46.70%)7 (46.70%)Divorced4 (26.70%)5 (33.30%)EducationHigh school3 (20%)2 (13.30%)&,gt 0.999Bachelor5 (33.30%)7 (46.70%)Master7 (46.70%)6 (40%)SexMale8 (53.30%)8 (53.30%)0.839Female7 (46.70%)7 (46.70%)Age (Mean&,plusmn SD)15&,ndash 50 (y)38.13&,plusmn 9.1434.73&,plusmn 9.260.320 P values were calculated for the unpaired t test (P&,le 0.001). Unpaired t test were applied and P values of less than 0.001 were considered significant. |