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ABSTRACT Introduction: Epilepsy contributes to a significant psychosocial and mental health burden in rural populations, where stigma, limited awareness, and poor access to care impede early recognition and support for comorbid anxiety and depression, adversely affecting quality of life and treatment adherence. Materials and Methods: A community-based quantitative cross-sectional study was conducted among 100 adults (18–65 years) with clinically confirmed epilepsy, identified from Primary Health Centre records in rural South India. Anxiety and depression symptoms were screened using the Hospital Anxiety and Depression Scale, and quality of life was assessed using Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Perceived barriers to care were evaluated using structured interviewer-administered questionnaires. Associations were analyzed using Chi-square or Fisher’s exact test, with significance set at P < 0.05. Results: Seventy-two percent and 74% of participants screened positive for anxiety and depression, respectively. Psychological distress showed a significant association with longer epilepsy duration ( P = 0.067), poor treatment adherence ( P = 0.016), and perceived stigma ( P = 0.001). Seizure type was not significantly associated with mental health outcomes ( P = 0.142). QOLIE-31 scores revealed marked impairment in emotional well-being and social functioning among screen-positive participants. Conclusion: Rural adults with epilepsy experience high levels of screen-positive anxiety and depression symptoms, driven by modifiable barriers including stigma and economic challenges. Routine mental health screening and integrated rural epilepsy care models are essential, while interpreting results as screen-positive symptoms rather than clinical diagnoses.