Psychological treatments for people with epilepsy

Review question

In this Cochrane Review, we wanted to find out if the well-being (quality of life) of people with epilepsy could be improved by participation in educational or skills-based psychological therapies.

Why is this important?

Epilepsy is a brain-condition in which sudden bursts of intense electrical activity happen in the brain and cause the brain's messages to get mixed up, resulting in a seizure. Seizures affect people in different ways: they may cause unusual sensations, movements or feelings, loss of awareness, falls, stiffness or jerking. Epileptic seizures can occur repeatedly and without any triggers. Seizures can happen anytime and anywhere; they can come on suddenly and can happen often.

Epilepsy can significantly impact a person’s wellbeing and quality of life. For instance, many people with epilepsy experience depression and anxiety, memory problems, unemployment and discrimination, adverse side effects from medications, challenges to independence and worries about seizures and their consequences.

Treatments for epilepsy typically focus on stopping or reducing the number of seizures a person has with as little side effects as possible. However, psychological therapies, usually delivered by psychologists, psychiatrists or other healthcare professionals could improve well-being in people with epilepsy.

What did we do?

On 12 August 2019, we searched research databases for studies that measured the effects of psychological therapy offered to people with epilepsy on their quality of life. We found 36 studies, which involved 3,526 people with epilepsy. Participants of most studies were adults (27 studies); only three studies included adolescents and adults, and six involved children and adolescents.

Most studies (27) measured the effects of “skills-based” psychological therapies. These treatments teach people skills they can use in their daily lives. The treatment approaches of skills-based therapies included: cognitive behavioral therapy (CBT) including CBT techniques such as breathing, reasoning or visualizing; counseling; and exercises in mindfulness. The other nine studies measured educational therapies. These treatments aimed to increase people’s knowledge of epilepsy and related conditions, treatments for epilepsy, or about how the brain works. The studies compared the effects of the psychological therapies with a person's usual care, antidepressant medicines or social support.

The 36 studies had different designs and assessed people's quality of life using different scales, so we couldn't compare them all. However, we were able to compare the results of 11 studies of skills-based therapies because they used the same scale to assess quality of life.

What did we find?

The 11 studies (involving 643 adults and adolescents) were conducted in Europe (3 studies), the USA (4), Hong Kong (2), Mexico (1) and Australia (1). People in the studies were followed and assessed from 12 weeks to 2 years.

The 11 studies measured different aspects of quality of life. People received skills-based psychological therapies reported better quality of life overall than those who received usual care (8 studies), social support (2) or antidepressant medicines (1).

Ten of these 11 studies also looked at subscales of the quality of life questionnaires to assess specific aspects of quality of life. People in these studies reported better results on the six subscales, - emotional well-being, energy and fatigue, overall well-being, seizure worries, medication effects, and social function, which are combined to calculated overall quality of life.

Key messages

We concluded that skills-based psychological therapies may improve well-being (quality of life) in adults and adolescents with epilepsy.

We are moderately confident in our result from these 11 studies of psychological therapies in people with epilepsy. We believe that more studies on this specific outcome of quality of life would be unlikely to change our findings.

This review is current up to 12 August 2019.

Authors' conclusions: 

Implications for practice: Skills-based psychological interventions improve HRQOL in adults and adolescents with epilepsy. Adjunctive use of skills-based psychological treatments for adults and adolescents with epilepsy may provide additional benefits in HRQOL when these are incorporated into patient-centered management. We judge the evidence to be of moderate certainty.

Implications for research: Investigators should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of intervention protocols is necessary to ensure reproducibility.

When examining the effectiveness of psychological treatments for people with epilepsy, the use of standardized HRQOL inventories, such as the Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. Unfortunately, there is a critical gap in pediatric RCTs and RCTs including people with epilepsy and intellectual disabilities.

Finally, in order to increase the overall quality of RCT study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued. As attrition is often high in research that requires active participation, an intention-to-treat analysis should be carried out. Treatment fidelity and treatment competence should also be assessed. These important dimensions, which are related to 'Risk of bias' assessment, should always be reported.

Read the full abstract...
Background: 

Given the significant impact epilepsy may have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is increasing clinical interest in evidence-based psychological treatments, aimed at enhancing psychological and seizure-related outcomes for this group.

This is an updated version of the original Cochrane Review published in Issue 10, 2017.

Objectives: 

To assess the impact of psychological treatments for people with epilepsy on HRQOL outcomes.

Search strategy: 

For this update, we searched the following databases on 12 August 2019, without language restrictions: Cochrane Register of Studies (CRS Web), which includes randomized or quasi-randomized controlled trials from the Specialized Registers of Cochrane Review Groups including Epilepsy, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to 09 August 2019), and PsycINFO (EBSCOhost, 1887 onwards), and from PubMed, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies.

Selection criteria: 

We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQOL was the main outcome. For the operational definition of 'psychological treatments', we included a broad range of skills-based psychological treatments and education-only interventions designed to improve HRQOL, seizure frequency and severity, as well as psychiatric and behavioral health comorbidities for adults and children with epilepsy. These psychological treatments were compared to treatment as usual (TAU), an active control group (such as social support group), or antidepressant pharmacotherapy.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane.

Main results: 

We included 36 completed RCTs, with a total of 3526 participants. Of these studies, 27 investigated skills-based psychological interventions. The remaining nine studies were education-only interventions. Six studies investigated interventions for children and adolescents, three studies investigated interventions for adolescents and adults, and the remaining studies investigated interventions for adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from 11 studies (643 participants) that used the Quality of Life in Epilepsy-31 (QOLIE-31) or other QOLIE inventories (such as QOLIE-89 or QOLIE-31-P) convertible to QOLIE-31. We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes in the QOLIE-31 total score (mean improvement of 5.23 points, 95% CI 3.02 to 7.44; P < 0.001), and the overall QoL score (mean improvement of 5.95 points, 95% CI 3.05 to 8.85; P < 0.001) exceeded the threshold of minimally important change (MIC: total score: 4.73 points; QoL score: 5.22 points), indicating a clinically meaningful postintervention improvement in HRQOL. We downgraded the certainty of the evidence provided by the meta-analysis due to serious risks of bias in some of the included studies. Consequently, these results provided moderate-certainty evidence that psychological treatments for adults with epilepsy may enhance overall HRQOL.

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