Epilepsy is defined as the chronic predisposition of the brain to have recurrent seizures. It has been recognised that individuals with epilepsy, especially those who continue to have seizures despite adequate medication (drug-resistant epilepsy), are at increased risk of psychiatric disorders or psychological difficulties. Individuals with epilepsy often have lower quality of life (QoL) compared to those with other chronic diseases. Factors that have been shown to contribute to poor health-related quality of life (HRQoL) include medical parameters (such as seizure frequency and severity and antiepileptic drug side effects) and complex psychological parameters (including depression and anxiety, fear of losing control, worries about seizure occurrence, and negative coping). While medical providers focus on minimizing seizures and side effects, a primary role that mental and behavioral health providers (i.e. psychologists, psychiatrists, and social workers) can have with individuals with epilepsy is to optimize HRQoL by providing evidence-based psychological treatments.
This review aimed to assess the effects of psychological treatments on HRQoL for people with epilepsy.
Characteristics of the Studies
We included 24 studies that met the inclusion criteria (2439 participants). The majority of trials investigated psychological interventions, such as cognitive, behavioral and mindfulness-based interventions. The remaining studies focused on education, self-management, and drug adherence. Two studies investigated interventions for children and adolescents, and five studies investigated interventions for adolescents and adults. The evidence presented in this review is up to date to September 2016.
Quality of the Studies
We assessed variable quality in the design and reporting across studies. However, there were some quality issues with the majority of studies.
Based on satisfactory comparability, we combined data from nine adult studies (468 participants) providing HRQoL outcomes in a meta-analysis. These results provided moderate-quality evidence that psychological treatments may enhance overall QoL and emotional well-being, and reduce fatigue in adults and adolescents with epilepsy.
We found moderate-quality evidence that psychological and self-management interventions were beneficial for adults and adolescents with epilepsy, by improving overall quality of life and emotional well-being and reducing fatigue. Adjunctive use of psychological treatments may provide additional benefits to QoL in adults with epilepsy who incorporate patient-centered management. The uniform use of Quality of Life in Epilepsy Inventories when researching psychological treatments for people with epilepsy, would increase comparability.
Implications for practice: Psychological interventions and self-management interventions improved QoL, and emotional well-being, and reduced fatigue in adults and adolescents with epilepsy. Adjunctive use of psychological treatments for adults and adolescents with epilepsy may provide additional benefits to QoL in those who incorporate patient-centered management.
Implications for research: Authors should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of the intervention protocol is necessary to ensure reproducibility.
When researching psychological treatments for people with epilepsy, the use of Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. There is a critical gap in pediatric RCTs for psychological treatments, particularly those that use an epilepsy-specific measure of HRQoL.
Finally, in order to increase the overall quality of study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued when conducting RCTs. As attrition is often high in research that requires active participant participation, an intention-to-treat analysis should be carried out.
Given the significant impact epilepsy can have on the health-related quality of life (HRQoL) of individuals with epilepsy and their families, there is great clinical interest in evidence-based psychological treatments, aimed at enhancing psychological well-being in people with epilepsy. A review of the current evidence was needed to assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes, in order to inform future therapeutic recommendations and research designs.
To assess the effects of psychological treatments for people with epilepsy on HRQoL outcomes.
We searched the following databases on 20 September 2016, without language restrictions: Cochrane Epilepsy Group Specialized Register, CENTRAL, MEDLINE PsycINFO, ClinicalTrials.gov, WHO 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.
We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQoL was the main outcome measure. For the operational definition of 'psychological treatments', we included a broad range of treatments that used psychological or behavioral techniques designed to improve HRQoL, seizure frequency and severity, and psychiatric comorbidities for adults and children with epilepsy, compared to treatment as usual (TAU) or an active control group.
We used standard methodological procedures expected by the Cochrane Collaboration.
We included 24 completed RCTs, with a total of 2439 participants. Eleven studies investigated psychological interventions, such as cognitive, behavioral, and mindfulness-based interventions. The remaining studies were classified as educational interventions (N = 7), self-management interventions (N = 3), adherence interventions (N = 1), and mixed interventions (N = 2). Two studies investigated interventions for children and adolescents, and five studies investigated interventions for adolescents and adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from six adult studies, two studies on adolescents and adults, and one on adolescents and young adults (468 participants) for HRQoL, measured with the Quality of Life in Epilepsy-31 (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 of the QOLIE-31 total score (mean improvement of 5.68 points (95% CI 3.11 to 8.24; P < 0.0001), and three subscales, emotional well-being (mean improvement of 7.03 points (95% CI 2.51 to 11.54; P = 0.002); energy and Fatigue (mean improvement of 6.90 points (95% CI 3.49 to 10.31; P < 0.0001); and overall QoL (mean improvement of 6.47 points (95% CI 2.68 to 10.25; P = 0.0008) exceeded the threshold of minimally important change (MIC), indicating a clinically meaningful post-intervention improvement of QoL. We downgraded the quality of the evidence provided by the meta-analysis because of serious risk of bias in some of the included studies. Consequentially, these results provided evidence of moderate quality that psychological treatments for adults with epilepsy may enhance overall QoL in people with epilepsy.