Neurology > Seizures
Self-Management Interventions Show Modest Benefit in Epilepsy
More tailored approaches may be needed
by Judy George, Senior Staff Writer, MedPage Today July 01, 2019
Educational interventions increased self-management behaviors among patients with epilepsy, a small systematic review and meta-analysis found.
Psychosocial therapy interventions also appeared to improve their quality of life, reported Matthew Luedke, MD, of Duke University Medical Center and Durham Veterans Affairs Medical Center in North Carolina, and co-authors in Annals of Internal Medicine.
And while the self-management interventions studied did not decrease seizure rates, "one well-designed educational intervention that was developed with the input of patients decreased a composite outcome of seizures, emergency department visits, and hospitalizations," Luedke told MedPage Today.
Self-management programs are systematic approaches to give patients more knowledge and skills to manage their medical condition. These programs are well-established for other chronic diseases, but the most effective self-management interventions for epilepsy patients are unknown.
Patient self-management behaviors are important to reducing breakthrough seizures in epilepsy. Even on medication, only about 70% of people with epilepsy remain seizure-free, noted Barbara Jobst, MD, PhD, of Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, in an accompanying editorial.
The effect of epilepsy can extend well beyond seizures, she added: "Patients with epilepsy may have depression and cognitive impairment despite seizure cessation. Among persons with temporal lobe epilepsy, 50% are depressed and 80% have cognitive problems in at least one domain. This comorbidity often is more disabling than the seizures themselves."
In this study, Luedke and colleagues looked at 15 studies that focused on six components of epilepsy self-management: acquiring knowledge, symptom monitoring, managing medications, problem solving and decision making, safety, and changing health behaviors. The researchers categorized self-management programs into two groups: educational interventions and interventions based on psychosocial therapy such as problem-solving or cognitive behavioral therapy. They focused on three primary outcomes: self-management behaviors, quality of life, and seizure rates.
Self-management programs varied widely: some were in a group format with professional educators, for example; others used mobile technology or one-on-one telephone support. While the researchers determined that meta-analysis was difficult because of heterogeneity and high risk of bias, they calculated standardized mean difference (SMD) where possible, classifying 0.2 SMD as small, 0.5 as medium, and 0.8 as large. Their analysis showed:
Education interventions led to a modest increase in self-management behaviors at 6 months (SMD 0.52; 95% CI 0.0-1.04)
Psychosocial therapy–based approaches improved quality of life, though with low certainty
Self-management interventions did not reduce seizure rates, but one educational intervention decreased a composite of seizures, emergency department visits, and hospitalizations
A previous systematic review that included only face-to-face interventions reported positive effects on seizure frequency, Jobst noted. But "seizures are not the only factor leading to disability, so the absence of an intervention's effect on seizure frequency does not negate the benefit of self-management any more than normal blood sugar levels obviate the need to manage diabetic neuropathy," she added.
This analysis has several limitations, the researchers observed. Studies that focused on depression were excluded. Most studies had an unclear or high risk of bias and enrolled fewer than 100 patients. Interventions were delivered in various ways and often were described incompletely, and some outcomes were not reported. Self-reported outcomes, especially seizure rates, were hard to measure.
Whether epilepsy will respond to self-management interventions in the same way as other chronic conditions is not clear, the authors noted. "To fully understand the potential of self-management support, we need additional studies that incorporate input from patients and other stakeholders into the intervention design," Luedke said. Future research also should involve intervention strategies designed to deliver self-management support tailored to the individual patient, he noted.
This project was funded by the U.S. Department of Veterans Affairs, and the VHA Office of Research and Development Quality Enhancement Research Initiative. This work was also supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation at the Durham Veterans Affairs Health Care System.
Researchers reported relationships with Eisai Pharmaceuticals, Biogen, UCB, Monteris, Cadwell, Jazz Pharmaceuticals, Marinus Pharmaceuticals, Sanofi, Otsuka, Improved Patient Outcome, Novo Nordisk, Proteus, and Abbott.
Source Reference: Luedke M, et al "Self-management of Epilepsy: A Systematic Review" Ann Intern Med 2019; DOI: 10.7326/M19-045.
Source Reference: Jobst B "Progress in Chronic Disease: Self-management for Patients With Epilepsy" Ann Intern Med 2019; DOI: 10.7326/M19-1483.
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