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Epilepsy Currents

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Epilepsy Currents Podcasts will bring you all the features you know and love about the journal in an innovative format you can take with you wherever you go. The primary content of Epilepsy Currents consists of commentaries written by our expert editorial board on recent high-impact research papers in Epilepsy. Each podcast episode will highlight one of these recent publications and the accompanying commentary. High-yield topics of interest to our engaged epilepsy community will be presented and discussed by one of our contributing editors and the original authors to give you an in-depth, rigorous, and personal view of current topics in epilepsy and the people behind them. Topics will include both clinical and basic sciences, emphasizing bringing our larger community together around the mission we share: To advance research, education, and practice for all professionals working in epilepsy.

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Recent Episodes

Episode thumbnail for Epilepsy Currents - Episode 12- "Drugs, Diets, and DEEs — Add-on Ketogenic Diet versus Antiseizure Medications Alone in Children with Developmental and Epileptic Encephalopathies"

July 15, 2026

Epilepsy Currents - Episode 12- "Drugs, Diets, and DEEs — Add-on Ketogenic Diet versus Antiseizure Medications Alone in Children with Developmental and Epileptic Encephalopathies"

Join Dr.Marawar in a conversation with Dr. Chalongchai Phitsanuwong and Dr. Priyamvada Tatachar as they discuss the article, "Add-on ketogenic diet versus antiseizure medications alone in children with developmental and epileptic encephalopathies: a prospective comparative cohort study" and its accompanying Epilepsy Currents commentary "Drugs, Diets, and DEEs: A Comparative Review of Medical and Dietary Treatments in Developmental and Epileptic Encephalopathies". Click <a href= "https://journals.sagepub.com/doi/full/10.1177/15357597261433562">here</a> to read the article. This podcast was sponsored by <a href= "https://www.ucbcompass.com">UCB</a>. <img src= "//assets.libsyn.com/show/412622/UCB_LOGO_TAG.jpg" alt="" width= "300" height="97" /> We'd like to acknowledge Epilepsy Currents podcast editor Dr. Adriana Bermeo-Ovalle, contributing editor Dr. Rohit Marawar, and the team at Sage. <hr /> This episode covers a 2025 Frontiers in Neurology study by Hu et al. and its accompanying Epilepsy Currents commentary on ketogenic diet therapy for developmental and epileptic encephalopathies (DEEs). Host Dr. Rohit Marawar speaks with Dr. Chalongchai Phitsanuwong and Dr. Priyamvada Tatachar about the study's findings that add-on ketogenic diet nearly doubled seizure-freedom rates versus medication adjustment alone, and produced meaningfully better developmental/cognitive outcomes. They discuss the rationale for earlier diet initiation, practical implementation (patient evaluation, dietician-led clinics, monitoring), manageable side effects, the search for response biomarkers, referral pathways for general neurologists, and the future of DEE treatment moving toward genetically targeted therapies alongside continued diet use. Key takeaways: 1.<span style= "font-style: normal; font-variant: normal; font-size-adjust: none; font-language-override: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-weight: normal; font-stretch: normal; line-height: normal; font-family: 'Times New Roman';"> Ketogenic diet outperformed medication adjustment alone: ~50% seizure response rate vs. ~29%, and ~20% seizure-free vs. ~10% (RR 1.73 for response, RR 1.9 for seizure freedom), consistent with prior literature (40-60% response, 10-30% freedom in DEEs). 2.<span style= "font-style: normal; font-variant: normal; font-size-adjust: none; font-language-override: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-weight: normal; font-stretch: normal; line-height: normal; font-family: 'Times New Roman';"> Developmental gains, not just seizure control, may be the more striking finding: 36% vs. 5% showed developmental improvement on formal assessment, occurring even without medication changes, suggesting the diet has an intrinsic neuroprotective effect independent of seizure reduction. 3.<span style= "font-style: normal; font-variant: normal; font-size-adjust: none; font-language-override: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-weight: normal; font-stretch: normal; line-height: normal; font-family: 'Times New Roman';"> Both experts argue for earlier initiation of ketogenic diet, especially in syndromes like epilepsy with myoclonic-atonic seizures (Doose syndrome, 79% response rate) and infantile epileptic spasms, rather than reserving it as a last resort after drug resistance and developmental regression are already established. 4.<span style= "font-style: normal; font-variant: normal; font-size-adjust: none; font-language-override: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-weight: normal; font-stretch: normal; line-height: normal; font-family: 'Times New Roman';"> Side effects (mostly GI, constipation, "keto flu") are generally mild and manageable with proper monitoring (renal, bone health, lipids, micronutrients), and only ~3% discontinued therapy in the study; dedicated multidisciplinary keto clinics significantly improve feasibility and adherence. 5.<span style= "font-style: normal; font-variant: normal; font-size-adjust: none; font-language-override: normal; font-kerning: auto; font-optical-sizing: auto; font-feature-settings: normal; font-variation-settings: normal; font-weight: normal; font-stretch: normal; line-height: normal; font-family: 'Times New Roman';"> No validated biomarker yet predicts individual response to the diet (early signals around acetylcarnitine levels), but resources exist for clinicians to start a program, including the Charlie Foundation, Matthew's Friends Foundation, the International Neurological Ketogenic Diet Society, and ILAE regional clinic listings.  <hr /> Dr. Rohit Marawar (Host): Imagine a child whose first year of life is measured not in milestones, but in seizures, dozens a day, while medication after medication is tried and falls short, and development quietly regresses. For children with developmental and epileptic encephalopathies, this is an all too common story. But what if one of our oldest therapies, a carefully formulated diet, could change not just the seizures, but the trajectory of a child's development? Welcome to the Epilepsy Currents podcast, the podcast for Epilepsy Currents Journal, exploring the latest research and expert commentaries from the world of epilepsy. UCB is the proud sponsor of this episode, Episode Number 12 of Epilepsy Currents podcast. I'm your host and associate editor for the podcast, Rohit Marawar. Today, we are discussing a prospective comparative cohort study by Hu and colleagues, published in Frontiers in Neurology in 2025, and the accompanying Epilepsy Currents commentary, Drugs, Diets, and DEEs to help us unpack what this means for clinical practice. We are joined by two expert voices in pediatric epilepsy. First is Dr. Chalongchai Phitsanuwong, author of the commentary. Dr. Phitsanuwong is a pediatric epileptologist with a focus on ketogenic diet therapy, practicing at Bumrungrad International Hospital in Bangkok, Thailand. Welcome, Dr. Phitsanuwong. Chalongchai Phitsanuwong, MD: Hello and good evening. Thank you very much for having me today. Host: And then, we are also joined by Dr. Priyamvada Tatachar, a pediatric epileptologist based in Chicago with a special interest in tuberous sclerosis and who also contributed to the commentary. Welcome, Dr. Tatachar. Priyamvada Tatachar, MBBS, MD: Good morning from Chicago, and thank you for having me on this podcast. Host: Great to have you both with us. Let's dive in. Dr. Phitsanuwong, I'm going to start with you. To set the stage for our audience, what exactly are developmental and epileptic encephalopathies, sometimes abbreviated as DEEs, and how often are they likely to be drug resistant? Chalongchai Phitsanuwong, MD: Thank you very much, Dr. Marawar. So, developmental and epileptic encephalopathies, or DEEs, represent some of the most severe forms of epilepsy. It's characterized by frequent seizures and abundant epileptiform activity on the EEG. It is commonly associated with developmental slowing and/or regression, like you said. The current consensus is that both the underlying etiology and the seizures or epileptiform discharges contribute directly to this developmental stagnation or regression. DEEs carry an exceptionally high prevalence of becoming drug-resistant epilepsy, reaching up to 70% in some cohorts, by comparison to the typical 1/3 we see in general epilepsy population. So, more than double the numbers. Host: Dr. Tatachar, from a frontline clinical standpoint, what does the day-to-day burden of a drug-resistant DEE looks like for a child and their family, and where do current medication strategies most often fall short? Priyamvada Tatachar, MBBS, MD: I think the word overwhelming comes to mind when families face the diagnosis of developmental and epileptic encephalopathies. For most patients and parents, the initial diagnosis is basically an uncharted territory that comes with a lot of fear, uncertainty, financial and social burdens, and the day-to-day challenges of caring for a child with significant medical, social, and developmental needs. It's a very daunting situation for them. Now, the current medical management focuses on the perspective of seizure control with several drugs added either alone or in combination for this reason. And as Dr. Phitsanuwong said, DEEs are particularly drug resistant. And based on the child's underlying diagnosis, additional challenges also need to be addressed for these families. Host: Dr. Phitsanuwong, the Hu, et al study, which you wrote the commentary for, found around a 50% seizure response rate with add-on ketogenic diet versus around 29% with anti-seizure medication adjustment alone, and a seizure-free rate of around 20% with diet versus around 10% with ASMs alone, both of which were deemed statistically significant. Now, how meaningful is a difference of that size to you, and how does it compare with what prior studies have shown? Chalongchai Phitsanuwong, MD: I think the result of this study is a highly meaningful context. Seizures in DEEs, like Dr. Tatachar said, are generally very difficult to control and have a high probability, of becoming drug resistant. In this prospective controlled trial, Hu and colleagues evaluated the patient with DEE who was still having seizure despite trying on an average of three anti-seizure medications already. And they found that adding ketogenic diet led to a significant higher seizure response rate. In the study, they defined as more than 50% seizure reduction, and they got the relative risk of 1.73. But what really stands out is the six-month seizure freedom rate from that. The dietary therapy group was nearly twice as likely to achieve the complete seizure freedom compared to continued medication alone, with relative risk of 1.9, so almost double. And this finding also aligned beautifully with the historical retrospective and prospective data that we have, where we typically see the seizure response rate around 40-60% in patients with DEE alongside around 10-30% complete seizure freedom rate. So, I think that it carries quite a meaningful result. Host: Great. Continuing with you, Dr. Phitsanuwong. So beyond seizure counts, the study also reported better EEG improvement and developmental gains in the diet group, 36% versus around 5% on formal assessment. Now, why is that developmental signal so important in this population, and how much weight should we give it? Chalongchai Phitsanuwong, MD: This is very important question because this highlights a critical paradigm shift in how we approach the treatment of DEEs currently. Because DEEs are commonly associated with developmental stagnation and regression that can also worsen over time, our therapeutic success cannot be measured solely just by the seizure control or seizure count. We should also focus equally on the neurodevelopmental and cognitive outcomes. While many anti-seizure medication, they are good, they can effectively reduce seizures. They frequently carry a heavy cognitive burden causing sedation, psychomotor slowing, impaired concentration, particularly in the setting of polypharmacy, which quite common in the patient with DEEs. Ketogenic diet therapy, on the other hand, offers a distinct advantage on this point. Multiple studies has shown that it can actively promote cognitive and developmental improvement, particularly in alertness, attention, and global cognitive abilities. Interestingly, there's one landmark systematic review by van Berkel and colleagues showed that this cognitive benefit appears to be independent to seizure control, meaning even patients can experience meaningful cognitive gains even before a significant seizure reduction is achieved or apparent. The study by Hu and colleagues strongly reinforces this, because they use formal age-appropriate assessment tools, and they documented a highly significant improvement as you showed the number, 30% to only 5% in developmental and cognitive scores in the dietary therapy group compared to the medication group. And what makes this finding so clean is that it occurred without adjusting or reducing baseline medication during the study period. This provides a strong signal that the ketogenic diet may exert an intrinsic neuroprotective benefit that directly support development and cognition in this patient population. Host: Dr. Tatachar, when you counsel a family about starting ketogenic diet, what are the practical realities they need to understand about feasibility, adherence, and the support a clinic has to provide? Priyamvada Tatachar, MBBS, MD: Families and providers even usually are concerned about ketogenic diet initiation because they think it's a very complicated process. And unfortunately, this delays the initiation in many patients. It is really not that complicated if we understand the process well. Before initiating keto, a comprehensive evaluation of the child, their underlying diagnosis, specifically genetic diagnosis, the comorbidities, their metabolic health, whether they're oral or tube-fed status, and what are the social determinants of health? These are important things to assess to see if it's a feasible option for the family. In addition, are there any food allergies, cultural or religious restrictions, any restrictive eating behaviors in that child. For example, in autism spectrum disorders. These are important parameters to assess, then we can tailor the diet for that particular family. It usually involves sitting down and going over the treatment roadmap with the family with a keto dietician and talking about the entire process with the risk and benefits discussed in a very open and transparent manner. For this particular reason, dedicated ketogenic diet clinics are very helpful because they sit down with time, explain the rationale, initiation process, the formulas, the different types of the ketogenic diet from the most restrictive classic keto to the lesser restrictive diets, and which may also help improve adherence with the family. We have to monitor. There are surveillance labs that need to be ordered and followed up. And of course, the initial initiation part involves frequent telephone calls, telemedicine contact with the families that provides that extra layer of support and reassurance for the families that are already going through a lot. And this significantly improves adherence, and we've had families on ketogenic diet for over 10 years with really good compliance. Host: Dr. Phitsanuwong, your commentary makes the case for considering the ketogenic diet early rather than waiting until epilepsy is firmly drug resistant. What is the argument for early initiation? And what holds clinicians back from doing it? In addition, how long should it be continued, and what are the outcomes after the diet is stopped? Chalongchai Phitsanuwong, MD: Thank you for the series of questions. While we do not yet have a definitive and solid evidence to use ketogenic diet therapy before drug resistance develops across all the DEEs, largely because most of the literature focuses on drug-resistant cohorts. There are certain syndrome-specific DEEs where the ketogenic diet therapy can and should be deployed early. A prime example is epilepsy with myoclonic-atonic seizures, formerly called Doose syndrome. Overwhelmingly, global evidence demonstrates that ketogenic diet therapy is one of, if not, the most effective interventions we have for this population. In a large multi-center cohort study by Nickels and colleagues showed that dietary therapy yield a striking 79% seizure respond rate and a 57% seizure freedom rate in Doose syndrome, compared to just 26% respond rate with the standard anti-seizure medications. And crucially, in the same study, the authors identified that failing ketogenic diet therapy was an independent predictor of overall treatment failure in these children. Another compelling example that I can think of is in the infantile epileptic spasm syndrome. Data consistently shows that utilizing ketogenic diet therapy as a second-line therapy after failure of hormonal therapy or vigabatrin use, a 30% to 40% spasm-free rate along the clear EEG improvement. However, in fact, there's a recent randomized control trial published in 2025 from India by Mahesan and colleagues compared ketogenic diet therapy directly to ACTH as a first-line treatment for infantile epileptic spasm syndrome. And they found that they both have comparable efficacy, but with a lower relapse rate and more favorable side effect profile in the ketogenic diet arm. Giving these data points at this point and keeping in mind that we discussed earlier that the ketogenic diet also have intrinsic cognitive benefits, I believe that it's very reasonable to initiate dietary therapy early in selected patients with DEE. I don't think that we should feel compelled to wait until the epilepsy become firmly drug resistant and developmental slowing or regression is already apparent before we consider ketogenic diet therapy. And for your next question about what holds clinician back, personally, I think that it is truly multifactorial. It often stems from structural barriers, like a lack of a specialist ketogenic dietician in your institute or limited access to a dedicated ketogenic diet center. As Dr. Thatcher mentioned that it works best when you have the multidisciplinary dedicated program. But there are also some clinical and educational hurdles. For example, a general unfamiliarity on how to initiate, monitor, and manage the diet, which naturally affects the clinician's comfort level to even offer the patient or the family the diet. And additionally, I think that, there's still some perception of the patient's families or even clinicians that the diet are simply too difficult to implement or adhere to. And this factor leads many clinicians to hold back on starting the diet and viewing the diet therapy as an option of last resort, which is highly, highly unfortunate and not what the scientific data supports. Your last question is how long the diet should be continued for this question, I think it's highly individualized. It depends on the epilepsy diagnosis, specific syndrome, its natural history, their response to the therapy, any perceived cognitive benefits from the diet, and ultimately, it's a family's choice. Having said that, as a general rule of thumb, usually, we look at the landmark study from Johns Hopkins Hospital led by Dr. Kossoff, which they found that among the patients who responded remarkably well on the diet and achieved two years of seizure freedom, roughly around 80% of those patients remained seizure-free after the diet was discontinued. This also sends us a signal that the diet may have the long-lasting benefit with the patient because even after the diet is discontinued, 80% remain seizure-free. And because of this, it has become a clinical practice that to discuss about the diet discontinuation to the patient and family after the two years of the complete seizure freedom. However, the ultimate decision usually lies on the patients and the family decision. Host: Wonderful. Thank you for that answer. Dr. Tatachar, adverse effects in the study were mostly mild and gastrointestinal, with only about 3% discontinuing the therapy. In real-world practice, how manageable are the side effects and what monitoring do you put in place, for example, around growth, kidney stones, or bone health? Priyamvada Tatachar, MBBS, MD: It's a great question. Initial side effects are common, especially when we are starting the diet, depending also on the age and the pre-morbid condition of the patient. We tend to do it as an inpatient setting. For that reason, it also provides us a time and opportunity to educate the caregivers. Most commonly when we start, there is something known as the keto flu, which is a fatigue that sets in because the brain is adjusting to the alternative source of nutrition. Gastrointestinal side effects are quite common, but they are quite manageable as well. Constipation being the most common side effect of the ketogenic diet, and we use osmotic laxatives, for example, to tackle that. Improving hydration is very important as well. Now, we also have to provide education about sick days and illnesses and how to combat these illnesses, while on the ketogenic diet for the family so that they can adequately manage and not have adverse side effects from that. Now, the long-term management and it's important to pay attention to kidney health and prompt supplementation. For example, with citrate salts, potassium citrate has been known to reduce renal stones. Surveillance is important, so we usually have labs done on these families. We also monitor fasting lipid profile as well as bone health like calcium and vitamin D and offer supplementation for trace minerals which may become deficient. For example, selenium and zinc and acetylcarnitine, for instance. These parameters are important to manage as we continue to monitor and surveil the child. It's very important also to make sure that the calorie intake is adequate for the growth of the child, and we plot their growth in an ongoing basis. For this reason, management of kids with developmental and epileptic encephalopathy is crucial in a multidisciplinary care setting, and this helps in providing a comprehensive care for that child. Host: Wonderful. Dr. Phitsanuwong, the study could not identify any predictor of who responds to the diet. You raise a very interesting idea of a biomarker to guide therapy selection. How close are we to that, and what would it change? Chalongchai Phitsanuwong, MD: Yeah. Thank you for the question. This is great question. So far, we do not have clear definitive biomarkers to predict an individual patient's response to ketogenic diet therapy. In clinical practice, we still rely primarily on syndrome-specific data or the underlying etiology to guide our expectations rather than individualized testing. However, there's some interesting research looking into biochemical predictors of the response. For instance, there's a notable study by Dr. Natasha Schloeler from University College London and Great Ormond Street Hospital, published in Epilepsia, showed that the diet responder cohort has a significantly higher baseline acetylcarnitine level compared to the non-responder group. And upon their follow-up study, they found that the specific carnitine fractions show a trend. It's not statistically significant, but it show a positive trend as a positive predictor of ketogenic diet response. So, this is some signal in biochemical, study. I believe that if we can uncover reliable biomarkers, not just for the dietary therapy, but for other anti-seizure medications as well, it would completely transform our practice. It would allow clinicians to tailor the treatments to the individual patient right from day one, and finally moving us away from the trial and error approach, that it's a good educated guess what we do, but we have to admit on some level it's a trial and error approach. So, to have biomarkers would be an ideal. Host: Dr. Tatachar, for a general neurologist who does not run a dedicated ketogenic diet program, what is a realistic pathway to offer dietary therapy to a patient who might benefit? When to refer and what to set up locally? And is there a centralized database that provides information on which centers provide the ketogenic diet? Priyamvada Tatachar, MBBS, MD: Yes. Especially in the last few years, there has been robust research on the ketogenic diet, notably for weight loss, but this has helped because this has brought a lot of keto-friendly food into the consumer space as well. Understanding the concepts in dietary therapy initiation by using verified online resources that are available and enlisting a keto dietician would be the first steps for a clinician who's interested in setting up a diet clinic. In addition, there is the International Neurological Ketogenic Diet Society. Now, this society has webinars and symposia for those wanting to specialize in dietary therapies. In the United States, the Charlie Foundation for Ketogenic Diet and, in the UK, the Matthew's Friends Foundation, they have a keto college impact symposium that will help initiate people for the ketogenic diet program. And then, they can go back and set it up in their respective clinical practice. The Charlie Foundation actually has a list of all the ketogenic diet clinics in the US. And internationally, the International League Against Epilepsy, the ILAE, has a website for all the regional clinics listed around the world as well. Now, every state has a verified center and a provider who feels that patients may benefit from the diet. It should be able to look that up and then refer patients to that center. And I think, as Dr. Phitsanuwong can attest, it is a very close-knit community. And they're always willing to help new patients or set up new programs, and they're always willing to offer assistance to any new clinician that's interested Host: Thank you. Dr. Phitsanuwong, to close, you suggest combining modalities, diet with surgery or diet with neurostimulation. Where do you see the treatment of DEEs heading over the next few years? And what is the one message you would want a clinician or a parent to take from this discussion? Chalongchai Phitsanuwong, MD: I personally see that the treatment of DEEs are gearing toward more and more etiologically and genetically specific therapies. With the emergence of gene editing or replacement therapy, the RNA-based antisense oligonucleotides and novel small molecules for specific genetic epilepsies. The pipeline is incredibly active and highly exciting right now. However, because DEEs are extraordinarily heterogeneous and driven by a vast variety of etiologies, it is unlikely that we will have a specific disease-modifying therapy for every single one of them in the near future. And because of that, I still personally believe that ketogenic diet therapies would remain a highly attractive option because they offer proven efficacy in the seizure control. They can promote development and cognitive abilities, and also provide a variety of the diet types that we can tailor toward the individual patient's circumstances and needs. If there is one message that I could leave it to other peers and the patients, it would be I would humbly but strongly encourage other peer neurologists and patients and families to employ the dietary therapy sooner rather than later for the patients with developmental and epileptic encephalopathies before the developmental regression or stagnation would become apparent. Host: Thank you both for such a clear and practical discussion. Today, we heard that for children with developmental and epileptic encephalopathies, the ketogenic diet is more than a last resort. In this study, it roughly doubled the seizure-free rate compared with medication adjustment alone, improved EEG findings and, importantly, was linked to better developmental progress, all with side effects that were largely mild and manageable. For clinicians listening, perhaps the takeaway is this: when a child with a DEE isn't responding to medications, dietary therapy deserves a seat at the table early, not after every other option is exhausted when development has already suffered. And for families, it's a reminder that meaningful options exist and that the right team can make this therapy feasible. Special thanks to our sponsor, UCB. For over three decades, UCB has been committed to people living with epilepsy and their families by leading in research, development, and treatment innovation. Past breakthroughs are only a prologue to the future as UCB reimagines how they care for patients and their families. Learn more at <a href= "https://www.ucbcompass.com">ucbcompass.com</a>. If you found value in this episode, share with a colleague, a trainee, or a family who might benefit from this conversation. And as always, subscribe and follow Epilepsy Currents on your favorite podcast app for insights that bridge research and real life. You can also find us on epilepsycurrents.org. Until next time, take care and keep the dialogue going.

April 9, 2026

Epilepsy Currents - Episode 11 -"TRADEOFFS: What Are Patient-Reported Outcome Measures Missing?"

Join Dr. Bermeo in a conversation with Dr. Danielle Becker, Dr. Jacqueline French and Dr. Ammar Kheder as they discuss the article, "TRADEOFFS: What Are Patient-Reported Outcome Measures Missing?" Click <a href= "https://journals.sagepub.com/doi/full/10.1177/15357597251386804?_gl=1*1bn829z*_up*MQ..*_ga*MTgzNzA3MzY0NC4xNzY3ODIwOTg5*_ga_60R758KFDG*czE3Njc4MjA5ODgkbzEkZzAkdDE3Njc4MjA5ODgkajYwJGwwJGg3Nzg1NjM0NjE"> here</a> to read the article. This podcast was sponsored by <a href= "https://www.ucbcompass.com">UCB</a>. <img src= "//assets.libsyn.com/show/412622/UCB_logo.png" alt="" width="336" height="108" /> We'd like to acknowledge Epilepsy Currents podcast editor Dr. Adriana Bermeo-Ovalle, contributing editor Dr. Rohit Marawar, and the team at Sage. <hr /> The episode focuses on epilepsy outcomes that matter beyond seizure counts alone, using two 2025 papers and a related commentary to rethink how success should be measured in epilepsy care. Validation of the Seizure-Related Impact Assessment Scale by Dr. French and authors introduces a brief patient-reported tool that captures how many days are lost to seizures and how many are lost to treatment side effects. More Than Seizure Control: Multi-Dimensional Outcome Reporting in Epilepsy (MORE) as a patient-centered framework, redefining success in treatment by Dr. Kheder proposes a broader framework that combines seizure control, quality of life, and the patient's own experience of treatment. The commentary by Dr. Becker, TRADE-OFFS: What Are Patient-Reported Outcome Measures Missing?, ties these ideas together by emphasizing that better seizure control is not always a true success if it comes with worse cognition, mood, fatigue, or day-to-day functioning. The overall message is that epilepsy treatment should be judged not only by fewer seizures, but by whether life is actually better. Key Takeaways <ol start="1" type="1"> <li class="MsoNormal" style= "line-height: normal; font-size: 12pt;"> Seizure counts alone do not capture treatment success Across the discussion, a major point was that patients often care just as much, or more, about cognition, mood, side effects, independence, work, driving, and daily function as they do about seizure frequency.</li> <li class="MsoNormal" style= "line-height: normal; font-size: 12pt;"> SERIAS measures the real-life impact of seizures and side effects Validation of the Seizure-Related Impact Assessment Scale highlights a simple tool that asks how many days, or parts of days, were disrupted by seizures and separately by treatment-related adverse effects. This helps clinicians see the net impact of treatment rather than focusing only on seizure reduction.</li> <li class="MsoNormal" style= "line-height: normal; font-size: 12pt;"> MORE broadens outcome measurement beyond seizure control More Than Seizure Control: Multi-Dimensional Outcome Reporting in Epilepsy (MORE) as a patient-centered framework, redefining success in treatment proposes a structured way to combine seizure control, quality of life, and patient experience, so that meaningful improvement is recognized even when seizure reduction is modest.</li> <li class="MsoNormal" style= "line-height: normal; font-size: 12pt;"> The commentary frames these issues as trade-offs TRADE-OFFS: What Are Patient-Reported Outcome Measures Missing? emphasizes that every treatment decision should consider what is gained and what is lost. A patient may have fewer seizures but worse fatigue, worse memory, heavier medication burden, or new social and functional problems.</li> <li class="MsoNormal" style= "line-height: normal; font-size: 12pt;"> These approaches could improve both clinic care and research trials The discussion suggests that tools like SERIAS and frameworks like MORE could help with medication decisions, surgical counseling, neuromodulation follow-up, and clinical trials by capturing outcomes that matter most to patients in everyday life.</li> </ol> <hr /> Adriana Bermeo-Ovalle, MD (Host): What if the most difficult part of living with epilepsy is not the seizures? Most people living with epilepsy report being more burdened by stigma, social limitations, and psychiatric comorbidities than by seizures themselves. So, the real question becomes: how do we measure the impact of epilepsy and the success of our treatments beyond side effects and seizure counts? UCB is the proud sponsor of Episode 11 of Epilepsy Currents Podcast. I am the senior podcast editor for Epilepsy Currents, the official journal of the American Epilepsy Society. Today, we will be discussing the epilepsy outcomes beyond seizures with a phenomenal panel of speakers. Let me first introduce our own Epilepsy Currents contributing editor, Dr. Danielle Becker, who's a recurrent guest in our Epilepsy Currents podcast. Dr. Becker wrote a commentary titled TRADE-OFFS: What Are Patient‑Reported Outcome Measures Missing? This commentary was published in October 2025. Dr. Becker, welcome back. Danielle Becker, MD, MS: Thank you so much for having me. Host: It is also my pleasure to welcome Dr. Jackie French, senior author of one of the studies which inspired that commentary published in Neurology in August 2025, titled Validation of the Seizure-Related Impact Assessment Scale. Dr. French is Professor of Neurology in the Comprehensive Epilepsy Center at NYU Grossman School of Medicine and Founder and Director of the Epilepsy Study Consortium and leader of multiple initiatives in our epilepsy community. Dr. French, welcome. It is a pleasure to have you. Jacqueline French, MD: It's great to be here. Thanks a lot for inviting me. Host: And last but not least, I am very happy to introduce Dr. Ammar Kheder, who wrote a second paper referenced also in Dr. Becker's commentary titled More Than Seizure Control: Multi-Dimensional Outcome Reporting in Epilepsy (MORE) as a patient-centered framework, redefining success in treatment. This article was published in epilepsy in March 2025. Dr. Kheder is Associate Professor at Emory University and Assistant Medical Director for Epilepsy and Neurodiagnostics at WellStar Health Systems in Georgia. Welcome, Dr. Kheder. Ammar Kheder, MD: Thank you so much for having me. It's a pleasure to be here with you today. Host: Okay. So, let's get started. Dr. Becker, how would you describe the current state of patient-reported outcomes in epilepsy? What are we still missing? What are we not capturing? Danielle Becker, MD, MS: Thank you for this important question. I feel the current state focuses on seizure frequency and seizure freedom, but we need to acknowledge that seizure freedom may not be the number one goal of our patients or the only thing that matters. And the other question is at what costs. So, there are other important factors: cognition, memory, mood, side effects, quality of life. And when you talk to patients, they often will focus on functional outcomes such as driving and employment and their independence. But they will also talk about the treatment-related adverse events and the unpredictability of seizures and how that individually affects their everyday lives. So as was mentioned in the two reporting outcome papers that we'll talk about today, they call for the incorporation of individual priorities for patients' subjective experiences really to promote that patient-centered care and improvement in outcomes not only looking at seizure frequency or seizure freedom, but also at that balance or tradeoff of treatment-related adverse events. So ultimately, with where we are today, I think we need to refocus our epilepsy care on considering outcomes that are most important to each individual patient and their families, and really move to that patient-centered care of the goals that are most important to them, as well as their seizure frequency and seizure freedom possibility. Host: Thank you for that, Dr. Becker. Very important to keep in mind what matters to each patient, what maybe to ask our patients, what really matters to you on an individualized basis. Dr. Kheder, can you please give us a quick overview of what MORE is and what it was designed to measure? And how do you envision people to use it? Ammar Kheder, MD: Well, thank you for this question. MORE is a way for capturing what doing well in epilepsy actually means in real life. I see it as a complementary to what Dr. French has done in making impact visible over time, and to the questions Dr. Becker raises about what current outcomes don't fully capture when taken individually. So instead of focusing only on seizures, MORE brings together three domains: seizure control, quality of life, and the patient's own experience. The idea in my mind is simple, a treatment isn't necessarily successful unless it improves how someone lives, not just how often they have seizures. For example, if you have two patients who might have the same seizure reduction, but one has gone back to work and reduced medication while the other is cognitively worse and more depressed, MORE is designed to see that difference. It's meant to be practical using structured questions that can fit into a routine clinic visit. It's less about replacing existing systems and more about bringing together dimensions that have often been measured separately. Host: Very interesting. I'm sure we will go over how to integrate that into the clinic and what we do on a practical basis every day. Dr. French, can I ask you the same questions for the SERIAS approach? Can you give us a high-level overview of how does it measure and what does it add compared to our tracking of traditional outcomes? Jacqueline French, MD: Absolutely. So, unlike the MORE, it really squarely focuses on whether your treatment, whatever it is, has made a positive or negative impact on an individual's life. So, it doesn't measure everything that's important to a person with epilepsy. It really focuses on has the intervention improved seizures and has the intervention, on the other hand, caused a disability because of the side effects that now have arisen? Because often when you look at outcomes from interventions, you say, "Oh, X percent of the population had a 50% reduction or a 75% reduction in seizures. And y percent had side effects or had to drop out because of side effects," but you don't know how those two interconnect with each other. So, you don't know whether there are people who are very happy having fewer seizures and no side effects, or did everybody who got improvement in seizures have side effects. And also, the other principle of the SERIAS is to keep it simple. So, it's just a series of five questions, and it really asks about ability, disability in regards to seizures and side effects. So, how many days or portions of days were you unable to do what you wanted to do because of seizures, and then independently because of the side effects of the medication, to see what those trade-offs are. And the other thing that it brings to the table is that it does not only focus on the number of seizures, but the impact of the seizures. So, many of my patients tell me, "I have a seizure in the morning. And as a result of that seizure, I am dysfunctional, not only for the day that the seizure happened, but I don't really get back to my normal function until three days later for a serious seizure." And we wanted to be able to capture that if that is occurring, and that's very important to patients as well. Host: Sure. We get a better idea of what is beyond a number of seizure, right, or a percentage of seizure. I do think the same, Dr. Kheder, we got a better idea of what doing well with epilepsy goes beyond that. But, if you don't mind, can you give us a more detailed overview of what this 40‑40‑20 split across the seizure control, quality of life, and patient experience? And why did you decide over this split? How did you and your team decide to go over a split like this and to use that as a scale or a split in the MORE scale? Ammar Kheder, MD: Thank you. Yeah. It wasn't meant to be mathematically exact. In a way, it was more meant to be clinically honest. Seizure control still anchors epilepsy care, so it carries weight. But quality of life deserves equal importance because it often determines whether a treatment actually helps the person sitting in front of us. The final piece is the patient's own experience, how they feel about the outcome, whether they'd recommend the treatment or choose it again. So, the 40-40-20 structure really reflects the balance, correcting the historical emphasis on seizures without dismissing them. For instance, a patient might have only moderate seizure reduction, but a big improvement in mood, daily function, medication burden. In MORE, that can still score as meaningful success. It's in some ways a starting point and something can evolve as we learn from patients and also from tools like the SERIAS. Host: Thank you. Dr. French, you gave us an idea of how do we use the days of impact and the time loss. Can you tell us how do you use that to make decisions in the clinic? Because you can get this approach, but as Dr. Becker was telling us, it can mean different things for different patients, meaning for some people, you know, a different side effect may be okay to withstand, versus for another one, this can be really not something they can live with. So, can you help us understand that approach and how do you use that maybe to make decisions or to help patients make decisions in the clinic? Jacqueline French, MD: By the way, I just wanted to point out that the SERIAS is based entirely on another scale in the neurology community called the MIDAS, the Migraine Disability Assessment Scale. And I think that the reason that the MIDAS has become a staple in the headache and migraine world, is because also having a headache can have many consequences and can cause disability that far outlasts just the onset of the headache or the type of headache can really be different from one to another. And the purpose of the scale, the MIDAS scale, has gone to the point where, for example, there are many MIDAS scales that are available online to tell people what their level of disability is. And if you find that many of the days of the month are disabling or the headache is disabling, then actually that—when presented to a physician—can open the door to a higher level of care. So, it's not only saying, "This is how you were last month. This is how you are this month." But if you see that a high proportion of days for an individual are impacted by their epilepsy, then hopefully physicians will say, "This person needs to be sent for a higher level of care. This person should have access to an epilepsy center, epilepsy surgery, the more expensive medications in some cases." So, it can be used in that way as well. But I think very importantly in the clinic, and I'm very happy to say that many people have already reached out to us to acquire the scale to be used in clinic so that we can learn more about how it helps or how it doesn't help and how it really measures things. So, I'm really interested to see what happens in those regards. But I think that if you have someone back to the clinic and you look and you see that, since you made this change in medication, they have marked many days as being disabled by side effects, that will focus your attention on that, and you will start asking questions of that individual in regards to what the side effects are and how they are impacting their ability to function. And I did also want to mention that there's two versions of the SERIAS, and people can choose whichever one they want. One is to just verbally say how many days or portions of days, and people can fill it in. But another one, which some people find easier is the traffic light version in which people just are presented with a traffic light with a green light, meaning everything's fine for the day; a yellow light, meaning things were not as they should have been, but I was able to perform some functions; and a red light, which means that day was basically lost to me. And I think that that really resonates with people, including parents. I've heard this a lot from parents whose children have, for example, a developmental and epileptic encephalopathy. And they put it in terms of good days and bad days. There are good days and bad days and very bad days. And if that day, the child had a series of seizures in the morning and they spent the entire day in the emergency room, that is a lost day, that's a red day, for example. You don't have to be seizing throughout the entire day for it to be a red day. And you basically can ask someone how many of your days this month were red, yellow, and green. And for some people, that is a very simple and straightforward concept, and they are able to recall over the course of the month and give you an idea of how many days they were functioning well. And by the way, when we assessed the scale with Dr. Emma Foster in Melbourne, many, many people with epilepsy had mostly functional days. So if you do see someone where a lot of days are dysfunctional, that is not typical for a person with epilepsy. And I just want people to be aware of that. Host: Yes, absolutely. Dr. Becker, I really like how you place this under the title of trade-offs. Like, what do we exchange for what, right? So, in real life, what are we trading for what? What examples do you find in your clinic? And how can clinicians talk about this in a way that is helpful? What kind of clinical pearls or real life scenarios come to mind? Or can clinicians talk about this? What can we learn from this? Or what do you want our listeners to remember from your commentary? Danielle Becker, MD, MS: So, I think I like the word tradeoff because it's catchy, but it's also honest. It's what we need to be thinking about when we're talking to our patients. Seizure control at what cost? And the tradeoff is really seizure control versus the treatment-related adverse effects, especially someone who may have a seizure once a month, but has adverse effects from their anti-seizure medications every single day. And I love the way Dr. French talked about green, yellow, red type of day. It may be that there's a day that they don't have any seizures, but it's a yellow or red day because of the side effects that they're having from their medications. And the SERIAS paper also looks at disability and what the term disability means for the patients. Also, did the disability result from the seizures or from the treatment themselves? And so, that's really what I wanted people to think about, because it's very impactful to a patient's quality of life. And we might make what we feel is an important modification to a treatment regimen that improves the patient's seizure control, but at what expense? So if we increase a medication and their seizures are reduced by half, but their tiredness is hugely increased to the point where they may not be able to function, they may not be able to go to work, that is negatively impacting their quality of life, even though their seizures have improved. And in the SERIAS paper, they also talk about time lost. And we often think of time lost as the seizure, right? How long did you have altered awareness or altered consciousness during the seizure, but it's also time lost of when you could enjoy time with your family, your loved ones, feel fully functional at work. And so, some examples that I feel like—besides the one I just mentioned about tiredness—is also when we think about seizure freedom, right? We do this huge surgical workup and we do neuropsychological evaluations, and we're trying to predict what is the impact on their quality of life, what's the impact on their memory, on their cognition. And even if someone becomes seizure-free, if their memory or cognition is impacted to the point that they can no longer work, how will they rate their quality of life? Was that tradeoff worth it? And that's something that we can't necessarily say as providers, but patients—they are the ones that are individually living this every single day, and they are the ones that need to be involved in this conversation. And then, one other example, I think of another patient that I sent for surgery and she became seizure-free. She had a right temporal lobectomy, but she could no longer read social cues as well, especially from her husband. And it actually created a lot of stress in the relationship, which was something that we sometimes don't know. But the point is that it's more than just seizure frequency. It's more than just seizure freedom. Each individual patient has their own goals, and we need to be addressing them and finding out what impacts their everyday lives. Host: Yeah. That is such an important point. And the reality is that sometimes with surgery, there's so many unintended consequences, some that we really cannot truly foresee. That is a very good segue to my next question. I would like to ask Dr. Kheder, how do you see that we can use this type of beyond seizure outcomes, and these type of conversations when we talk about surgery and neuromodulation? Have you used the MORE scale or how do you think we can use these type of scales beyond pharmacological interventions? Ammar Kheder, MD: Yeah. I think this is a great question. And in fact, the way the concept of MORE was developed, in some ways, started out with trying to capture some of the gaps in our current systems where we don't really capture harm very well. So in some of those surgical patients, for example, a patient can be seizure-free, but worse overall. And we have no structured way to reflect that. The MORE allows that to be somewhat visible by allowing the negative score when things such as cognition, mood, or function decline or side effect perhaps are severe. So, more specifically about conversations related to surgery or neuromodulation, that matters. Because we're not just asking will the seizures improve, but also what is the overall trajectory likely to be? For example, if a patient has corpus callosotomy and seizures are reduced to some extent, but it causes major cognitive and functional decline, the MORE score can actually fall into a negative territory, which communicates that the net impact is potentially harmful. In some ways, as we discussed trade-offs, it helps make these trade-offs more explicit and more honest, especially in situations where the surgical decision is somewhat not straightforward. So, I think that's perhaps one advantage with using something like the MORE scale. Host: Thank you. Dr. French, how about in medication trials in which we are sometimes just so focused on seizure counts and seizure reduction? Should we use more non-seizure outcomes, and how to integrate that into medication trials? Jacqueline French, MD: Yeah, I think that for trials, the SERIAS has a couple of benefits that we are very significantly working on. The first is that for many of the developmental and epileptic encephalopathies, the seizures are so rapid and so brief, and they come in clusters that they actually we consider them uncountable. We can't count the atypical absences, the myoclonic clusters. I usually represent this by talking about if seizures were birds and we were asking parents to count every single bird that flies over their head every day, obviously, it would be an impossible task. But if you see a flock of birds, a large flock of birds flying over, it's basically impossible to figure out how many birds are in that flock. But if you ask a question such as, "Did you see a lot of birds today? Did you see not that many or none at all?" That's a much easier question to answer. So in fact, in studies of developmental and epileptic encephalopathies, several people are now using a daily SERIAS, so a daily traffic light of red, yellow, and green, to get a sense of how the other seizures are impacting. And also, again, back to the consequences of seizures, there have been so many attempts to do seizure severity scales to put into clinical trials. And unfortunately, they become very long, very complex. Sometimes some of the scales take up to an hour to complete, an hour of both the patient and the caregiver and observer and a coordinator. So, we needed an easier way—a simpler and easier way—to try and address whether seizures are not only becoming less frequent, but also becoming less impactful. And again, it all comes back to impact on the individual. And finally, to your point, I think that taking into account, as Dr. Becker said, the tradeoff of, yes, your seizures went down, but have you now lost the ability to function, have you lost function because of significant side effects, and do it within an individual rather than within the entire population so you can see those trade-offs, whether people actually have more functional days overall or less functional days overall after the treatment has been initiated will be very insightful when looking at the results of clinical trials. Host: Great. I have one more question for all of you before we finish our podcast today. If we can close with one practical message for clinicians as they are with the patients in the clinic to consider different outcomes, Dr. Becker, what would be one practical message for clinicians to do better in regard to non-seizure outcomes? Danielle Becker, MD, MS: So, one thing I would want to bring up is drug load. We didn't talk that much about that, but we talked about treatment-related adverse events. And a lot of that is from our anti-seizure medications. And so, how does drug load or the number of medications they're on, or the doses that they're on, how does that affect our patients' everyday functioning? And it's important to think about this outside of surgery and also post-surgery or post-neuromodulation, to remember that if we add a medication on that helps someone with better seizure control or better seizure frequency, don't forget about the other comorbidities that can develop and impact them every day. And so, think about reducing those medications. If you've added a medication or if they've had a surgery or had a neuromodulation device that improves their seizure frequency, don't forget about the other piece of the picture: At what cost? What changed? And if there were comorbidities that worsened that you need to address those just as much as the seizure frequency or potential for seizure freedom. Host: That's a great clinical pearl. Dr. Kheder, what is your take-home message for our listeners today? What can we do better? Ammar Kheder, MD: I think for me the simplest shift is really to ask one extra question at every visit. Are you actually doing better, not just in terms of seizures, but in terms of how are you living? Can you drive? Can you go to work? Can you go to school? Can you get on a public transport? Are you able to think clearly? Do you feel emotionally stable day to day? If we consistently ask that and take it seriously, our care starts to change. What I like about SERIAS and what Dr. Becker's focus on trade-offs is that they push us in the same direction where we align how we measure outcomes with how patient actually experienced epilepsy. Host: That is another wonderful message for our listeners today. Dr. French, any other pearls that come to mind? Jacqueline French, MD: Yeah. I cannot help but remember a patient of mine who, when he came into the office after a medication change, and I said, "How are things going? My seizures are great. I'm seizure-free. I haven't had any seizures." Are you tired during the day? "No, I'm not tired during the day." And finally, I hit on the correct question only after asking many questions, and that is, "And how is your sleep?" And it turned out that he was sleeping not his usual eight hours a night, but now was requiring 12 hours a night of sleep. And if any of us can imagine life, if we needed 12 hours a night of sleep, that doesn't—you know, he was actually an attorney, which doesn't give you much time to live any life other than working and sleeping. And you can go through many questions and not necessarily hit on the one that is the important one. So, this sort of allowing people to tell you, translating it all—as Dr. Becker said—into lost time, lost function sometimes helps start that conversation that ultimately gets to what's the most important thing that has changed for that particular individual. Host: Yes. Thank you for that. I have learned a lot. I think asking the right questions and sometimes patients want to please us, right? They want to tell us that they're doing great. Thank you all for a wonderful conversation. I want to thank you all for joining us today for this conversation at Epilepsy Currents podcast. And I also want to thank you all our listeners. Special thanks to our sponsor, UCB. UCB, for over three decades, has been committed to people living with epilepsy and their families by leading in research development and treatment innovation. Past breakthroughs are only a prologue to the future as UCB reimagines how we can care for patients and their families. To learn more, go to <a href= "https://www.ucbcompass.com">www.ucbcompass.com</a>. Thanks to Dr. Rohit Marawar and the SAGE Podcast Production Team. We look forward to having you join our next podcast episode. Remember to subscribe to Epilepsy Currents Podcast wherever you get your podcast, and send us your feedback, suggestions, or questions through our website, epilepsycurrents.org, and follow us on X former Twitter @aescurrents. See you next time.

July 29, 2025

Epilepsy Currents - Episode 10 -"The Stigmatizing Impact of Perceived Epilepsy Stigma"

Join Dr. Marawar in a conversation with Dr. Danielle Becker and Dr. Martha Sajatovic, as they discuss the article, "The Stigmatizing Impact of Perceived Epilepsy Stigma" Click <a href= "https://journals.sagepub.com/doi/10.1177/15357597251325682">here </a>to read the article. This podcast was sponsored by the <a href= "https://www.aesnet.org/">American Epilepsy Society</a> through a grant from the Centers for Disease Control (CDC). This activity is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,500,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government. <img src= 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width="467" height="204" /> We’d like to acknowledge Epilepsy Currents podcast editor Dr. Adriana Bermeo-Ovalle, contributing editor Dr. Rohit Marawar, and the team at Sage. <hr /> Summary In a baseline analysis from the CDC-funded SMART self-management trial, Dr. Martha Sajatovic’s team evaluated 120 adults with uncontrolled epilepsy using the 10-item Epilepsy Stigma Scale. Higher perceived stigma was not tied to seizure frequency or most demographics; instead it clustered around a short list of modifiable factors: being single, receiving little social support, scoring low on the Epilepsy Self-Efficacy Scale, and reporting poorer day-to-day functioning. Dr. Danielle Becker’s accompanying commentary argues that these “big three” drivers—self-efficacy, social isolation, and depression—form a hidden clinical burden as real as any EEG abnormality and should be addressed as routine vitals in epilepsy care. Both authors highlight peer-led programs such as SMART, which blend nurse facilitation with a trained person-with-epilepsy co-leader, as a scalable way to lift self-confidence, expand support networks, and ultimately blunt stigma’s impact. Key Takeaways <ol> <li>Core Correlates of Stigma: In the SMART cohort, the strongest independent predictors of high stigma scores were low social support, low self-efficacy, and poorer functional status; seizure count and most demographic variables showed no significant link.</li> <li>Self-Efficacy Is Central—and Modifiable: Lower confidence in managing seizures (self-efficacy) tracked closely with higher stigma. Boosting patients’ belief that they can control triggers, medications, and disclosure decisions is a direct route to stigma reduction.</li> <li>Depression Magnifies Stigma’s Weight: Undiagnosed or undertreated depression deepens perceived stigma and worsens quality-of-life scores, underscoring the need for systematic mood screening and at least initial SSRI therapy while specialty referrals are arranged.</li> <li>Peer-Led Self-Management Programs Work: Evidence-based curricula such as SMART (eight weekly Zoom sessions co-led by a nurse and a trained person with epilepsy) consistently raise self-efficacy scores, increase rescue-plan use, and shrink stigma—benefits that persist when agencies or clinics adopt the program.</li> <li>Clinic & Policy Action Points: Ask about stigma, self-efficacy, and mood at every visit; offer a printed or electronic referral to a vetted self-management course or local support group; and advocate for payer coverage of these programs so that addressing stigma becomes as routine—and reimbursed—as ordering an MRI.</li> </ol> <hr /> Dr Rohit Marawar (Host): [00:00:00] Picture this scenario. Two patients leave clinic on the same day. One with excellent seizure control, yet feeling ashamed to mention their diagnosis. The other with daily seizures, but surrounded by supportive friends who see them not their epilepsy. Those contrasting stories sit at the heart of today's conversation about stigma and invisible force as real as any spike and view on an EEG. Welcome to Epilepsy Currents podcast, the podcast for Epilepsy Currents Journal, exploring the latest research and expert commentaries from the world of epilepsy. I'm your host and associate editor for the podcast, Rohit Marwar. To unpack why stigma still sticks, and more importantly, what we can do about it. We are joined by two leading voices. First is Dr. Martha Stoic, first author of the article, clinical Correlates of Perceived Stigma Among People Living With Epilepsy, enrolled in a Self-Management Clinical Trial. Published in Epilepsy and Behavior Journal in [00:01:00] 2024. She's a professor and director of the Neurological and Behavioral Outcome Center, university Hospitals, Cleveland Medical Center in Cleveland, Ohio. Welcome Dr. Wick. Dr Martha Sajatovic: Thank you. Dr Rohit Marawar (Host): Then we have Dr. Daniel Baker, whose commentary, the stigmatizing impact of perceived epilepsy stigma. Puts those findings in a broader public health frame. Dr. Becker is the division director of epilepsy and associate professor of neurology at the Ohio State University Wexner Medical Center. Welcome, Dr. Becker. Dr Danielle Becker: Thank you for having me. Dr Rohit Marawar (Host): Great to have both of you on our podcast today. Let's dive in. To kick things off, Could you give us a quick elevator pitch of your study, who you enrolled, what you measure, and the takeaway finding our listeners should remember? Dr Martha Sajatovic: Yes. Thank you. I'm happy to talk about that. So, this analysis comes from a larger parent study. That was funded by the Centers for Disease Control and Prevention, or CDC. we are part of a, network called the Managing [00:02:00] Epilepsy Well or MU Network, which has been supported by the CDC for many years. The goal of the MU network is to develop, and test, evidence-based epileptic self-management. Curricular programs. This, analysis came from one of our randomized clinical trials that we are doing, testing a program called the Smart Epilepsy Self-Management, program. In this analysis, we focused just on baseline data. So we weren't looking at outcomes, but we were interested in looking at the correlations or the associations between, perceived stigma. So stigma that people, perceive people with epilepsy perceive in relation to demographic and other, clinical variables. So, basically we found that, stigma was related to, not very many demographic variables, really just, not being married or, cohabiting, but we did find that, higher levels of stigma were associated with. Less social support. So I was thinking of that in the little scenario that you gave, lower, scores [00:03:00] on a standardized rating of self-efficacy and lower functioning as well. So, there's appears to be that inverse, relationship. Dr Rohit Marawar (Host): Dr. Becker, you call stigma a hidden burden in your commentary from your vantage point, what does the burden look like in the everyday lives of people living with epilepsy in 2025? Dr Danielle Becker: Thank you. So I do wanna say that I think this hidden burden is not only on our patients, but also on the caregivers. Both the patients and the caregivers live with fear that a event or a seizure can happen at any time, and we know that that's associated with significant emotional burden. This emotional burden leads to both mental and physical health. It leads to anxiety and depression. We also know that it affects opportunities for patients with employment, with education, with developing social relationships. So in all we know that it, really is impacting mental health and we really, through this commentary and through Martha's. Paper and [00:04:00] work with the smart program. We know that when you have depression, especially undiagnosed depression, it worsens stigma and really that is a heavy burden on our patients and caregivers. Dr Rohit Marawar (Host): Well said, Dr. Vic. We hear the terms stigma and perceived stigma to. Around, and I think you also mentioned that just now, but how do you separate the two and why did you land on the 10 item epilepsy stigma scale? To capture it, Dr Martha Sajatovic: so that's a really excellent question. There are actually different types of stigma. if you look at the stigma literature, so there's, felt stigma, you know, if I am going to discriminate against you, sometimes called proceed stigma. there's, what we. As individuals get from our society or from those who are close to us, how do we get treated or discriminated against? there's also a, internalized stigma. Where were people? you know, if you tell something to somebody often enough that's negative [00:05:00] about themselves, often, eventually they will start to believe that. So what we are really looking at is a standardized scale. So there aren't actually that many specific, epilepsy stigma scales around. Rather, this was one that had already been tested and used, and we, thought would be generalizable to, the other literature. So what do people with epilepsy experience and what do they perceive? Dr Rohit Marawar (Host): Okay, great. and I'll stay with you Dr. So. We have moved away from the term epileptic people to the more app appropriate term persons with epilepsy or people with epilepsy. I noticed that you use the term people living with epilepsy in this study, which was a first for me. Why did you use that term, and why is that wording choice important in the fight against stigma? I. Dr Martha Sajatovic: Thank you for noticing that and appreciate that. so the goal here is that we really want to have the language that we are using be very person centered, right? in the smart program, which we'll probably talk about in a, couple [00:06:00] minutes, but, we really stress the. The point that you are a person that's living with epilepsy, you are not epilepsy. And epilepsy may impact your life in substantial ways often, but you are still an individual. You have stresses, you have joys. and so really anything that helps reinforce that, you are not this disease. Your person living with epilepsy is, extremely important. And over time, I think. Words matter. If we use words in ways that are appropriate and uplift people rather than grind them down, hopefully we can eventually win this battle against stigma. Dr Rohit Marawar (Host): Dr. Becker. thinking back to the 2012 Institute of Medicine call for action. Where have we moved the needle on epilepsy stigma and where are we still spinning our wheels? Dr Danielle Becker: So I think we've moved the needle as far as accreditation of different epilepsy centers as far as working with mental health providers and [00:07:00] primary care as far as the foundation work that we. Done support groups, resources with epilepsy foundation, epilepsy alliance, discussion about seizure action plans and seizure rescue medications, having more acceptable routes of administration. I think we've also done a great job in increasing awareness about sudden unexpected death in epilepsy and discussing it and acknowledging that people do wanna hear about it. I think where we still have a lot of work is still in awareness, especially workplace awareness. I have a patient right now who is fighting for her job and we filled out all the paperwork. She has a rescue plan, she has a nasal spray, and she was let go. And so I think as much as we try to increase awareness. What we really need to do is that people are still gonna have seizures and they're gonna be unpredictable, but give them something predictable to do in that unpredictable world. Help them have action plans, help their employers with [00:08:00] education and understanding, and try to help them have a life that they want. If it's that they wanna work, if it's that they want to be part of an organization, increase their. Resources, their support. And I think we are doing a good job, but there's still a lot that needs to be done. And while awareness and talking about that, one in 26 people have epilepsy, that does bring it to the table. But there's more that we have to do. The other thing that I think we are still spitting our wheels is access to care for all. We talk about the fact that there are patients in rural settings. There might only be one neurologist. There's patients that have refractory epilepsy and may not get evaluations of comprehensive epilepsy centers. We want to be able to improve access for all treatment for patients with epilepsy and all medications. Dr Rohit Marawar (Host): Dr. Vic, your data shows that lower self-efficacy [00:09:00] walks hand in hand with higher stigma in plain language. What is self-efficacy and why does it matter so much here? Dr Martha Sajatovic: Yeah, so self-efficacy is very important. We did see that self-efficacy popped in our multi-variate, models as being, highly relevant. to stigma. So, self-efficacy is a term that fits in with, a model of behavioral change. We use the social cognitive model in our, evidence-based epilepsy self-management programs. And just to kind of break it down, people have, they have to have several things that they need in order to make positive behavioral change. First of all, you have to have the knowledge. So, if I need to know what I should do and what I should try to avoid in managing my epilepsy. So I have, I mean, that's critical, but just giving people education is not enough. Right. That's why many times we as clinicians, you know, we give people, patient printed materials or we tell them to do this and that, and, somehow it just doesn't. Materialize. So it's that self-efficacy. So they have to have the knowledge, but then they need to have [00:10:00] the confidence and the motivation so that, that's just self-efficacy. I feel confident that if I make this behavioral change, that I will get the desired outcomes that I know what to do and I feel like I can do it. So that's self-efficacy and those are really critical. And one of the problems that we have in many clinical care settings is that. Clinicians are very busy. When we're in there seeing patients, we have to think about, how many seizures have you had, what it could look like, what were the precipitants? I have to look at perhaps medication changes or side effects or drug levels. Right? very often the thing that gets left. By default is, how confident do you feel in managing your epilepsy? But our data really highlights that. That's extremely important. It's a point the clinician should consider, but there are also other evidence-based practices that we can pull in to, identify, strengths or gaps and self-efficacy, and then downstream the [00:11:00] effects on epilepsy self-management. Dr Rohit Marawar (Host): Dr. Becker, if self-efficacy, social support, and depression are the big three drivers of perceived stigma, what practical high yield steps can busy clinicians take to hit each of those targets? Dr Danielle Becker: Well, for one, we know that depression is one of the most common mental health diagnosis in patients living with epilepsy. So first and foremost, screen for mood disorders. And not only screen for them, but I am an advocate of at least trying one medication, one SSRI. While we are putting in a referral to psychiatry, I, I do not under state or underestimate the complexity of treating depression, but I think in starting one medication while we're starting the pathway to get them to specialized psychiatry or psychological care. I also think encouraging supportive social relationships, support groups, and also as we're talking about today, educating and making people aware that there are epilepsy, self-management support [00:12:00] groups that are taught by peer educators that can also help and give resources. So ultimately, I think by improving education, communication and access to available resources, that helps address. Reduce the epilepsy related burden that ultimately we would be improving quality of life. Dr Rohit Marawar (Host): Dr. Vic, I would love your input also, if you could wave a magic wand and change one everyday habit in epilepsy clinics tomorrow. To lighten the stigma load. What would you pick and why? Dr Martha Sajatovic: my, first, choice would be to listen to Dr. Becker. That would be my first recommendation, but, I concur. epilepsy screening, and I would say, where we are not yet, so it is not a standard of care, but it should be, is that we should be able to provide evidence-based epilepsy, self-managed for everybody with epilepsy. So my vision is, similar to what we have in, diabetes care, right? If you're diagnosed with diabetes, you, they're certified diabetes educator and you have a [00:13:00] curriculum for diabetes education that is offered and paid for by health insurers. Everywhere in the US right? Almost everybody has access to that. So I believe we should have similar, again, this relates to Dr. Becker's access to care. Right? People should have the opportunity. I'm doing a, project now working with three epilepsy focused social service agencies where the agencies, have been trained to offer our self-management program. what they're telling me is that sometimes people actually have to be through the course and go through the curriculum several times. Right. So, this is all a practice, right? for most of us, We become what we practice and we have to continue to practice to continue to improve. So that would be my, magic wand wish is that people should have access to evidence-based epilepsy self-management programs. And there are a number of 'em that have been developed by the MU network. But right now, unfortunately, a standard of care is, I would say, in many clinics not access to any of [00:14:00] these evidence-based programs. Dr Rohit Marawar (Host): A lot of the self-management management programs come down to self-motivation. Also, even if we provide the information to the patient, there needs to be that self-motivation and how can we champion that? Dr Martha Sajatovic: So, this is where I think peer supports, and reinforcement are really important. I'm in involved in another project, another CDC funded project now. Dr. Mike Pri and Dr. Mark Gran, pri of the University of Cincinnati and Dr. Gran's from the University of Iowa. And what that project does is it filters the, electronic health record to identify people with epilepsy that might be candidates for self-management. And then, when the patient comes to the clinic. The clinician can say, oh, there's this program, I think you might benefit from this. Right? And the patient might say, oh, I'm busy, or, I got a lot in my life right now. But you know, it comes up again and again. Right? Because we, don't see our patients just one time. Usually we see [00:15:00] them multiple times. So it's really that opportunity, I would say, sometimes people need to hear something. Multiple times. Right. We know that when we watch, TV like commercials come on more than once. Right. And when you've heard it for the fifth or sixth or 10th time sometimes. Oh yeah. Okay. I'll, think about that. So I would say continue to reinforce it and, you know, your, your interaction is incredibly important to your patients living with epilepsy. They wanna hear from you about, do you recommend this? that will, I think, go a long way to increasing that motivation, increasing that, ability for to people to just give it a try. what I like to tell, people who are thinking about. Getting into a program is that I believe our self-management programs are kind of like an excellent piece of chocolate cake. Once you have that first bite, once you get into that group and you're there with eight or 10 other people and you're talking about the same shared concerns and overlapping problem problems, and [00:16:00] solutions, it's incredibly empowering. So it's really just hearing it again and again and continuing to offer that social support. Dr Rohit Marawar (Host): Dr. Becker kind of flipping the lens to patients themselves, and we kind of talked about it just now, what simple strategies can people living with epilepsy use day to day to push back against perceived stigma? Dr Danielle Becker: first and foremost, to be the driver of their own care and be their self-advocate. So Dr. Vic just talked about self-efficacy. Talk about self-efficacy with them and make them understand. Help them understand their active role in their disease journey, help them focus on what they've accomplished, help them focus on achievable goals. Bring it up. Focus on things beyond their seizures. I think when we, as providers ask how they're doing or how they're feeling or about their mood, they are willing to tell us. But if we don't ask, they don't know, and then they don't have the resources. So. [00:17:00] Resources are provided to encourage them to partake in those resources, to participate in support groups, to show them that there are virtual support groups if they can't drive or if it's not easy to get somewhere, help them understand the available resources with the epilepsy foundation in associations in their area. But really. Stress that there is social support, there are personal relationships, and we know that this together helps provide protection against the impact of stigma and chronic disease. So really showing them how to find the resources, how to access them and encourage them to access them. And even if they come back and say. No, I didn't do that because let's not forget, they also have depression too. And so depression can affect motivation as we talked about. And so you be their advocate as well. You be the one that checks in with them and asks them, and even if they said no in the past that we [00:18:00] shouldn't give up and continue to empower them to know that they do have the tools to get involved, which does help reduce depression and stigma. Dr Rohit Marawar (Host): Dr. Becker peer led programs like Smart Aim to boost self-efficacy and cut stigma. Uh. How can we as epileptologists or a typical epilepsy clinic, weave the core elements of these programs into routine care without overloading our healthcare providers? Dr Danielle Becker: The first step is to be aware of these programs. A lot of us have epic or medical records where we can make dot phrases that actually have a bulleted synopsis of what these self-management tool or programs are. Talk to your patients about it. We know our patients have poor memory. put that dot phrase in the patient instruction so that they can go home, they can talk to their families about it. It's not that hard for us to give the information. It's much harder to make sure that they follow up with the information. So set something up within your [00:19:00] program where you supply the information and then we have our nurses maybe check in to see if they actually enrolled. A lot of times what happens is, is that we will give the information and then we don't follow up, and so that actually can overload the staff because patients continue to have depression and. poor self-efficacy and stigma and they will call in more. But if we initially can help set up a support system and help them learn how to manage their epilepsy by just giving a little bit of information and a way to access this, it will over time reduce load on staff and improve the quality of life for our patients. I also, I think it's important to note that these are national virtual programs. So even just reaching out to Dr. Vic and seeing how to get the patient's access and then supplying either the patients with the ability to enroll [00:20:00] or if there's, a trial or something like that. making sure that the patient's willing to, and supplying their information, but basically being a partner with them to discover these different resources. Dr Rohit Marawar (Host): Dr. S looking ahead. What study design tweaks in future studies or research advances you would like to see that would move the field forward? Dr Martha Sajatovic: Yeah. Thank you for that. so. Currently we're in the process of, scaling up and testing and doing performance evaluation of smart being conducted within the clinical setting, using Epic. And, that is the health record that we're using to identify people. Community settings is another one, right? Social service agencies, who wanna become smart program or other evidence-based program adopters can. So, you know, there's more than one way to skin a cat. You could get through your healthcare system, you could get through the community. I think there's some, there are some other things that we're doing. So, we have a project now where we're tying. The smart program into, rescue medicine [00:21:00] prescribing, right? So people are prescribed, rescue medicine, but since those are self-administered meds, right, getting training and support and weaving that into the whole package of care, I think is something that, definitely needs to be investigated further. We hope to be able to move the ball down the field. I've got a project running now in Uganda, so, epilepsy. Stigma is alive and well, unfortunately, in the US it's alive, and well globally. it definitely takes different characteristics and looks a little different, across different cultures. So that's a another area that, is huge and needs to be addressed. and then there's another area that we, we are trying to get, support to do this, but I think it's really, really critical is. Currently our, program, the smart program, is, targeted to adults with epilepsy only. And I think where we really need to go next is looking at, adolescents and families. we do have caregivers and care partners that sit in on our epilepsy groups, our self-management groups. But, I think we [00:22:00] need to customize it a bit more for, younger people in their developmental stages and kind of working with their family. So I would say, stay tuned. I, hope that our team gets the opportunity to move forward. 'cause I think it's incredibly, important future need, current need that hopefully we can address in the future. Dr Rohit Marawar (Host): So we have mentioned the smart program many times. Dr. Vic, in this recording, can you touch on it a little bit like what it is exactly? Dr Martha Sajatovic: Yeah, yeah, yeah. I'm happy to, I'm happy to talk about the smart program till the cows come home. One of my favorite topics, but it is a remotely delivered, Program we do, we use Zoom or a similar type of video conferencing. what's unique about the program, it is as co-led by a nurse, doesn't have to be an epilepsy specialty nurse. As a matter of fact, I tend to look for nurses that really love education rather than, necessarily going, you know, they're not prescribing or going into the medical weeds very much. But also the secret sauce is a person living with Eoli who's been trained to deliver the program. So they co-lead it. Then you've usually got between six and [00:23:00] 10, people living with epilepsy in the group. They have eight sessions that last maybe 45 minutes to an hour. for about eight weeks. For eight weeks. sometimes we might skip a week or two if it's a holiday or our leaders, have some changes in their schedule. But generally, it's done in. About eight to 10 weeks. So it's a relatively brief intervention. There are some brief follow-up phone calls that the nurse does, but every, session has a very specific curriculum. There's handouts, there's worksheets. I get people that say, oh, I'm already part of a self-help group. I don't feel I need this. and what we really need to, qualify here is that this is vastly different from a self-help Groups very tightly structured. of homework. It is a commitment that somebody has to commit. We ask 'em to commit to eight hours of programming. but we tell them that we, can recommend very strongly that this will be worth your while. And if we listen to the testimonials that we've gotten from our participants, many of them, when they're done, they say, I [00:24:00] wanna be a, peer educator. How can I become a peer educator? And to me that's the strongest endorsement that this was a valuable experience for you. Dr Rohit Marawar (Host): Thank you. Sounds like a great program. Something I look forward to Recommending to my patients. Dr Martha Sajatovic: We, but also, just do wanna say that smart's not the only game in town. there are a number of really excellent evidence-based epilepsy, self-management programs, and I would say, getting your patient into one of these programs is, another way for you to advance their care. Dr Rohit Marawar (Host): Dr. Becker, we have the most challenging question for you. So imagine you've got five minutes with a health policy leader. What single policy change would you champion to shrink epilepsy stigma over the next five years? Dr Danielle Becker: So this is a very tough question, but given the focus of this podcast, for me, it would be funding the self-management. Resource showing support and increased improved access to self-management programs that we know focus on support, [00:25:00] but are led by other individuals that have epilepsy that have. An idea of, what the patient's going through different than their caregivers or their providers, and can help guide with resources with a set curriculum and to help reduce depression, improve self-efficacy, improve social support, improve quality of life. And then as Dr. Avi just said. there's many on the market, but these self-management programs not only teach someone how to manage their epilepsy, they can teach them how to manage the repercussions of the seizures, how to manage the changes in mood, and very importantly, as she just stated, how to manage. Seizure action plans and seizure rescue, right? All of these things lend into hand improving quality of life for our patients. I can't stress enough that epilepsy is not just about the [00:26:00] seizures. And when you look at core health related outcomes, the impact on patients' lives is just as debilitating, if not more debilitating than the seizures. So you, Mr. Congressman I ask that you help us provide financial support to continue this advocacy for our patients, for education, for support, and improve their quality of life. Dr Rohit Marawar (Host): Thank you for answering that, and thank you both for that thoughtful tour of the science and the human side of epilepsy stigma. Today we heard that self-efficacy can be coached, social support can be built, and depression can be found and treated. That each move chips away at stigma's power. For clinicians listening, maybe the takeaway is this. Think and ask about stigma. It's as clinically relevant as seizure count for people living with epilepsy. Remember, you're not alone. Community and self-confidence are potent medicine. I. If [00:27:00] you found value in this episode, share it with a colleague, a patient, or a policymaker who can push the conversation further. And as always, subscribe and follow epilepsy currents on your favorite podcast app. For insights that bridge research and real life, you can also find us on epilepsy currents.org. Until next time, take care and keep the dialogue going.

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What is Epilepsy Currents?: Epilepsy Currents Podcasts will bring you all the features you know and love about the journal in an innovative format you can take with you wherever you go. The primary content of Epilepsy Currents consists of commentaries written by our expert editorial board on recent high-impact research papers in Epilepsy. Each podcast episode will highlight one of these recent publications and the accompanying commentary. High-yield topics of interest to our engaged epilepsy community will be presented and discussed by one of our contributing editors and the original authors to give you an in-depth, rigorous, and personal view of current topics in epilepsy and the people behind them.

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