Janelle L. Wagner

Background and ObjectivesDespite its proven effectiveness, epilepsy surgery for drug-resistant epilepsy (DRE) remains underutilized and frequently delayed. Previous studies of epilepsy duration bef...

Objective: Mental health conditions often co‐occur with epilepsy, causing burden and stress beyond seizures. Some of these conditions can emerge early and even predate the onset of seizure and/or epilepsy diagnosis. This systematic review synthesizes evidence on mental health outcomes in adults with newly diagnosed epilepsy (NDE). Methods: A systematic literature search was conducted up to September 2025. All quantitative studies were included without restriction to study types. Mental health outcomes included a board range of mood, anxiety, quality of life, and stigma as primary or secondary outcome measures that were assessed and reported using validated scales. Standard methodological procedures for literature search, data collection, assessment of risk of bias, and analysis were used based on the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) 2020 guideline. Results: Twenty‐one publications ( n = 4728 adults) across 10 countries were included, of which 12 (57%) showed low risk of bias. Methodological heterogeneity precluded meta‐analysis. Depressive and anxiety symptoms were the most frequently assessed, with 11%–50% (data from 14 papers) and 25%–35% (11 papers) of NDE screened positive on validated screening tools, respectively. Structured diagnostic tools in two papers revealed clinical depression in 2.9%–13.3% and anxiety/neurotic disorders in approximately one‐quarter of NDE. The prevalence of perceived stigma was reported in 25%–53% of NDE; quality of life was impaired by mood symptom, stigma, and role disability. Significance: Mental health conditions impose a substantial early burden among adults with NDE. Managing this burden requires integrating routine screening into early care pathways as a first step, coupled with a tiered psychiatric diagnostic process. Psychoeducation on these mental health risks should also be integrated into epilepsy care to promote awareness and access to services.

Objective: Epilepsy duration is a modifiable risk factor in the outcome of definitive epilepsy surgery; however, an analogous effect in palliative procedures has not been shown. We reviewed the Pediatric Epilepsy Surgery Database data for an association between epilepsy duration and seizure reduction in palliative procedures. Methods: Patients enrolled between January 2018 and April 2025 who underwent their first epilepsy surgery with palliative intent with 6 months of follow‐up were included. Procedures included neuromodulation, corpus callosotomy, hemispherotomy, lesionectomy, and lobectomy where surgical intent was not seizure freedom. Outcomes of seizure freedom, 90% seizure reduction, and 50% seizure reduction were considered at 6–12 months and >12 months from surgery. Duration from epilepsy onset to surgery was compared for patients above and below each outcome threshold at each time point. Logistic regression analysis for the association between epilepsy duration and seizure reduction adjusted for potential confounders including procedure type, etiology, and other clinical factors. Logistic regression analysis was performed on the overall cohort and subgroups of patients with each procedure. Results: A total of 588 patients were included. Initial univariate analysis suggested that epilepsy duration at time of surgery was significantly associated with seizure freedom and 90% seizure reduction at both 6–12 months and >12 months. After adjusting for confounders, only seizure freedom at >12 months was significantly associated with duration of epilepsy. When individual procedures were considered, only lobectomy was sensitive to duration of epilepsy in multivariate analysis, with significant impacts on >50% and >90% seizure reduction at >12 months. Lesional epilepsy predicted seizure freedom at >12 months. Neuromodulation and corpus callosotomy were less likely to achieve seizure reduction than other procedures. Significance: We did not find an association between early epilepsy surgery and seizure reduction. This reflects the heterogeneity of our population, including different types of surgical procedures and lesional and nonlesional epilepsies.

Objective: Despite being safe and effective, surgery for pediatric epilepsy is underutilized. Social determinants of health (SDoH) are important to consider when examining this treatment gap. This study examined the potential systemic inequities at three different stages in the journey toward epilepsy surgery across the Pediatric Epilepsy Research Consortium (PERC). Methods: Any youth in the PERC prospective surgery database (≤18 years) was eligible and included if sociodemographic factors were also available. We examined if there were differences in disparity factors in: (1) referral to Phase I evaluation, (2) offering of surgery, and (3) completion of surgery. Results: Of 1309 patients, the majority were male (53%, p = .04), White (82.2%, p < .001), not Hispanic or Latino (84.3%, p < .001), and privately insured (56.3%, p < .001). Of the youth who were offered surgical treatment ( n = 1103, 84.3%), there were no significant differences in race/ethnicity or sex. Those with a structural lesion were more likely to be offered surgery, and historically marginalized youth were more likely to have a lesion. Of patients who completed surgery ( n = 927, 84.0%), White patients were 1.88 times (95% confidence interval [CI]: 1.14–3.04) more likely than Black patients to complete surgery ( p = .01). Significance: Youth who began surgery evaluation are not representative of the demographics of those with epilepsy in the United States, with greater representation of White, non‐Hispanic male individuals. In addition, youth who began surgery evaluation disproportionally have private insurance. At the next stage of offering surgery, there were no differences based on SDoH. However, there is evidence that underrepresented youth that were magnetic resonance negative were less likely to be referred for surgical workup and that Black youth were less likely to undergo surgery. Therefore, efforts to provide equitable opportunity for all youth with refractory epilepsy should be concentrated at the referral for surgery evaluation point of care; however, additional efforts are also needed at later stages.

Persons with epilepsy (PWE) are at 3 to 5 times higher risk for behavioral health concerns, under which we summarize here as anxiety, depression, attention-deficit/hyperactivity disorder, substance use, cognitive disorders, etc., compared to those without epilepsy (1,2). These concerns are more detrimental to health-related quality of life (HRQOL) and health outcomes than seizure-specific factors (3). Studies have examined the potential shared neuropathophysiology and genetics of epilepsy and behavioral health symptoms (4,5). To further elucidate this complicated relationship, recent studies have suggested a bidirectional relationship between cognitive (e.g., memory, processing speed, IQ, etc.) and mental or behavioral health (e.g., anxiety, depression, substance use) symptoms as well a common mechanism for these co-occurring symptoms in PWE (6). These behavioral health concerns often remain undetected, with nearly two-thirds not receiving indicated behavioral health care (e.g., psychoeducation, cognitive-behavioral therapy (CBT), etc.), resulting in higher rates of unmet needs compared to other populations (7)(8)(9)(10). Indeed, insufficiently managed behavioral health concerns in PWE are associated with higher rates of health care utilization and poorer health outcomes (11)(12)(13).To address these gaps, the goal of this research topic was to promote the prevention of and early intervention for behavioral health concerns in PWE. Seven papers included in this research topic support aspects of neurology provider-led integrated behavioral health care (14), including promotion of identifying behavioral health issues through patient discussions and screening (Chan et al. Screening for anxiety and depression in routine epilepsy encounters has been identified as a quality indicator by the American Academy of Neurology (AAN;15) and highlighted in consensus recommendations (16); however, few screening instruments have been developed and validated for PWE (17). In this special report, Chan et al. developed and validated the traditional-Chinese version of the well-established Epilepsy Anxiety Survey Instrument (EASI) and its brief screener (brEASI). They demonstrated strong reliability (i.e., internal consistency, test re-test) and construct validity (i.e., factor structure, convergent, divergent), providing support for use of these screening measures. Huang et al. found an increased odds of 26% for epilepsy in those adults who reported smoking tobacco, suggesting an association between nicotine use and seizures. Further investigation into the biological mechanisms underlying this association is warranted, particularly with relation to sex hormones, as well as potential psychosocial explanations (e.g., stress reduction, insomnia). This study and other recent investigations indicate the importance of screening for substance use in PWE, especially given the potential interference of substances with ASMs and neurological functioning.When significant behavioral health concerns are identified, neurology providers are encouraged to consider: (1) treating mild anxiety and depression according to consensus recommendations, typically with SSRIs [16,18], or (2) referring to a behavioral health care specialist (e.g., psychiatrist, psychologist, social worker, etc.) for moderate to severe symptoms. In this research topic, Kiriakopoulos and colleagues examined the benefit of HOme Based Self-management and COgnitive Training CHanges lives (HOBSCOTCH). Results were promising with teens and adults aged 16-83 years reporting significantly improved HRQOL and cognition following the 8-week program.Providing psychoeducation on the etiologies and treatments for behavioral health concerns in PWE is critical to improve patient understanding. Two papers address the possible underlying pathophysiology of seizures and co-occurring behavioral health symptoms. Hao et al. studied stereo-electroencephalography (SEEG) in 5 patients with drug-resistant epilepsy who exhibited slapping automatisms, including one person with comorbid obsessive-compulsive disorder (OCD). Preliminary findings highlight a potential shared orbitofrontal-striatal-pallidal-thalamic network between frontal/temporal epilepsy, slapping automatism, and OCD. In addition, Tang and colleagues examined circadian rhythms using actigraphy. Compared to the general population, PWE showed significant differences in intraday stability (IS), or the fidelity of the pattern of rest to activity with respect to the light-dark cycle, and the peak activity period over 10 consecutive hours (M10), suggesting a disruption in the 24-hour rest-activity circadian rhythm. While additional research is necessary, these findings may shed light on the seizure susceptibility and sleep difficulties that PWE experience. The importance of sleep-wake behaviors for PWE is a critical component of psychoeducation.A broader framework for psychoeducation includes community-based education on the overlap between epilepsy and behavioral health symptoms to reduce stigma and promote awareness. Younes et al. assessed the knowledge, awareness, and attitudes toward epilepsy. Cultural adaptations included measures translated into Arabic and selection of measures that inquired about epilepsy in the context of Middle Eastern cultural beliefs. Results revealed that most respondents had a good knowledge of epilepsy (87%) and positive attitude toward patients with epilepsy (88%). However, 38.5% were "frightened" over individuals having seizures, suggesting the need for additional psychoeducation about how to respond to a seizure. Finally, managing ASMs, the primary and first-line treatment for seizures, is a standard aspect of epilepsy care but can have undesired side effects. In a systematic review and meta-analysis, Xu and colleagues synthesize the data on use of ASMs in pregnant women with epilepsy. Six cohort studies showed that in-utero exposure to valproate was associated with an increased risk...