Authors :
Farren Briggs, PhD – University of Miami
Lisa Tan, MD – University Hospitals Cleveland
Rachel Branning, MD – University Hospitals Cleveland
Gena Ghearing, MD – Mount Sinai
Lesley Armah, BS – Case Western Reserve University
Presenting Author: MARTHA SAJATOVIC, MD – Case Western Reserve University
Rationale:
The SMART (Self-Management for people with epilepsy and a history of negative health events) intervention improves epilepsy self-management, as measured by the Epilepsy Self-Management Scale (ESMS). However, the mechanisms underlying its effects remain poorly understood. In people with epilepsy, self-management skills are important for preventing seizures and maintaining their quality of life. This study proposes that stigma, self-efficacy, and depression impact a patient’s ability to improve their self-management skills and thus, quality of life. The aim of this project was to evaluate whether improvements in depressive symptoms, epilepsy-related stigma, and self-efficacy mediate the effect of the SMART intervention on ESMS over a 6-month period.Methods:
Participants with epilepsy (n = 117) were enrolled in a clinical trial comparing the SMART intervention to standard care. We measured depressive symptoms using the PHQ-9, stigma using the Epilepsy Stigma Scale (ESS), and self-efficacy using the Epilepsy Self-Efficacy Scale (ESES) at baseline, 13 weeks, and 6 months. Linear regression with cluster-robust standard errors (clustered by rural-urban status) was used to estimate direct and indirect (ACME) effects. Mediators were evaluated across three time intervals: baseline → 13 weeks, 13 weeks → 6 months, and baseline → 6 months. Depressive symptoms and stigma were reverse-scored so that positive changes indicate improvements.
Results:
Improvements in depressive symptoms (PHQ-9 reversed) from baseline to month 6 significantly mediated the SMART intervention’s effect on increasing ESMS (ACME = 0.83, 95% CI: 0.21–1.46, p = 0.0089), accounting for 23.2% (p = 0.015) of the total effect. Increases in self-efficacy (ESES) mediated 4.6% of the intervention’s effect from baseline to 6 months (ACME = 0.155, 95% CI: 0.038–0.272, p = 0.0095; % mediated = 4.6%, p = 0.00063). Improvements in depressive symptoms and self-efficacy at specific time intervals were not significant but the direction of the ACME coefficients were consistent with overall change from baseline to month 6. Improvements in perceived stigma (ESS, reversed) did not mediate the effect of SMART on ESMS for any time interval considered.Conclusions:
These findings suggest that the SMART intervention improves epilepsy self-management in part by reducing depressive symptoms and enhancing self-efficacy. Improvements in these domains accounted for meaningful proportions of the intervention's overall effect on ESMS over six months, with depressive symptom reduction emerging as a particularly robust mediator. In contrast, reductions in perceived stigma did not contribute significantly to SMART’s impact. These results are consistent with past studies that have shown that improvements in depression severity mediated the effect of self-management interventions (Briggs et al., 2020). These results highlight the importance of emphasizing mood and self-efficacy in self-management strategies for people with epilepsy (PWE), offering mechanistic insight that can inform future intervention design and refinement.Funding:
Cooperative Agreement Number 6 U48DP006389 from the Centers for Disease Control and Prevention (CDC).