Epilepsy Essentials: Mindfulness and Epilepsy

There has been a noticeable rise in attention to mindfulness in both mainstream and medical literature. Celebrities are sharing their meditation practice, smartphone meditation apps are being developed, and magazines on “living a mindful life” line the grocery store aisles. Increasing interest in mindfulness likely has a basis in the expanding scientific evidence that mindfulness interventions may have significant health benefits. As neurologists, our patients will be asking us about the benefits of mindfulness. Although still in its infancy, for people with or treating epilepsy, the research suggests promising benefits.

Background

Mindfulness, a meditation-based therapy, is described most simply as focusing attention completely on the present moment without judgement or reaction. Several mindfulness-based techniques have been incorporated into psychotherapy. Modifications of the technique make mindfulness practice more accessible and less intimidating to many. Increasing evidence of benefits of mindfulness practice for an expanding number of health conditions fuels research into incorporating the techniques into medicine.

The National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine recognizes this area as “focusing on interactions among brain, mind, body, and behavior, and the powerful ways emotional, mental, social, spiritual, and behavioral factors can directly affect health.”¹ There is emerging neuroscience literature on underlying physiologic and anatomic bases of mindfulness-intervention benefits. Sophisticated imaging techniques including diffusion tensor imaging (DTI) and functional MRI (fMRI) are being used to study neurobiologic correlates of mindfulness practice. A review summarizing outcomes of these studies highlights changes in cortical thickness and regional connectivity.² Many of these changes are seen in the very areas epileptologists have recognized as having structural anatomic significance in epilepsy. This finding, in turn, generates further interest in use of mindfulness-based interventions for epilepsy.

Mindfulness and Seizure Control

More than 30% of people with epilepsy do not achieve seizure freedom with medication, despite continued ad-vances in treatment.³ The high prevalence of medication-resistant epilepsy drives pursuit of new treatments. Initial studies of mindfulness-based epilepsy therapies, although lacking rigorous study design, showed promising results for decreasing seizure frequency. Small randomized controlled studies have demonstrated similar findings.^4,5

The International League Against Epilepsy (ILAE) Psychology Task Force has published evidence-based recommendations on psychologic epilepsy treatments.⁶ The task force reviewed 11 studies of psychologic interventions and education programs with an outcome measure of decreased seizure frequency. Only 1 study received a strong recommendation with level II evidence (ie, moderate-to-high quality evidence of clinically meaningful effect on symptoms and functional outcomes).⁵ Participants were randomly assigned to receive mindfulness therapy or a social support group. The primary outcome measure was quality of life (QOL) and a secondary outcome measure was seizure frequency reduction. After a 6-week baseline period and a 6-week intervention period, seizure frequency assessment was done 6 weeks after the last intervention using seizure diaries and the Seizure Severity Questionnaire. Those who received mindfulness therapy had statistically significant reductions in seizure frequency from baseline compared with those who received social support.

Another controlled trial in people with refractory epilepsy investigated progressive muscle relaxation (PMR), which has been shown to reduce perceived stress, vs control-focused attention activity (CFAA). Both groups had a statistically significant reduction in seizure frequency compared with baseline that was sustained for 3 months after intervention.⁷ Reductions in seizure frequency were similar to treatment arms of anticonvulsant drug trials. Another study has shown improvement in seizure frequency with mindfulness-based Acceptance and Commitment Therapy (ACT).

Mindfulness and Cognition

Cognitive dysfunction as a comorbidity of both well-controlled and medication-resistant epilepsy has been studied extensively and highlights a variety of factors felt to contribute to differences in cognitive function. Studies show negative cognitive effects related to epilepsy age of onset, seizure severity, structural abnormalities, and even the presence of EEG.^8-10 Frequently, standard-of-care treatment—anticonvulsant medication—also results in adverse cognitive effects.⁸ Cognitive comorbidities occur in both focal and generalized epilepsies, and a broad range of neuropsychologic impairments has been demonstrated, including impaired memory, executive dysfunction, and attention difficulties.¹⁰

Acceptance and Commitment Therapy improves health-related QOL (HRQOL) in persons with epilepsy who have cognitive impairment.⁴ The study that received a strong recommendation in the ILAE evidence-based recommendations⁶ showed improved verbal memory for participants who received the mindfulness-based intervention.⁵ Improvements in other cognitive measures, including attention, were not seen, however. Difficulties with attention, including attention deficit hyperactivity disorder (ADHD), are a common comorbidity in epilepsy, particularly for children and adolescents. To date, there is little research on benefits of mindfulness interventions for ADHD symptoms in people with epilepsy. Mindfulness-based interventions in people with other conditions however, have been shown to improve attention, making this a likely area for future investigation in epilepsy.

Mindfulness and Mood Disorders

Estimates suggest at least 50% of people with epilepsy experience symptoms of a mood disorder. Benefits of mindfulness-based interventions for mood disorders are well established.⁴ The single study with ILAE evidence-based strong recommendation used both the Beck Depression Inventory (BDI) and the Beck Anxiety Index (BAI) as measures pre- and postintervention.⁵ Only participants who received the mindfulness intervention had statistically significant reductions in BAI scores postintervention. Although these participants also had reduced BDI scores, further data analysis deemed this finding clinically insignificant. In 2 randomized controlled trials conducted within Project UPLIFT, part of the CDC’s Managing Epilepsy Well Network,¹¹ mindfulness-based interventions improved depression, and further studies are ongoing.

Mindfulness and Stress Reduction

Another potential application of mindfulness interventions in people with epilepsy is stress reduction. Mindfulness-based therapies have been shown to significantly reduce perceived stress, which is an identified seizure trigger for people with epilepsy. The neuroscience literature implicates stress-induced physiologic changes as potentially increasing the tendency for epileptic seizures to occur.¹² In the study that used PMR and CFAA behavioral interventions,⁷ people in both treatment groups reported subjective decreases in stress and significant reduction in seizure frequency. This suggests that mindfulness for stress reduction may be a powerful adjunctive therapy for patients with epilepsy.

Mindfulness in Clinical Practice

This article wouldn’t be complete without addressing the practical implications of bringing mindfulness-based interventions to our patients. Access to behavioral and psychologic therapies presents an ongoing barrier in the care of people with epilepsy. This observation has led to the increased development of self-management tools and the exploration of other means of access to care, including virtual care and applications that can be accessed from home (eg, web-based therapies or smartphone applications). The Managing Epilepsy Well Network is a collaborative research network under the CDC’s Prevention Research Center.¹¹ Their Project UPLIFT continues to explore the use of mindfulness-based interventions utilizing telephone and web-based access. Based on the ILAE evidence-based recommendations, the preferred modality for delivery of psychologic intervention “remains an ongoing area of development.”⁶