In management of epilepsy, it is important to consider the high rates of emotional distress and psychosocial problems, which negatively impact patients’ ability to cope with disease and their QOL. The lifetime prevalence of depression and anxiety disorders is significantly higher in PWE than in the general public or in patients with several other chronic conditions, such as asthma (Ettinger, Reed, Cramer, & Epilepsy Impact Project Group, 2004; Kanner, 2007). Depression is the most common emotional concern in epilepsy, with the rates of depression reported to be as high as 55 % among patients treated in specialized medical centers (Dodrill, 2008). The level of depression is not usually well accounted for by seizure variables, suggesting that psychological, social, and medication variables play a significant part in this relationship (Bishop & Allen, 2007). It has been shown that depression but not seizure frequency predicts QOL in treatment resistant epilepsy, and this has led many investigators to conclude that treatment of depression may be inadequately prioritized in the epilepsy management in these patients (e.g., Boylan et al., 2004; Thapar, Kerr, & Gordon, 2009).

Anxiety disorders are also commonly comorbid with epilepsy, with reported prevalence rates ranging from 19 % to over 50 % across studies and the different settings where epilepsy patients were assessed (Beyenburg, Mitchell, Schmidt, Elger, & Reuber, 2005). The unpredictable timing and intrusive nature of seizures demand constant vigilance and often result in chronic and disabling anxiety, which can have a profound influence on the QOL of epilepsy patients. Seizure frequency has been linked to anxiety in some but not all studies. In older adults, including those with infrequent seizures (i.e., less than one per year), the fear induced by the possibility of a seizure may be sufficient to significantly reduce QOL (McLaughlin, Pachana, & Mcfarland, 2008).

The level of distress in PWE is also increased by cognitive problems, and distress in turn exacerbates cognitive dysfunction. At the same time, distressed patients are more prone to overreactions to memory failures, some of which may be normal forgetfulness. It has been shown that perceived cognitive functioning was strongly correlated with mood and weakly correlated with memory performance scores (Elixhauser, Kline Leidy, Meador, Means, & Willian, 1999).

Living with epilepsy also implies psychosocial challenges. Psychosocial functioning in PWE has to do with the level of effectiveness with which individuals are able to function in their social environment, including situations pertaining to education, employment, interpersonal relationships, as well as relationships with their physicians, adjustment to seizures, and medical management of epilepsy. For instance, psychosocial factors that have been implicated in the high unemployment rate among PWE include social isolation, lack of information, social skills deficits, and lack of family support (Bishop & Allen, 2007). Some of the psychosocial problems may be related to the perceived social stigma associated with epilepsy. In fact, epilepsy in many cultures has often been regarded as one of the most stigmatizing conditions. The negative attitudes that PWE encounter typically result from lack of information and understanding of epilepsy; however, feeling stigmatized does not always correlate with the presence of prejudice but relies heavily on individuals’ perceptions. Stigma can be one of the most distressing consequences of having seizures, and it can lead to social isolation and have a negative impact on QOL (Prus, Nakhutina, & Grant, 2009). Perceptions of lower self-efficacy to manage epilepsy and poorer adherence to treatment were found in PWE who report higher levels of stigma (DiIorio, Osborne Shafer, Letz, et al., 2003), and lower levels of stigma were associated with finding and maintaining employment (Smeets et al., 2007). Smith et al. (2009) found complex interactions between demographic, clinical, and psychosocial factors at play with the perception of stigma and suggested that perceptions of self-efficacy in managing epilepsy are a point of intervention to improve stigma.

Compounding the emotional and psychosocial problems is the fact that epilepsy patients often have inadequate knowledge and misconceptions about their illness and its treatment. They may also possess poor understanding of the cognitive and emotional problems they may be experiencing and the way these problems may be impacting their daily lives. Lack of information and erroneous beliefs can result in dangerous consequences of AEDs misuse, with resultant increase in seizure frequency, misguided medication changes or emergency room visits, as well as heightened perceptions of stigma, social withdrawal, and depression.

To address emotional distress, psychosocial problems, and lack of disease-related information among PWE, a number of educational and psychotherapeutic interventions have been developed. These interventions have been provided by various types of professionals, including specialist epilepsy nurses, social workers, health psychologists, and only infrequently neuropsychologists. Infrequent participation of neuropsychologists is surprising given the need for understanding of cognitive deficits in PWE when attempting to effect behavior change in these patients and to teach them new information. In the next section, empirical evidence from psychoeducational and psychotherapeutic programs for PWE will be reviewed. It should be noted that differentiation among these interventions is difficult to make, as there is usually much overlap, whereby psychotherapy commonly includes patient education and psychoeducational programs often instruct patients in coping skills.

The focus of psychoeducation has been to impart knowledge about epilepsy and its treatment, improve coping skills and QOL, and increase compliance with treatment and seizure control. The educational programs have varied in their approach, and only a few have been evaluated using randomized, controlled methodology (May & Pfafflin, 2005). The results of studies conducted thus far are promising, and the need for educational interventions has been highlighted (Bradley & Lindsay, 2008).

Psychotherapeutic interventions include cognitive behavioral therapy, relaxation therapy, and EEG biofeedback, as well as patient education. These interventions have been used alone or in combination in treatment of epilepsy patients, with the aim of reducing depression and anxiety symptoms, decreasing seizure frequency, and improving QOL.

Epilepsy patients can present with cognitive deficits in various domains, including intellectual abilities, attention and concentration, memory, executive functions (e.g., organization, mental flexibility, problem-solving), language, visuospatial skills, processing and motor speed, as well as in social and emotional cognition. Memory impairment, attention and concentration deficits, and mental slowing are the most frequent cognitive problems associated with epilepsy (Aldenkamp, 2006; Jokeit & Ebner, 1999) and are commonly reported subjective complaints of PWE. Cognitive impairment in PWE appears to result from multiple factors, including the underlying etiology, neuronal dysfunction or loss, seizure-related variables, localization of the epileptogenic zone, adverse effects of antiepileptic drugs (AEDs), and comorbid psychiatric conditions, such as depression and anxiety (Aldenkamp, Baker, & Meador, 2004; Hermann & Whitman, 1984). These factors interrelate, resulting in heterogeneous nature of cognitive profiles that range widely in severity of deficits. Early seizure onset, long duration of the disease, and poor seizure control are associated with poor cognitive outcome (Elger, Helmstaedter, & Kurthen, 2004). While epilepsy surgery is an important treatment option allowing many patients to achieve seizure freedom, the surgical intervention carries the risk of causing additional cognitive impairments.

Patients often list memory problems as their greatest concern (Hendriks, 2001) with memory deficits, in varying degrees of severity, being the most common finding in objective neuropsychological evaluations. Seizures often originate in mesiotemporal structures that are essential for memory processes (Squire, Stark, & Clark, 2004), and NMDA receptors, critical in learning and memory, appear to play a prominent role in the neuropathology of epilepsy (Engel, Pedley, Aicardi, & Dichter, 2007). Learning and memory difficulties are the most frequent cognitive changes in patients with temporal lobe epilepsy (TLE), irrespective of the presence of overt damage in temporal lobe structures (Giovagnoli & Avanzini, 1999). Frontal lobe epilepsy (FLE) may affect an array of cognitive abilities, including memory, attention, and executive functions (Helmstaedter, Kemper, & Elger, 1996). The overall prevalence of memory problems in patients with refractory epilepsy has been estimated as high as 20–50 % (Halgren et al., 1991).

Deficits in cognitive functions are considered more debilitating than the actual seizures by some patients. Cognitive functioning may be a significant factor in determining educational attainment and employment status, and even subtle deficits may manifest themselves in demanding professional or academic settings. Cognitive deficits are also likely to negatively impact patients’ ability to adhere to their treatment regimens, especially when the regimens are complex and, thus, reliant on many cognitive abilities. In a study focused on medication adherence, study, 56 % of epilepsy patients reported forgetfulness as a reason for poor medication adherence, and the overall nonadherence rate was 68 % (Nakhutina, Gonzalez, Prus, & Grant, 2009). Finally, cognitive dysfunction is also one of the most frequently identified factors in reducing QOL (Bishop & Allen, 2003), even in patients with well-controlled epilepsy. In particular, individuals with impaired memory were found to have significantly worse QOL than the ones with unimpaired memory (Leidy et al., 1999).

Evidence-based cognitive remediation has the potential to improve cognitive status, functional abilities, and QOL in PWE. The interest in the possibility of rehabilitation of cognitive problems has greatly expanded in the last decades, and there is now a considerable amount of literature on cognitive rehabilitation (e.g., Sohlberg & Mateer, 2001; Wilson, 1987); however, the focus of this literature remains primarily on traumatic brain injury (TBI) and stroke, whereas applications to epilepsy patients have been very limited (Shulman & Barr, 2002). The attempts to investigate the efficacy of cognitive rehabilitation in PWE with adequate study of outcomes have been very few, and RCTs are grossly lacking. In the following section, (1) definition of cognitive remediation will be provided, (2) select remediation strategies with supportive evidence for use with brain injury and stroke patients will be summarized, and (3) limited empirical evidence from studies of cognitive interventions in PWE will be reviewed. The focus will be on rehabilitation of memory and attention problems, the most prevalent complaints in PWE and key domains targeted by existing remediation interventions in epilepsy patients.

Cognitive rehabilitation has been defined as a “systematic, functionally oriented service of therapeutic activities that is based on assessment and understanding of the patient’s brain-behavioral deficits” (Cicerone et al., 2000). Wilson has defined cognitive rehabilitation as “any intervention strategy or technique which intends to enable clients or patients, and their families, to live with, manage, by-pass, reduce or come to terms with cognitive deficits precipitated by injury to the brain” (Wilson, 1997). A comprehensive neuropsychological evaluation plays an important role in guiding cognitive remediation based on detailed information about patients’ level of intellectual functioning, cognitive profile (e.g., areas of cognitive deficits and preserved abilities), and severity of cognitive impairment. Cognitive remediation is also guided by patients’ functional goals or what is expected of them (e.g., return to work or school, participation at home).

Memory rehabilitation is a component of cognitive rehabilitation. Two broad approaches to memory rehabilitation have been employed: (1) restitution training and (2) strategy training. Using the restitution training approach, memory rehabilitation programs rely heavily on repetitive drills and practice of cognitive skills in attempts to restore the underlying impaired function. Tasks utilized for this purpose are often computerized, and software packages have been made commercially available. This approach has not been found to lead to general improvements in memory functioning (Prigatano et al., 1984). The strategy training approach to rehabilitation has received more research support, especially when targeting memory problems (Cicerone et al., 2000, 2005). This approach focuses on teaching patients compensatory strategies to circumvent difficulties that arise as a result of their memory impairment (Sohlberg & Mateer, 1989). Patients are taught the use of internal memory aids, such as mnemonics, visual imagery, and rehearsal, to help them remember and recall information and/or external memory aids, such as notebooks, voice organizers (Van den Broek, Downes, Johnson, Dayus, & Hilton, 2000), alarms, pagers (Wilson, Emslie, & Evans, 2001), mobile phones (Wade & Troy, 2001), and other assistive devices and environmental manipula-tions, to help reduce memory failures and executive functioning problems. The generalizability of internal memory aid use to natural settings has also been questioned. These techniques have been found ineffective for many patients with significantly compromised intellectual functioning and may be useful only for acquisition of specific and small bodies of information (Sohlberg & Mateer, 1989). The external memory aids can be very effective, particularly when dealing with severe memory impairment; however, these aids are often given with minimal instruction or formal training (Sohlberg & Mateer, 1989).

Cicerone and colleagues (2000) provided evidence-based recommendations for cognitive rehabilitation with TBI and stroke patients. Based on the review of findings from well-designed prospective RCTs, along with supportive evidence from less rigorous trials, Cicerone et al. (2005) suggested that the evidence for memory strategy training (including the use of internalized strategies and external memory compensations) for individuals with mild memory problems was “compelling enough” to recommend it as a practice standard. Teaching external memory aids with direct application to functional activities was offered as practice guidelines for patients with moderate to severe memory impairment, based on evidence of probable effectiveness (e.g., as seen in nonrandomized cohort studies or case-control studies).