Psychological treatments for adults and children with epilepsy: Evidence‐based recommendations by the International League Against Epilepsy Psychology Task Force

Given the significant impact that psychosocial factors and epilepsy treatments can have on the health‐related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness‐based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.

[1]  E. Goffman.  Stigma; Notes On The Management Of Spoiled Identity , 1964 .

[2]  D M Donovan,et al.  Cognitive-behavioral treatment of depressed affect among epileptics: preliminary findings. , 1984, Journal of clinical psychology.

[3]  G. Peterson,et al.  A Randomised Trial of Strategies to Improve Patient Compliance with Anticonvulsant Therapy , 1984, Epilepsia.

[4]  L. Brorson,et al.  Effects of a Broad‐Spectrum Behavior Modification Treatment Program on Children with Refractory Epileptic Seizures , 1985, Epilepsia.

[5]  J Bruni,et al.  Cognitive‐Behavior Therapy with Adult Patients with Epilepsy: A Controlled Outcome Study , 1986, Epilepsia.

[6]  J. Shope.  Compliance in children and adults: review of studies. , 1988, Epilepsy research. Supplement.

[7]  S. Chayasirisobhon,et al.  Sepulveda Epilepsy Education: The Efficacy of a Psychoeducational Treatment Program in Treating Medical and Psychosocial Aspects of Epilepsy , 1990, Epilepsia.

[8]  L. Melin,et al.  Effects of a Broad‐spectrum Behavioral Medicine Treatment Program on Children with Refractory Epileptic Seizures: An 8‐Year Follow‐Up , 1992, Epilepsia.

[9]  R. Collins,et al.  Recovery of Susceptibility to Audiogenic Seizure in Mice , 1993, Epilepsia.

[10]  Orrin Devinsky,et al.  Development and Cross‐Cultural Translations of a 31‐Item Quality of Life in Epilepsy Inventory , 1998, Epilepsia.

[11]  A. Mcbride,et al.  Psychosocial Care Needs of Parents of Children with NewOnset Seizures , 1998, The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses.

[12]  L. Goldstein,et al.  Fear of seizures: an investigation and treatment , 1998, Seizure.

[13]  J. Cramer,et al.  Development of the Quality of Life in Epilepsy Inventory for Adolescents: The QOLIE‐AD‐48 , 1999, Epilepsia.

[14]  Robert L. Glueckauf,et al.  Home-based, interactive videoconferencing for adolescents with epilepsy and their families. , 1999 .

[15]  G. Baker,et al.  The Stigma of Epilepsy: A European Perspective , 2000, Epilepsia.

[16]  C. Elger,et al.  Depression in patients with temporal lobe epilepsy is related to mesial temporal sclerosis , 2000, Epilepsy Research.

[17]  I. Kwan,et al.  Newly Diagnosed Epilepsy: Can Nurse Specialists Help? A Randomized Controlled Trial , 2000, Epilepsia.

[18]  [Epilepsies and time to diagnosis. Descriptive results of the CAROLE survey]. , 2000, Revue neurologique.

[19]  L. Long,et al.  An Assessment of Epilepsy Patients' Knowledge of Their Disorder , 2000, Epilepsia.

[20]  Sn Wong,et al.  Parental perception, worries and needs in children with epilepsy , 2000, Acta paediatrica.

[21]  J. Reiter,et al.  A neurobehavioral approach for treatment of complex partial epilepsy: efficacy , 2000, Seizure.

[22]  D. Upton,et al.  Epilepsy and the family: a review of current literature , 2000, Seizure.

[23]  B. Aldenkamp,et al.  Social Functioning, Psychological Functioning, and Quality of Life in Epilepsy , 2001, Epilepsia.

[24]  W. Brieger,et al.  Psycho-educational therapy among Nigerian adult patients with epilepsy: a controlled outcome study. , 2001, Patient education and counseling.

[25]  L. Marsh,et al.  Psychiatric complications in patients with epilepsy: a review , 2002, Epilepsy Research.

[26]  P. Carney,et al.  Videoconferencing-based family counseling for rural teenagers with epilepsy: Phase 1 findings. , 2002 .

[27]  Margarete Pfäfflin,et al.  The Efficacy of an Educational Treatment Program for Patients with Epilepsy (MOSES): Results of a Controlled, Randomized Study , 2002, Epilepsia.

[28]  H. Kimura,et al.  Morphologic Study of Neuronal Death, Glial Activation, and Progenitor Cell Division in the Hippocampus of Rat Models of Epilepsy , 2002, Epilepsia.

[29]  P. Leung,et al.  Cognitive-behavioral group treatment program for adults with epilepsy in Hong Kong , 2003, Epilepsy & Behavior.

[30]  Silke Lux,et al.  Chronic epilepsy and cognition: A longitudinal study in temporal lobe epilepsy , 2003, Annals of neurology.

[31]  A. Bye,et al.  Validation of the Quality of Life in Childhood Epilepsy Questionnaire in American epilepsy patients , 2003, Epilepsy & Behavior.

[32]  H. Kho,et al.  Factors affecting the quality of life in patients with epilepsy in Seoul, South Korea , 2003, Acta neurologica Scandinavica.

[33]  M. Griebel,et al.  Anxiety in children with epilepsy , 2003, Epilepsy & Behavior.

[34]  M. Brodie,et al.  Quality of life and psychosocial development in adolescents with epilepsy: a qualitative investigation using focus group methods , 2004, Seizure.

[35]  Robert M. Bernard,et al.  How Does Distance Education Compare With Classroom Instruction? A Meta-Analysis of the Empirical Literature , 2004 .

[36]  G. Guyatt,et al.  Grading quality of evidence and strength of recommendations , 2004, BMJ : British Medical Journal.

[37]  A. Adewuya,et al.  Prevalence of and risk factors for anxiety and depressive disorders in Nigerian adolescents with epilepsy , 2005, Epilepsy & Behavior.

[38]  G. Baker,et al.  Epilepsy and social identity: the stigma of a chronic neurological disorder , 2005, The Lancet Neurology.

[39]  A. Aldenkamp,et al.  Family factors and psychopathology in children with epilepsy: A literature review , 2005, Epilepsy & Behavior.

[40]  G. Bråthen,et al.  A structured, nurse-led intervention program improves quality of life in patients with epilepsy: A randomized, controlled trial , 2005, Epilepsy & Behavior.

[41]  F. Petermann,et al.  [Education of children with epilepsy and their parents by the modular education program epilepsy for families (FAMOSES)--results of an evaluation study]. , 2006, Die Rehabilitation.

[42]  Olafur Kjartansson,et al.  Depression and suicide attempt as risk factors for incident unprovoked seizures , 2006, Annals of neurology.

[43]  K. Meador,et al.  Rapid detection of major depression in epilepsy: a multicentre study , 2006, The Lancet Neurology.

[44]  Žarko Martinović,et al.  Preventing depression in adolescents with epilepsy , 2006, Epilepsy & Behavior.

[45]  Lennart Melin,et al.  Evaluation of Acceptance and Commitment Therapy for Drug Refractory Epilepsy: A Randomized Controlled Trial in South Africa—A Pilot Study , 2006, Epilepsia.

[46]  A. V. Cott,et al.  A psychosocial self-management program for epilepsy: A randomized pilot study in adults , 2007, Epilepsy & Behavior.

[47]  R. Barkley,et al.  Assessment of childhood disorders , 2007 .

[48]  K. Radhakrishnan,et al.  Women with Onset of Epilepsy Prior to Marriage: Disclose or Conceal? , 2007, Epilepsia.

[49]  S. Duncan,et al.  Men with epilepsy—The lost tribe? Results of a nationwide survey of men with epilepsy living in the UK , 2007, Seizure.

[50]  Scott B Patten,et al.  Psychiatric Comorbidity in Epilepsy: A Population‐Based Analysis , 2007, Epilepsia.

[51]  Lennart Melin,et al.  Acceptance and Commitment Therapy and yoga for drug-refractory epilepsy: A randomized controlled trial , 2008, Epilepsy & Behavior.

[52]  Bruce Hermann,et al.  Consensus statement: The evaluation and treatment of people with epilepsy and affective disorders , 2008, Epilepsy & Behavior.

[53]  E. Faught,et al.  Nonadherence to antiepileptic drugs and increased mortality , 2008, Neurology.

[54]  Tobias Loddenkemper.  Quo vadis Wada? , 2008, Epilepsy & Behavior.

[55]  G. Guyatt,et al.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations , 2008, BMJ : British Medical Journal.

[56]  H. Levin,et al.  Identifying depression in epilepsy in a busy clinical setting is enhanced with systematic screening , 2009, Seizure.

[57]  Robert A Gross,et al.  Levels of evidence , 2008, Neurology.

[58]  R. Faught,et al.  Impact of nonadherence to antiepileptic drugs on health care utilization and costs: Findings from the RANSOM study , 2009, Epilepsia.

[59]  J. Wuu,et al.  A lifetime psychiatric history predicts a worse seizure outcome following temporal lobectomy , 2009, Neurology.

[60]  Frances McCarty,et al.  A telephone-based self-management program for people with epilepsy , 2009, Epilepsy & Behavior.

[61]  E. Trevathan,et al.  Depression and anxiety in children and adolescents with epilepsy: Prevalence, risk factors, and treatment , 2009, Epilepsy & Behavior.

[62]  Robert James Mittan,et al.  Psychosocial treatment programs in epilepsy: A review , 2009, Epilepsy & Behavior.

[63]  U. Thyen,et al.  FLIP&FLAP—A training programme for children and adolescents with epilepsy, and their parents , 2009, Seizure.

[64]  Nancy J. Thompson,et al.  Distance delivery of mindfulness-based cognitive therapy for depression: Project UPLIFT , 2010, Epilepsy & Behavior.

[65]  C. Szoeke,et al.  Neuropsychiatric symptomatology predicts seizure recurrence in newly treated patients , 2010, Neurology.

[66]  A. Bagić,et al.  Essential services, personnel, and facilities in specialized epilepsy centers—Revised 2010 guidelines , 2010, Epilepsia.

[67]  C. V. van Donselaar,et al.  Course and outcome of childhood epilepsy: A 15‐year follow‐up of the Dutch Study of Epilepsy in Childhood , 2010, Epilepsia.

[68]  K. Mcfarland,et al.  A randomized trial of a group based cognitive behavior therapy program for older adults with epilepsy: the impact on seizure frequency, depression and psychosocial well-being , 2011, Journal of Behavioral Medicine.

[69]  Paul Ciechanowski,et al.  PEARLS depression treatment for individuals with epilepsy: A randomized controlled trial , 2010, Epilepsy & Behavior.

[70]  J. Zeber,et al.  Variation in Antiepileptic Drug Adherence Among Older Patients with New-Onset Epilepsy , 2010, The Annals of pharmacotherapy.

[71]  J. Rausch,et al.  Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy. , 2011, JAMA.

[72]  C. Lui,et al.  Announcement of a new Chinese name for epilepsy , 2011, Epilepsia.

[73]  J. Rausch,et al.  Treatment factors affecting longitudinal quality of life in new onset pediatric epilepsy. , 2011, Journal of pediatric psychology.

[74]  M. Whitehead,et al.  Factors predictive of resilience and vulnerability in new‐onset epilepsy , 2011, Epilepsia.

[75]  J. Trollor,et al.  International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy , 2011, Epilepsia.

[76]  Yvan Bamps,et al.  Results of a research study evaluating WebEase, an online epilepsy self-management program , 2011, Epilepsy & Behavior.

[77]  Paul Ciechanowski,et al.  Long-term outcomes from the PEARLS randomized trial for the treatment of depression in patients with epilepsy , 2011, Epilepsy & Behavior.

[78]  Lisa M. Caylor,et al.  Managing epilepsy well: Self-management needs assessment , 2011, Epilepsy & Behavior.

[79]  D. Drotar,et al.  Pediatric Self-management: A Framework for Research, Practice, and Policy , 2012, Pediatrics.

[80]  Michael Trimble,et al.  Depression and epilepsy: Epidemiologic and neurobiologic perspectives that may explain their high comorbid occurrence , 2012, Epilepsy & Behavior.

[81]  H. Hurt,et al.  Longitudinal Follow-up of Poor Inner-city Youth Between Ages 8 and 18: Intentions Versus Reality , 2012, Pediatrics.

[82]  A. Ahlbom,et al.  Hospitalization for psychiatric disorders before and after onset of unprovoked seizures/epilepsy , 2012, Neurology.

[83]  Ji Wang,et al.  A comparison of quality of life in adolescents with epilepsy or asthma using the Short-Form Health Survey (SF-36) , 2012, Epilepsy Research.

[84]  Yelena P. Wu,et al.  Uninformed clinical decisions resulting from lack of adherence assessment in children with new-onset epilepsy , 2012, Epilepsy & Behavior.

[85]  T. Glauser,et al.  Development and validation of the Pediatric Epilepsy Side Effects Questionnaire , 2012, Neurology.

[86]  Marco Mula,et al.  Epilepsy: Bidirectional link between epilepsy and psychiatric disorders , 2012, Nature Reviews Neurology.

[87]  F. Petermann,et al.  The psychoeducational program for children with epilepsy and their parents (FAMOSES): Results of a controlled pilot study and a survey of parent satisfaction over a five-year period , 2012, Epilepsy & Behavior.

[88]  P. Nieminen,et al.  Social competence in children with epilepsy — A review , 2012, Epilepsy & Behavior.

[89]  S. Elsas,et al.  Trigger self-control and seizure arrest in the Andrews/Reiter behavioral approach to epilepsy: A retrospective analysis of seizure frequency , 2012, Epilepsy & Behavior.

[90]  Hamid Haghani,et al.  Effects of an educational program on self-management in patients with epilepsy , 2013, Seizure.

[91]  Pei Lin Lua,et al.  A Randomised Controlled Trial of an Sms-Based Mobile Epilepsy Education System , 2013, Journal of telemedicine and telecare.

[92]  J. Varni,et al.  Health-related quality of life and symptom reporting: similarities and differences between children and their parents , 2013, European Journal of Pediatrics.

[93]  P. Kwan,et al.  Neurocognitive and psychological profiles of adult patients with epilepsy in Hong Kong , 2013, Epilepsy & Behavior.

[94]  S. Wiebe,et al.  Trajectories of health‐related quality of life in children with epilepsy: A cohort study , 2013, Epilepsia.

[95]  Varda Shalev,et al.  Prevalence of Epilepsy and Attention-Deficit Hyperactivity (ADHD) Disorder , 2013, Journal of child neurology.

[96]  A. Modi,et al.  Development and preliminary implementation of a psychosocial service into standard medical care for pediatric epilepsy. , 2013 .

[97]  M. Mula,et al.  Treatment of behavioral problems in intellectually disabled adult patients with epilepsy , 2013, Epilepsia.

[98]  J. Rausch,et al.  Changes in daily activity patterns of caregivers of children with newly diagnosed epilepsy: A case-controlled design , 2014, Epilepsy & Behavior.

[99]  J. Rausch,et al.  Antiepileptic drug nonadherence predicts pediatric epilepsy seizure outcomes , 2014, Neurology.

[100]  M. Pirovano,et al.  Comprehensive educational plan for patients with epilepsy and comorbidity (EDU-COM): a pragmatic randomised trial , 2014, Journal of Neurology, Neurosurgery & Psychiatry.

[101]  S. Moritz,et al.  Efficacy of a psychological online intervention for depression in people with epilepsy: A randomized controlled trial , 2014, Epilepsia.

[102]  J. Rausch,et al.  Parent and family stress factors predict health‐related quality in pediatric patients with new‐onset epilepsy , 2014, Epilepsia.

[103]  M. Gandy,et al.  Cognitive Behaviour Therapy to Improve Mood in People with Epilepsy: A Randomised Controlled Trial , 2014, Cognitive behaviour therapy.

[104]  P. Kwan,et al.  Psychobehavioral therapy for epilepsy , 2014, Epilepsy & Behavior.

[105]  N. Nayeri,et al.  The effect of self-management training on health-related quality of life in patients with epilepsy , 2015, Epilepsy & Behavior.

[106]  Anup D. Patel,et al.  Quality improvement in neurology , 2015, Neurology.

[107]  P. Kwan,et al.  Mindfulness-based therapy for drug-resistant epilepsy , 2015, Neurology.

[108]  G. Baker,et al.  Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, 2013–2017 , 2015, Epilepsia.

[109]  Saeid Abbasi,et al.  Efficacy of Attribution Retraining on Mental Health of Epileptic Children , 2015, Iranian Red Crescent medical journal.

[110]  A. Modi,et al.  Health care charges for youth with newly diagnosed epilepsy , 2015, Neurology.

[111]  Dulaney A. Wilson,et al.  Population‐based comparative analysis of risk of death in children and adolescents with epilepsy and migraine , 2015, Epilepsia.

[112]  E. Kerr,et al.  Near‐transfer effects following working memory intervention (Cogmed) in children with symptomatic epilepsy: An open randomized clinical trial , 2015, Epilepsia.

[113]  D. Friedman,et al.  Illness perceptions mediate the relationship between depression and quality of life in patients with epilepsy , 2015, Epilepsia.

[114]  A. Pakpour,et al.  A randomized controlled multimodal behavioral intervention trial for improving antiepileptic drug adherence , 2015, Epilepsy & Behavior.

[115]  C. Begley,et al.  Expanding the efficacy of Project UPLIFT: Distance delivery of mindfulness-based depression prevention to people with epilepsy. , 2015, Journal of consulting and clinical psychology.

[116]  Lisa M. Caylor,et al.  PACES in epilepsy: Results of a self‐management randomized controlled trial , 2015, Epilepsia.

[117]  M. Reuber,et al.  Cognitive impairment in adults with epilepsy: The relationship between subjective and objective assessments of cognition , 2015, Epilepsy & Behavior.

[118]  D. Dash,et al.  Impact of health education on drug adherence and self-care in people with epilepsy with low education , 2015, Epilepsy & Behavior.

[119]  I. Martínez-Juárez,et al.  Treatment of depression in patients with temporal lobe epilepsy: A pilot study of cognitive behavioral therapy vs. selective serotonin reuptake inhibitors , 2015, Epilepsy & Behavior.

[120]  A. Modi,et al.  Depression screening in pediatric epilepsy: Evidence for the benefit of a behavioral medicine service in early detection , 2015, Epilepsy & Behavior.

[121]  B. Thombs,et al.  Empirically Supported Treatment: Recommendations for a New Model , 2015 .

[122]  M. Vossoughi,et al.  Effect of motivational interviewing on quality of life in patients with epilepsy , 2016, Epilepsy & Behavior.

[123]  Tanja S. Kellermann,et al.  Development and validation of the NDDI‐E‐Y: a screening tool for depressive symptoms in pediatric epilepsy , 2016, Epilepsia.

[124]  W. Kronenberger,et al.  Epilepsy and attention-deficit hyperactivity disorder: links, risks, and challenges , 2016, Neuropsychiatric disease and treatment.

[125]  A. Pakpour,et al.  Correlation between adherence to antiepileptic drugs and quality of life in patients with epilepsy: A longitudinal study , 2016, Epilepsy & Behavior.

[126]  H. Meng,et al.  Systemic Family Therapy of Comorbidity of Anxiety and Depression with Epilepsy in Adolescents , 2016, Psychiatry investigation.

[127]  J. Rausch,et al.  A pilot randomized controlled clinical trial to improve antiepileptic drug adherence in young children with epilepsy , 2016, Epilepsia.

[128]  J. Rausch,et al.  Predictors of trajectories of epilepsy-specific quality of life among children newly diagnosed with epilepsy , 2016, Epilepsy & Behavior.

[129]  A. Aldenkamp,et al.  Psychiatric and Behavioural Disorders in Children with Epilepsy (ILAE Task Force Report): Anxiety, depression and childhood epilepsy. , 2016, Epileptic disorders : international epilepsy journal with videotape.

[130]  B. Schmitz,et al.  Efficacy of the epilepsy nurse: Results of a randomized controlled study , 2016, Epilepsia.

[131]  Shane W. Goodwin,et al.  Measurement equivalence of the newly developed Quality of Life in Childhood Epilepsy Questionnaire (QOLCE‐55) , 2016, Epilepsia.

[132]  Barbara C. Jobst,et al.  A cognitive behavioral intervention (HOBSCOTCH) improves quality of life and attention in epilepsy , 2016, Epilepsy & Behavior.

[133]  H. Hamer,et al.  Nonadherence to antiepileptic drugs in Germany , 2016, Neurology.

[134]  J. Rausch,et al.  Trajectories of Health-Related Quality of Life Among Children With Newly Diagnosed Epilepsy. , 2016, Journal of pediatric psychology.

[135]  G. Jackson,et al.  Two distinct symptom-based phenotypes of depression in epilepsy yield specific clinical and etiological insights , 2016, Epilepsy & Behavior.

[136]  A. Modi,et al.  Preliminary feasibility and efficacy of text messaging and application-based adherence interventions in adolescents with epilepsy , 2016, Epilepsy & Behavior.

[137]  J. Varni,et al.  Development of the PedsQL™ Epilepsy Module: Focus group and cognitive interviews , 2016, Epilepsy & Behavior.

[138]  Inbal Nahum-Shani,et al.  Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions , 2016, Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53.

[139]  S. Taylor,et al.  Characteristics associated with quality of life among people with drug-resistant epilepsy , 2017, Journal of Neurology.

[140]  Matthew Schmidt,et al.  Development of a web-based executive functioning intervention for adolescents with epilepsy: The Epilepsy Journey , 2017, Epilepsy & Behavior.

[141]  L. Goldstein,et al.  Psychological treatments for people with epilepsy. , 2017, The Cochrane database of systematic reviews.

[142]  Tanja S. Kellermann,et al.  Validation of the PedsQL Epilepsy Module: A pediatric epilepsy‐specific health‐related quality of life measure , 2017, Epilepsia.

[143]  Tanja S. Kellermann,et al.  Prediction of specific depressive symptom clusters in youth with epilepsy: The NDDI‐E‐Y versus Neuro‐QOL SF , 2017, Epilepsia.

[144]  J. Rausch,et al.  The impact of nonadherence to antiseizure drugs on seizure outcomes in an animal model of epilepsy , 2017, Epilepsia.

[145]  Self‐management interventions in pediatric epilepsy: What is the level of evidence? , 2017, Epilepsia.

[146]  Janelle L. Wagner,et al.  Pediatric Epilepsy and Behavioral Health: The State of the Literature and Directions for Evidence-Based Interprofessional Care, Training, and Research , 2017 .

[147]  M. Reuber,et al.  Predictors of health-related quality of life in patients with epilepsy and psychogenic nonepileptic seizures , 2017, Epilepsy & Behavior.

[148]  L. Goldstein,et al.  Cochrane systematic review and meta‐analysis of the impact of psychological treatments for people with epilepsy on health‐related quality of life , 2018, Epilepsia.