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  • Review Article
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The role of social context in cognitive and neurobehavioural outcomes in epilepsy

Nature Reviews Neurology volume 22, pages 152–171 (2026) Cite this article

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Abstract

Cognitive and psychiatric comorbidities are among the most persistent and disabling challenges experienced by children and adults with epilepsy, with serious implications for daily functioning, health-care utilization, long-term social outcomes and quality of life. Traditionally, research has focused on epilepsy-specific biological risk factors, such as seizure frequency or epilepsy syndrome, but growing evidence indicates that non-medical factors also shape neurodevelopmental, cognitive and neurobehavioural trajectories. This Review explores how individual-level and neighbourhood-level social factors, including income, education, health-care access and neighbourhood deprivation, contribute to disparities in cognitive and neurobehavioural outcomes across the lifespan in people with epilepsy. We propose the SocioBioCognitive Epilepsy framework, which integrates biological and social factors to better explain the heterogeneity of these outcomes, emphasizing critical developmental windows. We also recommend strategies to address social contributors to epilepsy, including self-management programmes, integration of community health workers into care teams and policy initiatives to address social needs in clinical settings. We highlight the need for a paradigm shift in epilepsy care from a seizure-centric model to a strategy that embraces holistic approaches across medical, educational and community domains. Future research should investigate the reversibility of social factors, explore biological mechanisms that link social adversity to brain outcomes and evaluate the real-world impact of integrated interventions.

Key points

  • Cognitive and psychiatric challenges in epilepsy are shaped not only by biological factors but also by social determinants such as income, education and neighbourhood disadvantage, which independently predict poor outcomes.

  • Empirical studies show that early-life disadvantage, individual socioeconomic status and neighbourhood deprivation affect cognitive and neurobehavioural outcomes in both children and adults with epilepsy, independently of seizure severity.

  • A new epilepsy care model must integrate social and biological influences, moving beyond seizure-focused approaches to address broader factors affecting health, quality of life and cognitive function.

  • We propose the SocioBioCognitive Epilepsy framework, which combines biological and social risk factors across developmental stages to better understand and target the multidimensional causes of neurobehavioural and cognitive outcomes in epilepsy.

  • Improving epilepsy outcomes requires self-management programmes, community health workers, multisector collaboration and policy change, alongside research exploring how reversing social disadvantage could improve brain health over the lifespan.

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Fig. 1: Causes of cognitive and neurobehavioural outcomes in epilepsy.
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Fig. 2: Social determinants of health.
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Fig. 3: The SocioBioCognitive Epilepsy framework.
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Fig. 4: US epilepsy initiatives and networks.
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References

  1. Aldenkamp, A. & Bodde, N. Behaviour, cognition and epilepsy. Acta Neurol. Scand. 112, 19–25 (2005).

    Article  Google Scholar 

  2. Hermann, B. & Seidenberg, M. Epilepsy and cognition. Epilepsy Curr. 7, 1–6 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Auvin, S. Paediatric epilepsy and cognition. Dev. Med. Child Neurol. 64, 1444–1452 (2022).

    Article  PubMed  Google Scholar 

  4. Novak, A., Vizjak, K. & Rakusa, M. Cognitive impairment in people with epilepsy. J. Clin. Med. 11, 267 (2022).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Oyegbile-Chidi, T. et al. The nature and course of neuropsychological morbidity in chronic temporal lobe epilepsy. Neurology 62, 1736–1742 (2004).

    Article  Google Scholar 

  6. Helmstaedter, C. & Witt, J.-A. Epilepsy and cognition — a bidirectional relationship? Seizure 49, 83–89 (2017).

    Article  PubMed  Google Scholar 

  7. Baxendale, S., Heaney, D., Thompson, P. J. & Duncan, J. S. Cognitive consequences of childhood-onset temporal lobe epilepsy across the adult lifespan. Neurology 75, 705–711 (2010).

    Article  PubMed  Google Scholar 

  8. Mula, M., Kanner, A. M., Jetté, N. & Sander, J. W. Psychiatric comorbidities in people with epilepsy. Neurol. Clin. Pract. 11, e112–e120 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kwon, C.-S. et al. Psychiatric comorbidities in persons with epilepsy compared with persons without epilepsy: a systematic review and meta-analysis. JAMA Neurol. 82, 72–84 (2024).

    Article  Google Scholar 

  10. Tellez-Zenteno, J. F., Patten, S. B., Jetté, N., Williams, J. & Wiebe, S. Psychiatric comorbidity in epilepsy: a population-based analysis. Epilepsia 48, 2336–2344 (2007).

    Article  PubMed  Google Scholar 

  11. Braakman, H. M. et al. Cognitive and behavioral complications of frontal lobe epilepsy in children: a review of the literature. Epilepsia 52, 849–856 (2011).

    Article  PubMed  Google Scholar 

  12. Menlove, L. & Reilly, C. Memory in children with epilepsy: a systematic review. Seizure 25, 126–135 (2015).

    Article  PubMed  Google Scholar 

  13. Gulati, S., Yoganathan, S. & Chakrabarty, B. Epilepsy, cognition and behavior. Ind. J. Pediatr. 81, 1056–1062 (2014).

    Article  Google Scholar 

  14. Nickels, K. C., Zaccariello, M. J., Hamiwka, L. D. & Wirrell, E. C. Cognitive and neurodevelopmental comorbidities in paediatric epilepsy. Nat. Rev. Neurol. 12, 465–476 (2016).

    Article  CAS  PubMed  Google Scholar 

  15. Baum, K. T. et al. The effect of temperament and neuropsychological functioning on behavior problems in children with new-onset seizures. Epilepsy Behav. 17, 467–473 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  16. Sillanpää, M. et al. Psychiatric and behavioural disorders in children with epilepsy (ILAE Task Force Report): epidemiology of psychiatric/behavioural disorder in children with epilepsy. Epileptic Disord. 18, S2–S7 (2016).

    Article  Google Scholar 

  17. Austin, J. K. et al. Recurrent seizures and behavior problems in children with first recognized seizures: a prospective study. Epilepsia 43, 1564–1573 (2002).

    Article  PubMed  Google Scholar 

  18. Almane, D. N. et al. The timing, nature, and range of neurobehavioral comorbidities in juvenile myoclonic epilepsy. Pediatr. Neurol. 101, 47–52 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lagunju, I., Bella-Awusah, T., Takon, I. & Omigbodun, O. Mental health problems in Nigerian children with epilepsy: associations and risk factors. Epilepsy Behav. 25, 214–218 (2012).

    Article  CAS  PubMed  Google Scholar 

  20. Dreier, J. W., Pedersen, C. B., Cotsapas, C. & Christensen, J. Childhood seizures and risk of psychiatric disorders in adolescence and early adulthood: a Danish nationwide cohort study. Lancet Child Adolesc. Health 3, 99–108 (2019).

    Article  PubMed  Google Scholar 

  21. Scott, A. J., Sharpe, L., Loomes, M. & Gandy, M. Systematic review and meta-analysis of anxiety and depression in youth with epilepsy. J. Pediatr. Psychol. 45, 133–144 (2020).

    Article  PubMed  Google Scholar 

  22. Powell, K. et al. Cognition and behavior in a prevalent cohort of children with epilepsy in rural northern Tanzania: a three-year follow-up study. Epilepsy Behav. 51, 117–123 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Hackett, R., Hackett, L. & Bhakta, P. Psychiatric disorder and cognitive function in children with epilepsy in Kerala, South India. Seizure 7, 321–324 (1998).

    Article  CAS  PubMed  Google Scholar 

  24. Yogarajah, M. & Mula, M. Social cognition, psychiatric comorbidities, and quality of life in adults with epilepsy. Epilepsy Behav. 100, 106321 (2019).

    Article  PubMed  Google Scholar 

  25. Ehrlich, T. et al. Beyond depression: the impact of executive functioning on quality of life in patients with temporal lobe epilepsy. Epilepsy Res. 149, 30–36 (2019).

    Article  PubMed  Google Scholar 

  26. Engelhart, P. et al. Determinants of health-related quality of life of patients with focal epilepsy: a systematic literature review. Epileptic Disord. 27, 9–30 (2025).

    Article  PubMed  Google Scholar 

  27. Giovagnoli, A. R. et al. Self-rated and assessed cognitive functions in epilepsy: impact on quality of life. Epilepsy Res. 108, 1461–1468 (2014).

    Article  PubMed  Google Scholar 

  28. McAuley, J. W. et al. Comparing patients’ and practitioners’ views on epilepsy concerns: a call to address memory concerns. Epilepsy Behav. 19, 580–583 (2010).

    Article  PubMed  Google Scholar 

  29. Hermann, B. P. et al. Neurobehavioural comorbidities of epilepsy: towards a network-based precision taxonomy. Nat. Rev. Neurol. 17, 731–746 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Allone, C. et al. Neuroimaging and cognitive functions in temporal lobe epilepsy: a review of the literature. J. Neurol. Sci. 381, 7–15 (2017).

    Article  PubMed  Google Scholar 

  31. Leyden, K. M. et al. What does diffusion tensor imaging (DTI) tell us about cognitive networks in temporal lobe epilepsy? Quant. Imaging Med. Surg. 5, 247–263 (2015).

    PubMed  PubMed Central  Google Scholar 

  32. Stasenko, A., Lin, C., Bonilha, L., Bernhardt, B. C. & McDonald, C. R. Neurobehavioral and clinical comorbidities in epilepsy: the role of white matter network disruption. Neuroscientist 30, 105–131 (2024).

    Article  CAS  PubMed  Google Scholar 

  33. Ives-Deliperi, V. & Butler, J. T. Mechanisms of cognitive impairment in temporal lobe epilepsy: a systematic review of resting-state functional connectivity studies. Epilepsy Behav. 115, 107686 (2021).

    Article  PubMed  Google Scholar 

  34. Fisher, R. S. et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 55, 475–482 (2014).

    Article  PubMed  Google Scholar 

  35. Singh, G. & Sander, J. W. The global burden of epilepsy report: implications for low-and middle-income countries. Epilepsy Behav. 105, 106949 (2020).

    Article  PubMed  Google Scholar 

  36. Jacoby, A. et al. Meanings of epilepsy in its sociocultural context and implications for stigma: findings from ethnographic studies in local communities in China and Vietnam. Epilepsy Behav. 12, 286–297 (2008).

    Article  CAS  PubMed  Google Scholar 

  37. Guo, W. et al. The stigma of people with epilepsy is demonstrated at the internalized, interpersonal and institutional levels in a specific sociocultural context: findings from an ethnographic study in rural China. Epilepsy Behav. 25, 282–288 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Solar, O. & Irwin, A. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). https://iris.who.int/server/api/core/bitstreams/ca294183-3263-470f-a5fe-8e124ec48c72/content (WHO, 2010).

  39. Braveman, P. & Gottlieb, L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 129, 19–31 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Griffith, D. M., Towfighi, A., Manson, S. M., Littlejohn, E. L. & Skolarus, L. E. Determinants of inequities in neurologic disease, health, and well-being: the NINDS social determinants of health framework. Neurology 101, S75–S81 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  41. Walsh, S., Merrick, R. & Brayne, C. The relevance of social and commercial determinants for neurological health. Lancet Neurol. 21, 1151–1160 (2022).

    Article  PubMed  Google Scholar 

  42. Venkataramany, B. S. & Sutton, J. M. Social determinants of health in oncology: towards a more personalized and equitable delivery of cancer care. Am. J. Clin. Oncol. 45, 273–278 (2022).

    Article  PubMed  Google Scholar 

  43. Adkins-Jackson, P. B. et al. The structural and social determinants of Alzheimer’s disease related dementias. Alzheimer’s Dement. 19, 3171–3185 (2023).

    Article  Google Scholar 

  44. Brandt, E. J. et al. Assessing and addressing social determinants of cardiovascular health: JACC state-of-the-art review. J. Am. Coll. Cardiol. 81, 1368–1385 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  45. Singu, S., Acharya, A., Challagundla, K. & Byrareddy, S. N. Impact of social determinants of health on the emerging COVID-19 pandemic in the United States. Front. Public Health 8, 406 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  46. Gómez, C. A. et al. Addressing health equity and social determinants of health through healthy people 2030. J. Public Health Manag. Pract. 27, S249–S257 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Szaflarski, M. Social determinants of health in epilepsy. Epilepsy Behav. 41, 283–289 (2014).

    Article  PubMed  Google Scholar 

  48. Bensken, W. P. et al. A framework for health equity in people living with epilepsy. Epilepsy Res. 188, 107038 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  49. Epilepsy: A Public Health Imperative. Summary (WHO/MSD/MER/19.2). https://iris.who.int/server/api/core/bitstreams/86547fff-ceeb-4bfd-9956-14323eaf6194/content (WHO, 2019).

  50. Burneo, J. G. et al. Disparities in epilepsy: report of a systematic review by the North American Commission of the International League Against Epilepsy. Epilepsia 50, 2285–2295 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Birbeck, G., Chomba, E., Atadzhanov, M., Mbewe, E. & Haworth, A. The social and economic impact of epilepsy in Zambia: a cross-sectional study. Lancet Neurol. 6, 39–44 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  52. Jennum, P., Debes, N. M. M., Ibsen, R. & Kjellberg, J. Long-term employment, education, and healthcare costs of childhood and adolescent onset of epilepsy. Epilepsy Behav. 114, 107256 (2021).

    Article  PubMed  Google Scholar 

  53. Kobau, R. et al. Epilepsy surveillance among adults — 19 states, behavioral risk factor surveillance system, 2005. MMWR Surveill. Summ. 57, 1–20 (2008).

    PubMed  Google Scholar 

  54. Livingston, G. et al. Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission. Lancet 404, 572–628 (2024).

    Article  PubMed  Google Scholar 

  55. Braveman, P., Egerter, S. & Williams, D. R. The social determinants of health: coming of age. Annu. Rev. Public Health 32, 381–398 (2011).

    Article  PubMed  Google Scholar 

  56. Stites, S. D. et al. Establishing a framework for gathering structural and social determinants of health in Alzheimer’s disease research centers. Gerontologist 62, 694–703 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  57. US Centers For Disease Control And Prevention Epilepsy Program. About one-half of adults with active epilepsy and seizures have annual family incomes under $25,000: the 2010 and 2013 US National Health Interview Surveys. Epilepsy Behav. 58, 33–34 (2016).

    Article  CAS  PubMed  Google Scholar 

  58. Allers, K. et al. The economic impact of epilepsy: a systematic review. BMC Neurol. 15, 245 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  59. Komolafe, M. A. et al. The social and economic impacts of epilepsy on women in Nigeria. Epilepsy Behav. 24, 97–101 (2012).

    Article  PubMed  Google Scholar 

  60. Wilmshurst, J. M., Birbeck, G. L. & Newton, C. R. Epilepsy is ubiquitous, but more devastating in the poorer regions of the world… or is it? Epilepsia 55, 1322–1325 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  61. Nimmo-Smith, V., Brugha, T. S., Kerr, M. P., McManus, S. & Rai, D. Discrimination, domestic violence, abuse, and other adverse life events in people with epilepsy: population-based study to assess the burden of these events and their contribution to psychopathology. Epilepsia 57, 1870–1878 (2016).

    Article  PubMed  Google Scholar 

  62. De Boer, H. M., Mula, M. & Sander, J. W. The global burden and stigma of epilepsy. Epilepsy Behav. 12, 540–546 (2008).

    Article  PubMed  Google Scholar 

  63. de Boer, H. M. Epilepsy stigma: moving from a global problem to global solutions. Seizure 19, 630–636 (2010).

    Article  PubMed  Google Scholar 

  64. Elliott, J. O., Charyton, C., Sprangers, P., Lu, B. & Moore, J. L. The impact of marriage and social support on persons with active epilepsy. Epilepsy Behav. 20, 533–538 (2011).

    Article  PubMed  Google Scholar 

  65. Kinariwalla, N. & Sen, A. The psychosocial impact of epilepsy on marriage: a narrative review. Epilepsy Behav. 63, 34–41 (2016).

    Article  PubMed  Google Scholar 

  66. von Gaudecker, J. R., Buelow, J. M., Miller, W. R., Tanner, A. L. & Austin, J. K. Social determinants of health associated with epilepsy treatment adherence in the United States: a scoping review. Epilepsy Behav. 124, 108328 (2021).

    Article  Google Scholar 

  67. Nathan, C. L. & Gutierrez, C. FACETS of health disparities in epilepsy surgery and gaps that need to be addressed. Neurol. Clin. Pract. 8, 340–345 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Correa, D. J. & Gutierrez, C. A. in Achieving Equity in Neurological Practice: Principles and Pathways 91–123 (Springer, 2024).

  69. Kiriakopoulos, E. T. et al. Shining a light: advancing health equity in overlooked epilepsy communities. Epilepsy Curr. https://doi.org/10.1177/15357597241258081 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  70. Andersson, K. et al. Socioeconomic outcome and access to care in adults with epilepsy in Sweden: a nationwide cohort study. Seizure 74, 71–76 (2020).

    Article  PubMed  Google Scholar 

  71. Begley, C. et al. Socioeconomic status, health care use, and outcomes: persistence of disparities over time. Epilepsia 52, 957–964 (2011).

    Article  PubMed  Google Scholar 

  72. Groover, O. et al. Mind the gap: health disparities in families living with epilepsy are significant and linked to socioeconomic status. Epileptic Disord. 22, 782–789 (2020).

    Article  PubMed  Google Scholar 

  73. Rubinger, L. et al. Socioeconomic status influences time to surgery and surgical outcome in pediatric epilepsy surgery. Epilepsy Behav. 55, 133–138 (2016).

    Article  PubMed  Google Scholar 

  74. Cihan, E. et al. Socioeconomic disparities in SUDEP in the US. Neurology 94, e2555–e2566 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  75. Reyes, A. et al. Disentangling deprivation: differential associations of the area deprivation index-3 factors with clinical, cognitive, and mood outcomes in epilepsy. Epilepsy Behav. 175, 110833 (2026).

    Article  PubMed  Google Scholar 

  76. Maloney, E. M., Corcoran, P., Costello, D. J. & O’Reilly, ÉJ. Association between social deprivation and incidence of first seizures and epilepsy: a prospective population-based cohort. Epilepsia 63, 2108–2119 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  77. Johnson, K. L., Wood, A. J., Hsia, R. Y. & Guterman, E. L. Characterizing emergency department and inpatient health care utilization after seizure-related hospitalization: a retrospective cohort study. Epilepsia 65, 698–708 (2024).

    Article  PubMed  Google Scholar 

  78. Paschal, A. M., Rush, S. E. & Sadler, T. Factors associated with medication adherence in patients with epilepsy and recommendations for improvement. Epilepsy Behav. 31, 346–350 (2014).

    Article  PubMed  Google Scholar 

  79. Thurman, D. J., Kobau, R., Luo, Y.-H., Helmers, S. L. & Zack, M. M. Health-care access among adults with epilepsy: the US National Health Interview Survey, 2010 and 2013. Epilepsy Behav. 55, 184–188 (2016).

    Article  PubMed  Google Scholar 

  80. Louis, S., Rabah, N., Rammo, R., Bingaman, W. & Jehi, L. Disparities in the nationwide distribution of epilepsy centers. Epilepsy Behav. 125, 108409 (2021).

    Article  PubMed  Google Scholar 

  81. Parko, K. & Thurman, D. J. Prevalence of epilepsy and seizures in the Navajo Nation 1998–2002. Epilepsia 50, 2180–2185 (2009).

    Article  PubMed  Google Scholar 

  82. Maqbool, U. et al. Disparities in epilepsy-associated mortality trends in the United States of America over two decades. J. Clin. Neurosci. 138, 111396 (2025).

    Article  PubMed  Google Scholar 

  83. Szaflarski, M. Racialized inequities in epilepsy burden and treatment. Neurol. Clin. 40, 821–830 (2022).

    Article  PubMed  Google Scholar 

  84. Ghebrehiwet, M. et al. Inequities in epilepsy: a scoping review. Neurol. Clin. Pract. 13, e200211 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  85. Town, M. Racial and ethnic differences in social determinants of health and health-related social needs among adults — behavioral risk factor surveillance system, United States, 2022. MMWR Morbidity Mortal. Wkly Rep. 73, 204–208 (2024).

    Article  Google Scholar 

  86. Saadi, A., Himmelstein, D. U., Woolhandler, S. & Mejia, N. I. Racial disparities in neurologic health care access and utilization in the United States. Neurology 88, 2268–2275 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  87. Bensken, W. P. et al. Racial and ethnic differences in antiseizure medications among people with epilepsy on Medicaid: a case of potential inequities. Neurol. Clin. Pract. 13, e200101 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  88. Martin, R. C. et al. What does the US Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia 58, 548–557 (2017).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  89. McClelland, S. 3rd, Guo, H. & Okuyemi, K. S. Racial disparities in the surgical management of intractable temporal lobe epilepsy in the United States: a population-based analysis. Arch. Neurol. 67, 577–583 (2010).

    Article  PubMed  Google Scholar 

  90. Burneo, J. G. et al. Racial disparities in the use of surgical treatment for intractable temporal lobe epilepsy. Neurology 64, 50–54 (2005).

    Article  CAS  PubMed  Google Scholar 

  91. Sánchez Fernández, I., Stephen, C. & Loddenkemper, T. Disparities in epilepsy surgery in the United States of America. J. Neurol. 264, 1735–1745 (2017).

    Article  PubMed  Google Scholar 

  92. Kong, W. Y., Saber, H., Marawar, R. & Basha, M. M. Racial and ethnic trends in antiseizure medications trial enrolment: a systematic review using ClinicalTrials.gov. Epilepsy Res. 173, 106613 (2021).

    Article  PubMed  Google Scholar 

  93. Pisu, M. et al. High health care costs in minority groups of older US Medicare beneficiaries with epilepsy. Epilepsia 60, 1462–1471 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  94. Homan, P., Brown, T. H. & King, B. Structural intersectionality as a new direction for health disparities research. J. Health Soc. Behav. 62, 350–370 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  95. Espinosa-Jovel, C., Toledano, R., Aledo-Serrano, Á., García-Morales, I. & Gil-Nagel, A. Epidemiological profile of epilepsy in low income populations. Seizure 56, 67–72 (2018).

    Article  PubMed  Google Scholar 

  96. Radhakrishnan, K. Challenges in the management of epilepsy in resource-poor countries. Nat. Rev. Neurol. 5, 323–330 (2009).

    Article  PubMed  Google Scholar 

  97. Alderwick, H. & Gottlieb, L. M. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 97, 407 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  98. Van Schooneveld, M. M. & Braun, K. P. Cognitive outcome after epilepsy surgery in children. Brain Dev. 35, 721–729 (2013).

    Article  PubMed  Google Scholar 

  99. Sajobi, T. T. et al. Multivariate trajectories across multiple domains of health-related quality of life in children with new-onset epilepsy. Epilepsy Behav. 75, 72–78 (2017).

    Article  PubMed  Google Scholar 

  100. Yam, W. K. et al. Health-related quality of life of children with epilepsy in Hong Kong: how does it compare with that of youth with epilepsy in Canada? Epilepsy Behav. 12, 419–426 (2008).

    Article  PubMed  Google Scholar 

  101. Boesen, M. S. et al. School performance and psychiatric comorbidity in juvenile absence epilepsy and juvenile myoclonic epilepsy: a Danish population-based cohort study. J. Neurol. 269, 4997–5007 (2022).

    Article  PubMed  Google Scholar 

  102. Berg, A. T. et al. Determinants of social outcomes in adults with childhood-onset epilepsy. Pediatrics 137, e20153944 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  103. Morales, K. et al. Long-term characterization of behavior phenotypes in children with seizures: analytic approach matters. Epilepsia 66, 265–278 (2025).

    Article  PubMed  Google Scholar 

  104. Oyegbile-Chidi, T. et al. The relationship between sleep, cognition and behavior in children with newly-diagnosed epilepsy over 36 months. Front. Neurol. 13, 903137 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  105. Eisner, J. et al. Long-term characterization of cognitive phenotypes in children with seizures over 36 months. Epilepsy Behav. 154, 109742 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  106. Hermann, B. P., Jones, J. E., Jackson, D. C. & Seidenberg, M. Starting at the beginning: the neuropsychological status of children with new-onset epilepsies. Epileptic Disord. 14, 12–21 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Oyegbile-Chidi, T. et al. Impact of sociodemographic disadvantage on neurobehavioral outcomes in children with newly diagnosed seizures and their unaffected siblings over 36 months. Epilepsia 64, 2172–2185 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  108. Morales, K. et al. Stratifying cognitive and behavioral comorbidities in children with new-onset seizures — the influence of sociodemographic disadvantage. Epilepsy Behav. 165, 110267 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  109. Oyegbile-Chidi, T. et al. The impact of sociodemographic disadvantage on cognitive outcomes in children with newly diagnosed seizures and their unaffected siblings over 36 months. Pediatr. Neurol. 148, 178–188 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  110. Struck, A. F. et al. Cognitive and brain health in juvenile myoclonic epilepsy: role of social determinants of health. Epilepsia 66, 1641–1651 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  111. Chin, R. F. et al. Outcomes of childhood epilepsy at age 33 years: a population-based birth-cohort study. Epilepsia 52, 1513–1521 (2011).

    Article  PubMed  Google Scholar 

  112. Tang, T., Zhang, R. & Pan, X. Meta-analysis of the risk of dementia in elderly patients with late-onset epilepsy. Clin. Neurol. Neurosurg. 223, 107499 (2022).

    Article  PubMed  Google Scholar 

  113. Stern, Y. Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol. 11, 1006–1012 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  114. Reyes, A. et al. Moving towards a taxonomy of cognitive impairments in epilepsy: application of latent profile analysis to 1178 patients with temporal lobe epilepsy. Brain Commun. 4, fcac289 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  115. Reyes, A. et al. Cognitive phenotypes in late-onset epilepsy: results from the atherosclerosis risk in communities study. Front. Neurol. 14, 1230368 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  116. Wang, L., Chen, S., Liu, C., Lin, W. & Huang, H. Factors for cognitive impairment in adult epileptic patients. Brain Behav. 10, e01475 (2020).

    Article  PubMed  Google Scholar 

  117. Hohmann, L., Holtkamp, M., Oltmanns, F. & Bengner, T. Associations of individual and structural socioeconomic status with cognition and mental distress in pharmacoresistant focal epilepsy. Epilepsy Behav. 116, 107726 (2021).

    Article  PubMed  Google Scholar 

  118. Partanen, E., Laari, S., Kantele, O., Kämppi, L. & Nybo, T. Associations between cognition and employment outcomes after epilepsy surgery. Epilepsy Behav. 131, 108709 (2022).

    Article  PubMed  Google Scholar 

  119. Hoffman, C. & Paradise, J. Health insurance and access to health care in the United States. Ann. N. Y. Acad. Sci. 1136, 149–160 (2008).

    Article  PubMed  Google Scholar 

  120. Weaver, M. R. et al. Variation in health care access and quality among US states and high-income countries with universal health insurance coverage. JAMA Netw. Open 4, e2114730 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  121. Nguyen, K. H. & Sommers, B. D. Access and quality of care by insurance type for low-income adults before the affordable care act. Am. J. Public Health 106, 1409–1415 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  122. Kamitaki, B. K. et al. Health insurance and transportation barriers impact access to epilepsy care in the United States. Epilepsy Res. 205, 107424 (2024).

    Article  PubMed  Google Scholar 

  123. Halpern, M. T., Renaud, J. M. & Vickrey, B. G. Impact of insurance status on access to care and out-of-pocket costs for US individuals with epilepsy. Epilepsy Behav. 22, 483–489 (2011).

    Article  PubMed  Google Scholar 

  124. Tian, N., Kobau, R., Zack, M. & Greenlund, K. J. Barriers to and disparities in access to health care among adults aged ≥18 years with epilepsy — United States, 2015 and 2017. MMWR Morb. Mortal. Wkly Rep. 71, 697–702 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  125. Puka, K., Smith, M. L., Moineddin, R., Snead, O. C. & Widjaja, E. The influence of socioeconomic status on health resource utilization in pediatric epilepsy in a universal health insurance system. Epilepsia 57, 455–463 (2016).

    Article  PubMed  Google Scholar 

  126. Reyes, A. et al. Individual-and community-level social determinants of health are associated with cognition in older adults with focal epilepsy. Epilepsy Behav. 158, 109927 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  127. Ross, C. E. & Mirowsky, J. The interaction of personal and parental education on health. Soc. Sci. Med. 72, 591–599 (2011).

    Article  PubMed  Google Scholar 

  128. Wang, X.-J. et al. Early-life risk factors for dementia and cognitive impairment in later life: a systematic review and meta-analysis. J. Alzheimer’s Dis. 67, 221–229 (2019).

    Article  Google Scholar 

  129. Glymour, M. M. & Manly, J. J. Lifecourse social conditions and racial and ethnic patterns of cognitive aging. Neuropsychol. Rev. 18, 223–254 (2008).

    Article  PubMed  Google Scholar 

  130. Li, Z. A. et al. Associations between socioeconomic status, obesity, cognition, and white matter microstructure in children. JAMA Netw. Open 6, e2320276 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  131. Chu, D. Y. et al. Association of neighborhood deprivation with white matter connectome abnormalities in temporal lobe epilepsy. Epilepsia 64, 2484–2498 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  132. Fuller-Thomson, E. & Brennenstuhl, S. The association between depression and epilepsy in a nationally representative sample. Epilepsia 50, 1051–1058 (2009).

    Article  PubMed  Google Scholar 

  133. Pulsipher, D. T., Seidenberg, M., Jones, J. & Hermann, B. Quality of life and comorbid medical and psychiatric conditions in temporal lobe epilepsy. Epilepsy Behav. 9, 510–514 (2006).

    Article  PubMed  Google Scholar 

  134. Gu, X.-M. et al. Influence of occupational status on the quality of life of Chinese adult patients with epilepsy. Chin. Med. J. 129, 1285–1290 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  135. Alanis-Guevara, I. et al. Sleep disturbances, socioeconomic status, and seizure control as main predictors of quality of life in epilepsy. Epilepsy Behav. 7, 481–485 (2005).

    Article  CAS  PubMed  Google Scholar 

  136. Jacoby, A., Snape, D. & Baker, G. A. Determinants of quality of life in people with epilepsy. Neurol. Clin. 27, 843–863 (2009).

    Article  PubMed  Google Scholar 

  137. Jokeit, H. & Ebner, A. Long term effects of refractory temporal lobe epilepsy on cognitive abilities: a cross sectional study. J. Neurol. Neurosurg. Psychiatry 67, 44–50 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  138. Pai, M. C. & Tsai, J. J. Is cognitive reserve applicable to epilepsy? The effect of educational level on the cognitive decline after onset of epilepsy. Epilepsia 46, 7–10 (2005).

    Article  PubMed  Google Scholar 

  139. Stasenko, A. et al. Can bilingualism increase neuroplasticity of language networks in epilepsy? Epilepsy Res. 182, 106893 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  140. Stasenko, A. et al. Dynamic neuroplasticity of language networks: the intersection of bilingualism and epilepsy. Proc. Natl Acad. Sci. USA 122, e2422742122 (2025).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  141. Stasenko, A. et al. Bilingualism and structural network organization in temporal lobe epilepsy: resilience in neurologic disease. Neurology 100, e1887–e1899 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  142. Reyes, A. et al. Does bilingualism increase brain or cognitive reserve in patients with temporal lobe epilepsy? Epilepsia 59, 1037–1047 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  143. Alexander, H. B. & Allendorfer, J. B. The relationship between physical activity and cognitive function in people with epilepsy: a systematic review. Epilepsy Behav. 142, 109170 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  144. Stasenko, A. et al. Exercise, memory, and the hippocampus: uncovering modifiable lifestyle reserve factors in refractory epilepsy. Epilepsy Behav. Rep. 28, 100721 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  145. Feter, N., Alt, R., Häfele, C. A., da Silva, M. C. & Rombaldi, A. J. Effect of combined physical training on cognitive function in people with epilepsy: results from a randomized controlled trial. Epilepsia 61, 1649–1658 (2020).

    Article  PubMed  Google Scholar 

  146. Reyes, A. et al. The impact of cerebrovascular risk factors on postoperative memory decline in patients with left temporal lobe epilepsy. Epilepsy Behav. 102, 106558 (2020).

    Article  PubMed  Google Scholar 

  147. McCagh, J., Fisk, J. E. & Baker, G. A. Epilepsy, psychosocial and cognitive functioning. Epilepsy Res. 86, 1–14 (2009).

    Article  PubMed  Google Scholar 

  148. Chen, H.-F., Tsai, Y.-F., Hsi, M.-S. & Chen, J.-C. Factors affecting quality of life in adults with epilepsy in Taiwan: a cross-sectional, correlational study. Epilepsy Behav. 58, 26–32 (2016).

    Article  PubMed  Google Scholar 

  149. Takahashi, K. et al. Network analysis of the relationship between social support and quality of life in patients with epilepsy. Epilepsy Behav. 149, 109504 (2023).

    Article  PubMed  Google Scholar 

  150. Samtani, S. et al. Associations between social connections and cognition: a global collaborative individual participant data meta-analysis. Lancet Healthy Longev. 3, e740–e753 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  151. Diez Roux, A. V. Investigating neighborhood and area effects on health. Am. J. Public Health 91, 1783–1789 (2001).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  152. Kind, A. J. & Buckingham, W. R. Making neighborhood-disadvantage metrics accessible — the neighborhood atlas. N. Engl. J. Med. 378, 2456 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  153. Singh, G. K. Area deprivation and widening inequalities in US mortality, 1969–1998. Am. J. Public Health 93, 1137–1143 (2003).

    Article  PubMed  PubMed Central  Google Scholar 

  154. Ministry of Housing, Communities & Local Government. The English Indices of Deprivation 2019 (IoD2019) (Ministry of Housing, Communities & Local Government, 2019).

  155. Kobau, R. & Moura, L. M. The importance of understanding neighborhood environments in neurology care. Neurology 100, 1079–1080 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  156. Richardson, R., Westley, T., Gariépy, G., Austin, N. & Nandi, A. Neighborhood socioeconomic conditions and depression: a systematic review and meta-analysis. Soc. Psychiatr. Psychiatr. Epidemiol. 50, 1641–1656 (2015).

    Article  Google Scholar 

  157. Hunt, J. F. et al. Association of neighborhood context, cognitive decline, and cortical change in an unimpaired cohort. Neurology 96, e2500–e2512 (2021).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  158. Vargas, T., Damme, K. S. & Mittal, V. A. Neighborhood deprivation, prefrontal morphology and neurocognition in late childhood to early adolescence. NeuroImage 220, 117086 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  159. Baxendale, S. & Heaney, D. Socioeconomic status, cognition, and hippocampal sclerosis. Epilepsy Behav. 20, 64–67 (2011).

    Article  PubMed  Google Scholar 

  160. Schraegle, W. A. et al. Disadvantage and neurocognitive comorbidities in childhood idiopathic epilepsies. Epilepsia 64, 1663–1672 (2023).

    Article  PubMed  Google Scholar 

  161. Busch, R. M. et al. Association of neighborhood deprivation with cognitive and mood outcomes in adults with pharmacoresistant temporal lobe epilepsy. Neurology 100, e2350–e2359 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  162. Schraegle, W. A. et al. Neighborhood disadvantage and intellectual development in youth with epilepsy. Epilepsy Behav. 149, 109492 (2023).

    Article  PubMed  Google Scholar 

  163. Hohmann, L., Berger, J., Kastell, S.-U. & Holtkamp, M. Perceived epilepsy-related stigma is linked to the socioeconomic status of the residence. Front. Public Health 10, 952585 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  164. Chiang, J. A. et al. Neighborhood disadvantage and health-related quality of life in pediatric epilepsy. Epilepsy Behav. 142, 109171 (2023).

    Article  PubMed  Google Scholar 

  165. Hertzman, C. & Boyce, T. How experience gets under the skin to create gradients in developmental health. Annu. Rev. Public Health 31, 329–347 (2010).

    Article  PubMed  Google Scholar 

  166. Walker, S. P. et al. Child development: risk factors for adverse outcomes in developing countries. Lancet 369, 145–157 (2007).

    Article  PubMed  Google Scholar 

  167. Noble, K. G. et al. Family income, parental education and brain structure in children and adolescents. Nat. Neurosci. 18, 773–778 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  168. Deary, I. J., Strand, S., Smith, P. & Fernandes, C. Intelligence and educational achievement. Intelligence 35, 13–21 (2007).

    Article  Google Scholar 

  169. Deary, I. J. et al. Intergenerational social mobility and mid-life status attainment: influences of childhood intelligence, childhood social factors, and education. Intelligence 33, 455–472 (2005).

    Article  Google Scholar 

  170. Calvin, C. M. et al. Intelligence in youth and all-cause-mortality: systematic review with meta-analysis. Int. J. Epidemiol. 40, 626–644 (2011).

    Article  PubMed  Google Scholar 

  171. Gow, A. J. et al. Stability and change in intelligence from age 11 to ages 70, 79, and 87: the Lothian Birth Cohorts of 1921 and 1936. Psychol. Aging 26, 232 (2011).

    Article  PubMed  Google Scholar 

  172. Whalley, L. et al. Childhood mental ability and dementia. Neurology 55, 1455–1459 (2000).

    Article  CAS  PubMed  Google Scholar 

  173. Holochwost, S. J., Towe-Goodman, N., Rehder, P. D., Wang, G. & Mills-Koonce, W. R. Poverty, caregiving, and HPA-axis activity in early childhood. Dev. Rev. 56, 100898 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  174. Clark, U. S., Miller, E. R. & Hegde, R. R. Experiences of discrimination are associated with greater resting amygdala activity and functional connectivity. Biol. Psychiatr. Cogn. Neurosci. Neuroimaging 3, 367–378 (2018).

    Google Scholar 

  175. Finley, A. J. et al. Differences in emotion expression, suppression, and cardiovascular consequences between Black and White Americans in the Midlife in the United States (MIDUS) Study. Psychosom. Med. 86, 748–757 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  176. Rosati, F. et al. The cardiovascular conundrum in ethnic and sexual minorities: a potential biomarker of constant coping with discrimination. Front. Neurosci. 15, 619171 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  177. Wendt, J., Neubert, J., Koenig, J., Thayer, J. F. & Hamm, A. O. Resting heart rate variability is associated with inhibition of conditioned fear. Psychophysiology 52, 1161–1166 (2015).

    Article  PubMed  Google Scholar 

  178. Kulshreshtha, A. et al. Association of stress with cognitive function among older Black and White US adults. JAMA Netw. Open 6, e231860 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  179. Girotti, M., Bulin, S. E. & Carreno, F. R. Effects of chronic stress on cognitive function — from neurobiology to intervention. Neurobiol. Stress. 33, 100670 (2024).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  180. Kivimäki, M. & Steptoe, A. Effects of stress on the development and progression of cardiovascular disease. Nat. Rev. Cardiol. 15, 215–229 (2018).

    Article  PubMed  Google Scholar 

  181. Ray, M. et al. Epigenomic links between social determinants of health and symptoms: a scoping review. Biol. Res. For. Nurs. 25, 404–416 (2023).

    Article  Google Scholar 

  182. Cubbin, C., Hadden, W. C. & Winkleby, M. A. Neighborhood context and cardiovascular disease risk factors: the contribution of material deprivation. Ethnicity Dis. 11, 687–700 (2001).

    CAS  Google Scholar 

  183. Brown, A. F. et al. Neighborhood disadvantage and ischemic stroke: the Cardiovascular Health Study (CHS). Stroke 42, 3363–3368 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  184. Hunt, J. F. et al. Association of neighborhood-level disadvantage with cerebral and hippocampal volume. JAMA Neurol. 77, 451–460 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  185. Taylor, R. L., Cooper, S. R., Jackson, J. J. & Barch, D. M. Assessment of neighborhood poverty, cognitive function, and prefrontal and hippocampal volumes in children. JAMA Netw. Open 3, e2023774–e2023774 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  186. Gordon, K. E. & Dooley, J. M. Food insecurity and epilepsy in a nationally representative sample. Epilepsy Behav. 43, 139–142 (2015).

    Article  PubMed  Google Scholar 

  187. Zhong, R., Zhong, B. & Zhang, K. Epilepsy, cardiovascular health, and all-cause mortality among adults: a cohort study. Seizure Eur. J. Epilepsy 133, 37–42 (2025).

    Article  Google Scholar 

  188. Hatton, S. N. et al. White matter abnormalities across different epilepsy syndromes in adults: an ENIGMA-Epilepsy study. Brain 143, 2454–2473 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  189. Whelan, C. D. et al. Structural brain abnormalities in the common epilepsies assessed in a worldwide ENIGMA study. Brain 141, 391–408 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  190. Johnson, E. K. et al. Program of active consumer engagement in self-management in epilepsy: replication and extension of a self-management randomized controlled trial. Epilepsia 61, 1129–1141 (2020).

    Article  PubMed  Google Scholar 

  191. Sajatovic, M. et al. A 6-month prospective randomized controlled trial of remotely delivered group format epilepsy self-management versus waitlist control for high-risk people with epilepsy. Epilepsia 59, 1684–1695 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  192. Spruill, T. M. et al. Telephone-based depression self-management in Hispanic adults with epilepsy: a pilot randomized controlled trial. Transl. Behav. Med. 11, 1451–1460 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  193. Streltzov, N. A. et al. Effectiveness of a self-management program to improve cognition and quality of life in epilepsy: a pragmatic, randomized, multicenter trial. Neurology 98, e2174–e2184 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  194. Mbalinda, S. N. et al. Self-management intervention for reducing epilepsy burden among adult Ugandans with epilepsy (SMART-U): randomised clinical trial protocol. Neuropsychiatr. Dis. Treat. 20, 2277–2286 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  195. Sajatovic, M. et al. Self-management for people with epilepsy and a history of negative health events (SMART): a randomized controlled effectiveness trial. Epilepsy Behav. 171, 110495 (2025).

    Article  PubMed  Google Scholar 

  196. Escoffery, C. et al. Replication of an evidence-based epilepsy self-management program in Georgia (USA): the HOBSCOTCH trial. Epilepsy Behav. 174, 110805 (2026).

    Article  PubMed  Google Scholar 

  197. Pandey, D. K. et al. Self-management skills and behaviors, self-efficacy, and quality of life in people with epilepsy from underserved populations. Epilepsy Behav. 98, 258–265 (2019).

    Article  PubMed  Google Scholar 

  198. Quarells, R. C. et al. Depression self-management in people with epilepsy: adapting project UPLIFT for underserved populations. Epilepsy Behav. 99, 106422 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  199. Blixen, C. et al. Engaging stakeholders in the refinement of an evidence-based remotely delivered epilepsy self-management program for rural populations. Epilepsy Behav. 118, 107942 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  200. Sudhakar, S. et al. Health literacy and education level correlates of participation and outcome in a remotely delivered epilepsy self-management program. Epilepsy Behav. 107, 107026 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  201. Pandey, D. K. et al. Enhancing epilepsy self-management and quality of life for adults with epilepsy with varying social and educational backgrounds using PAUSE to Learn Your Epilepsy. Epilepsy Behav. 111, 107228 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  202. McGee, R. E. et al. Depression and quality of life among African Americans with epilepsy: findings from the Managing Epilepsy Well (MEW) network integrated database. Epilepsy Behav. 94, 301–306 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  203. Shegog, R. et al. MINDSET: clinic-based decision support demonstrates longitudinal efficacy for increased epilepsy self-management adherence among Spanish speaking patients. Epilepsy Behav. 113, 107552 (2020).

    Article  PubMed  Google Scholar 

  204. Helmers, S. L. et al. Self-management in epilepsy: why and how you should incorporate self-management in your practice. Epilepsy Behav. 68, 220 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  205. Kiriakopoulos, E. T. et al. Real world telehealth delivery of an evidence based self-management education program for people with epilepsy and cognitive comorbidity. Front. Neurol. 16, 1617539 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  206. Caller, T. A. et al. A cognitive behavioral intervention (HOBSCOTCH) improves quality of life and attention in epilepsy. Epilepsy Behav. 57, 111–117 (2016).

    Article  PubMed  Google Scholar 

  207. Kiriakopoulos, E. et al. Increasing epilepsy self-management access by embracing a HUB and SPOKE model: the HOBSCOTCH Institute Translational Network (HITN). In American Epilepsy Society Meeting https://aesnet.org/abstractslisting/increasing-epilepsy-self-management-access-by-embracing-a-hub-and-spoke-model-the-hobscotch-institute-translational-network-hitn (2024).

  208. Bernstein, L., O’Connor, S., Dawson, T. & Kiriakopoulos, E. T. Improving access to evidence based self-management: assessing pre-implementation operational context of epilepsy center clinics. In American Epilepsy Society Meeting https://aesnet.org/abstractslisting/improving-access-to-evidence-based-self-management-assessing-pre-implementation-operational-context-of-epilepsy-center-clinics (2024).

  209. Kiriakopoulos, E. et al. A qualitative analysis of clinician perspectives on community health worker integration at epilepsy centers. Front. Neurol. 16, 1560077 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  210. Chu, F. et al. Clinician and patient readiness to engage with community health workers at epilepsy care centers. Front. Neurol. 16, 1580655 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  211. Kiriakopoulos, E. T., Chu, F., Jobst, B. & Kobau, R. Innovating the practice of epilepsy care to improve patient outcomes: a model for community health worker integration. Front. Neurol. 16, 1654687 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  212. DeMuro, L. et al. Partnering to expand the nontraditional epilepsy workforce: targeting community health workers (CHW) and resource specialists in epilepsy care. In American Epilepsy Society Meeting https://aesnet.org/abstractslisting/partnering-to-expand-the-nontraditional-epilepsy-workforce-targeting-community-health-workers-chw-and-resource-specialists-in-epilepsy-care (2024).

  213. Kiriakopoulos, E. T., Dawson, T., Schmidt, S. & Jobst, B. Pilot implementation of virtual epilepsy and self-management training for community health workers. In American Epilepsy Society Meeting https://aesnet.org/abstractslisting/pilot-implementation-of-virtual-epilepsy-and-self-management-training-for-community-health-workers (2021).

  214. Ghearing, G. R. et al. A randomized controlled trial of self-management for people with epilepsy and a history of negative health events (SMART) targeting rural and underserved people with epilepsy: a methodologic report. Trials 22, 821 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  215. Kottapalli, I. et al. A community-targeted implementation of self-management for people with epilepsy and a history of negative health events (SMART): a research and community partnership to reduce epilepsy burden. Epilepsy Behav. 126, 108440 (2022).

    Article  PubMed  Google Scholar 

  216. Butler, M., Palacios, M. E., Carr, C., Moore-Hill, D. & Vale, F. L. Analysis of participant race and sex reporting and disparities in US epilepsy clinical trials. Epilepsia 66, 768–775 (2025).

    Article  PubMed  Google Scholar 

  217. Pardhan, S., Sehmbi, T., Wijewickrama, R., Onumajuru, H. & Piyasena, M. P. Barriers and facilitators for engaging underrepresented ethnic minority populations in healthcare research: an umbrella review. Int. J. Equity Health 24, 70 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  218. Taylor, L. A. et al. Leveraging the social determinants of health: what works? PLoS ONE 11, e0160217 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  219. Basu, S. et al. Estimated costs of intervening in health-related social needs detected in primary care. JAMA Intern. Med. 183, 762–774 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  220. Kangovi, S., Mitra, N., Grande, D., Long, J. A. & Asch, D. A. Evidence-based community health worker program addresses unmet social needs and generates positive return on investment: a return on investment analysis of a randomized controlled trial of a standardized community health worker program that addresses unmet social needs for disadvantaged individuals. Health Aff. 39, 207–213 (2020).

    Article  Google Scholar 

  221. Jacob, V. et al. Economics of community health workers for chronic disease: findings from community guide systematic reviews. Am. J. Prevent. Med. 56, e95–e106 (2019).

    Article  Google Scholar 

  222. Johnson, J. G., Cohen, P., Dohrenwend, B. P., Link, B. G. & Brook, J. S. A longitudinal investigation of social causation and social selection processes involved in the association between socioeconomic status and psychiatric disorders. J. Abnorm. Psychol. 108, 490 (1999).

    Article  CAS  PubMed  Google Scholar 

  223. Richard, L., Gauvin, L. & Raine, K. Ecological models revisited: their uses and evolution in health promotion over two decades. Annu. Rev. Public Health 32, 307–326 (2011).

    Article  PubMed  Google Scholar 

  224. Meijer, M., Röhl, J., Bloomfield, K. & Grittner, U. Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies. Soc. Sci. Med. 74, 1204–1212 (2012).

    Article  PubMed  Google Scholar 

  225. Smithwick, J., Nance, J., Covington-Kolb, S., Rodriguez, A. & Young, M. ‘Community health workers bring value and deserve to be valued too’: key considerations in improving CHW career advancement opportunities. Front. Public Health 11, 1036481 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  226. Clarke, D. F. Diversity and underserved patient populations in epilepsy. Continuum 31, 247–264 (2025).

    Article  PubMed  Google Scholar 

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Acknowledgements

A.R. is supported by the National Institute of Neurological Disorders and Stroke (NINDS; 1K23NS138682-01A1), the Cleveland Clinic Epilepsy Center, the Cleveland Clinic Catalyst Grant and Neurological Institute Clinician Scientist Research Development Award, the American Epilepsy Society Sergievsky Award for Epilepsy Health Equity and Diversity and the Burroughs Wellcome Fund. R.M.B. receives support from the NINDS (R01 NS135080 and R01 NS120976), the National Institute on Aging (NIA; R33 AG039729) and the Cleveland Clinic Epilepsy Center. E.T.K. is supported by the Centers for Disease Control and Prevention Cooperative Agreement (NU58DP007541-01-00, NU48DP006877 and NU58DP007543) and the Department of Defense (CDMRP MS240260, CDMRP CA240965 and CDMRP EP240079). T.O.-C. is supported by the National Center for Advancing Translational Sciences and the NIH, through grant number UL1 TR001860 and linked award KL2TR001859. B.P.H. is supported by the NINDS (R01 NS111022, R01 NS120976 and R01 NS117568) and the NIA (R01 AG027161).

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Authors and Affiliations

  1. Cleveland Clinic Epilepsy Center, Neurological Institute, Cleveland, OH, USA

    Anny Reyes & Robyn M. Busch

  2. Department of Neurology, Neurological Institute, Cleveland, OH, USA

    Anny Reyes & Robyn M. Busch

  3. Geisel School of Medicine, Dartmouth College, Hanover, NH, USA

    Elaine T. Kiriakopoulos

  4. University of California, Davis, Davis, CA, USA

    Temitayo Oyegbile-Chidi

  5. University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Bruce P. Hermann

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  1. Anny Reyes
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  5. Bruce P. Hermann
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Correspondence to Anny Reyes.

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Nature Reviews Neurology thanks Martin Holtkamp, who co-reviewed with Louisa Hohmann; Magdalena Szaflarski; and Boris Bernhardt for their contribution to the peer review of this work.

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Review criteria

Topics reviewed included social determinants of health (SDOH) frameworks (Healthy People 2030, National Institute of Neurological Disorders and Stroke and epilepsy-specific models), social outcomes in epilepsy and the impact of individual-level determinants (education, income, occupation, insurance, housing, social support and language) and community-level determinants (neighbourhood deprivation, stigma, structural racism and health-care infrastructure) on cognitive, neurobehavioural (depression and anxiety) and quality-of-life (QoL) outcomes across the lifespan. Protective factors, such as education, cognitive reserve, bilingualism, physical activity and social connectedness, were also considered. PubMed, Web of Science and Google Scholar were searched, supplemented by snowballing from reference lists of key empirical papers and consensus documents (WHO, International League Against Epilepsy and International Bureau for Epilepsy), as well as by reviewing articles that cited key studies to capture more recent work. Search terms included ‘epilepsy AND social determinants of health’, ‘cognition AND epilepsy AND neighborhood deprivation’, ‘epilepsy AND social determinants of health AND quality of life’, ‘epilepsy AND social determinants of health AND stigma’ and ‘epilepsy AND socioeconomic status’. The main time frame was 2000–2025, with emphasis on the past decade; historical studies were cited when foundational to the field. Selection criteria included peer-reviewed original research, systematic reviews, meta-analyses and consensus guidelines and excluded case reports, small single-site studies without SDOH measures and articles limited to seizure control outcomes. Populations included children and adults with epilepsy, all epilepsy syndromes, racially and ethnically diverse populations, individuals with limited English proficiency, rural populations and low-income and middle-income countries. Outcomes of interest were cognitive domains (language, memory, executive function and processing speed), neurobehavioural outcomes (depression, anxiety, stigma, QoL and academic performance in children) and mechanistic brain measures (neuroimaging and connectivity). The narrative synthesis was organized by age group (children and adults) and determinant level (individual versus community) and type (education, income, neighbourhood, stigma and health-care access). Findings were contextualized globally, highlighting disparities, mechanisms and intervention opportunities.

Glossary

Cognitive reserve

The brain’s ability to compensate for pathology, influenced by education, occupation and stimulating life experiences.

Comorbidities

The presence of one or more additional medical conditions occurring during the course of a disease such as epilepsy, including distinct clinical diseases, syndromes or symptoms that interact with and influence the outcomes of the index disease.

Health disparities

Preventable disparities in health outcomes arising from social, economic and environmental disadvantages.

Inequities

Disparities that are avoidable and unjust, rooted in structural disadvantage.

Intersectionality

A framework that recognizes how overlapping social identities, such as race and ethnicity, sex and gender, socioeconomic status and geography, interact to compound risk, shape experiences and create interdependent systems of disadvantage and inequity.

Protective factors

Favourable social determinants of health or conditions such as higher education, cognitive reserve, bilingualism, stable employment, strong social support and physical activity that buffer against pathology or cognitive and neurobehavioural decline.

Social adversity

Exposure to challenging social conditions, such as poverty, discrimination, violence or social exclusion or isolation, that negatively affect health and well-being.

Social connectedness

The quality and quantity of social relationships and networks, which are linked to resilience, mood and quality of life.

Social needs

Patient-identified priorities among social risks (for example, ‘I need help with transportation’) that can be addressed in care.

Social risk factors

Adverse social conditions, such as food insecurity, housing instability and transportation barriers, that are associated with poor health outcomes.

Socioeconomic status

(SES). A measure of an individual’s or group’s social and economic standing in society. SES is typically defined by three main indicators, namely, education, income and occupation at the individual or household level.

Stigma

Negative attitudes, stereotypes and behaviours towards people with epilepsy that hinder access to care, education, employment and social participation, reinforcing social exclusion and contributing to poorer outcomes.

Systemic racism

Systemic policies and practices that produce and maintain racial and ethnic inequities across sectors such as health care, housing and education.

Treatment gap

The proportion of people with epilepsy who require care but do not receive minimally adequate, evidence-based treatment.

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Reyes, A., Busch, R.M., Kiriakopoulos, E.T. et al. The role of social context in cognitive and neurobehavioural outcomes in epilepsy. Nat Rev Neurol 22, 152–171 (2026). https://doi.org/10.1038/s41582-026-01184-0

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  • DOI: https://doi.org/10.1038/s41582-026-01184-0

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