[Occupational integration of patients with epilepsy]. / Berufliche Eingliederung von Menschen mit Epilepsie.

An overview is given initially of study findings pertaining to unemployment, work history and workplace experiences of people with epilepsy (disclosure, job reallocation, sick leaves, up-/downgrading, accidents). The author then describes new approaches to improving the vocational integration of persons with epilepsy, by focussing on the one hand on extending the range of occupational assessment, and the adoption of new job placement assessment, and the adoption of new job placement strategies on the other, which concurrently seek to influence those factors that are detrimental to the occupational outlook of the person with a seizure disorder (notably frequent seizures, psychiatric problems, low educational levels, negative employer attitudes). It is suggested that the feasibility of these new strategies, developed and field-tested primarily in the Anglo-American countries, should be verified within the social-legislational context of the Federal Republic of Germany.

Patients with epilepsy who discontinue treatment.

Out of 247 patients coming to an outpatient clinic (OPC) for patients with epilepsy during a time span of 18 months, 214 could be definitely rated with respect to continuation or discontinuation of treatment. 96 discontinued treatment, i.e., they did not keep their last appointment and also did not come to the OPC during the following 6 months or longer. The rate of discontinuation was especially high for patients who had had only one seizure, for patients with chronic alcoholism or alcoholic withdrawal seizures and for patients who had already had several seizures but objected to pharmacological treatment. One hundred and forty-nine patients had had at least 2 seizures and were on medication. In this group we looked for variables discriminating between continuation and discontinuation. Medical data were taken from the records and all patients received a questionnaire with 36 items. Medical variables such as type and duration of epilepsy had no influence on keeping appointments. There were, however, significant relations between continuation or discontinuation and perceived quality of care in the OPC, obligation of the patient to look after children, perceived discrimination of persons with epilepsy at the work place and the patient's feeling of being treated like a little child when the doctor utters his suspicions about non-compliance.

Measurement of compliance through patient interviews.

In this study different indices for compliance with antiepileptic drug (AED) treatment were derived from a sample of 41 patients with epilepsy, coming for the first time to an out-patient clinic: forgetting a dose, aids for drug intake (e.g., a pill box), tying intake to stable habits, intake at weekends, taking less than prescribed, taking more than prescribed, expected physical harm as a consequence of drug intake. Significant interrelations were found between reporting having thought of discontinuation because of physical harm and actual discontinuation in the past (P = 0.04), between use of an aid and tying intake to stable habits in the morning, at noon and in the evening (P = 0.01, P = 0.03, P = 0.08). There was a relation between using an aid and plasma levels of AEDs (P = 0.03). Finally an index was constructed from the different measures for intake behaviour. There was a correlation r = -0.60 with coefficients of variation for phenytoin, carbamazepine and phenobarbital (P = 0.05).

[Rehabilitation prognosis in the onset of epilepsy following entry into professional life]. / Rehabilitationsprognose bei Epilepsiebeginn nach Eintritt ins Berufsleben.

The type of occupation proposed as well as factors determining these proposals, i.e. vocational prognosis, were examined in 58 persons to be rehabilitated who already had been integrated into working life at the time of epilepsy onset and participated in a one- to three-week vocational assessment programme in a vocational training center. Suggestions for vocational retraining were made to 49 of the 58 clients, with clerical occupations proposed to almost half of them, manual ones to appr. one third, and technical training to a sixth of the clients. This distribution of training suggestions is the reverse of the clients' former occupations, and did not always meet the wishes expressed by the clients. Careful evaluation and counselling might reduce some of these discrepancies. The level of the occupational training proposed was influenced most strongly by work rate, with dosage of anticonvulsive drugs being the most important factor in slowing the clients' pace. Psychological problems were common, did however not primarily influence the level of training proposed, but rather the decision between vocational training vs. invalidity pension or medical treatment.

Postictal serum levels of antiepileptic drugs for detection of noncompliance.

Medication noncompliance (NC) is thought to be a major cause of insufficient seizure control. In an explorative study we investigated whether postictal serum levels (PISLs) of antiepileptic drugs (AEDs) are a reliable indicator of NC. Young adults with epilepsy on a stable AED regimen were asked to contact medical service as soon as possible when a seizure occurred to obtain serum levels of their AEDs. PISLs were compared with the mean value of two routine serum levels of the same medication. PISLs lower than 50% of the individual reference value were regarded as an indicator of NC. PISL samples in 61 seizures of 52 patients treated mainly with carbamazepine, valproic acid, or lamotrigine were evaluated. A drop in serum levels >50% indicating NC was noted in 44.3% of the seizures. Determination of PISLs seems to be a simple and useful method for detecting or ruling out irregular intake patterns as a cause of "breakthrough" seizures.

MOSES: an educational program for patients with epilepsy and their relatives.

The knowledge of patients with epilepsy about their own condition is poor, and thus the need for educational programs for people with epilepsy has long been recognized. However, no such programs have been established in their routine care. The Modular Service Package Epilepsy (MOSES) now tries to fill this gap for patients in German-speaking countries. The program was developed by a multidisciplinary group (neurologists, nonmedical professional helpers, and representatives of national epilepsy associations) for people with epilepsy older than 16 years, independent of the kind and severity of their epilepsy. MOSES is designed for group education and can be used in inpatient and outpatient settings in epilepsy centers, in clinics, and by neurologists in private practice. The program aims to help patients achieve a better understanding of their disease, to gain more self-confidence, and to take over responsibility, thus supporting patients to become experts in managing their own illness. Being modular in structure, MOSES includes nine units: living with epilepsy, epidemiology, basic knowledge, diagnostics, therapy, self-control, prognosis, psychosocial aspects, and network epilepsy. MOSES consists of a workout manual for patients and a trainer manual. For potential trainers, special "train-the-trainer seminars" are offered and considered mandatory. About 400 patients have participated in a MOSES training program in Germany, Switzerland, and Austria. The efficacy of the program is currently been evaluated.