Mediating effects of depression, stigma, and self-efficacy on self-management improvement in an evidence-based epilepsy self-management program

AIMS: To evaluate whether improvements in depressive symptoms, epilepsy self-efficacy, and perceived stigma mediate the association between the SMART intervention and epilepsy self-management. METHODS: 160 people with epilepsy were enrolled in a randomized controlled trial comparing SMART with standard care. Potential mediators included depressive symptom severity, self-efficacy, and perceived stigma measured at baseline, 13 weeks, and 6 months. Multivariable linear regression models estimated direct and indirect effects, with the indirect effect defined as the average causal mediation effect (ACME). Improvements in potential mediators were evaluated over three intervals: baseline to 13 weeks, 13 weeks to 6 months, and baseline to 6 months. RESULTS: Improvement in depressive symptoms from baseline to 6 months was significantly associated with mediation of SMART on ESMS improvement (ACME = 0.83; p = 0.0089), accounting for 23.2% of the total effect (95% CI 4.4, 41.9%; p = 0.015). Increases in self-efficacy from baseline to 6 months were also significantly associated with mediation of the effect of SMART on ESMS improvement (ACME = 0.155; p = 0.0095), accounting for 4.6% of the total effect (95% CI 2.0, 7.3%, p = 0.00063). Changes in perceived stigma did not significantly mediate the association between SMART and self-management. CONCLUSIONS: Findings suggest that SMART may improve epilepsy self-management competency in part through reductions in depressive symptoms and increases in self-efficacy, with depressive symptom improvement representing the larger of the two significant mediating pathways observed. Perceived stigma did not significantly mediate the intervention's association with self-management. These findings suggest that mood and self-efficacy may be important targets in epilepsy self-management interventions.