Objective To examine the factors and reasons influencing treatment initiation decisions in patients with newly diagnosed epilepsy. Methods We assessed antiseizure medication initiation decisions in adults with newly diagnosed epilepsy seen at first seizure clinics in Western Australia between 1999 and 2016 and followed to 2018. Results Of 610 patients (median age 40 years, 61.0% male), 426 (69.8%) were diagnosed after two or more seizures and 184 (30.2%) after a single seizure with risk factors for recurrence. Treatment was commenced in 427 patients (70.0%) at diagnosis, 112 (18.4%) during follow‐up, mostly after further seizures, whereas 71 (11.6%) remained untreated at last follow‐up. Elders (≥65 years, odds ratio [OR] = 3.06, 95% confidence interval [CI]: 1.62‐5.80), more seizures (OR = 3.48, 95% CI: 2.03‐5.96), and epileptogenic lesions on neuroimaging (OR = 2.15, 95% CI: 1.26‐3.68) had a higher likelihood of treatment at diagnosis. Patients with less than one seizure per year within the preceding year (OR = 0.40, 95% CI: 0.21‐0.73) and of higher socioeconomic status (OR = 0.985, 95% CI: 0.977‐0.994) were less likely to be treated. For 93 patients (15.2%), treatment was not recommended at diagnosis, most commonly because only a single seizure had occurred. Ninety patients (14.8%) declined recommended treatment, mostly because they were unconvinced of the need for treatment or the diagnosis. Significance Thirty percent of adults with newly diagnosed epilepsy were not immediately treated. Treatment initiation in this real‐world cohort was influenced by age, number of seizures prior to diagnosis, imaging findings, patient preferences, and socioeconomic status.

Objective.To determine the health economic burden of epilepsy for Australians of working age by using life table modelling, and to model whether improved seizure control may result in substantial health economic benefits.Methods.Life table modelling was used for working age Australians aged 15-69 years with epilepsy, and the cohort was followed until age 70 years. Published 2017 population and epilepsy-related data regarding epilepsy prevalence, mortality, and productivity were used. This model was then re-simulated, assuming the cohort no longer had epilepsy. Differences in outcomes between these cohorts were attributed to epilepsy. Scenarios were also simulated in which the proportion of seizure-free patients increased from baseline 70% up to 75% and 80%.Results.In 2017, Australians of working age with epilepsy followed until age 70 years were predicted to experience over 14,000 excess deaths, more than 78,000 years of life lost, and over 146,000 productivity adjusted life years (PALYs) lost due to epilepsy. This resulted in lost GDP of US$22.1 billion. Increasing seizure freedom by 5% and 10% would reduce healthcare costs, save years of life, and translate to US$2.6 billion and US$5.3 billion GDP retained, for seizure freedom rates of 75% and 80%, respectively.Conclusions.Our study highlights the considerable societal and economic burden of epilepsy. Relatively modest improvements in overall seizure control could bring substantial economic benefits.