# Mobile Applications for Epilepsy: Where Are We? Where Should We Go? A Systematic Review
## 4 Discussion
### Thoughts on Prior Work  
Previous reviews, which evaluated apps through MARS, also reached low values of engagement and information [15; 17]. These reviews were conducted in fall 2017 and between February 2018 and April 2019, respectively. Since then, there has been little to no improvement concerning these categories, which may play an important role in long-term adherence. These reviews also stated the lack of cohort studies and randomised trials associated to the apps. Since then, one app was developed in such way (_Brain4U_) [36], where its effectiveness was also tested with end-users [37]. However, this app was only available in Korean, and thus was excluded in the last selection of our review. Nonetheless, _Brain4U_ can be an example for how m-health systems should be deployed in the future. Thisclinical validation increases confidence over the use of the app, which could be helpful to keep engagement. Since these apps are designed for epileptic patients, doctors and patients should be involved in the app's design from day one. [PERSON] and colleagues [38] noted the significant difference between the number of people with epilepsy and the number of users in epilepsy self-management apps. In this work, it was proposed three ideas for closing the gap between the target audience and these apps. Another issue stated in previous studies is the target being mostly an adult audience [39]. _EpApp_ was the only app we found that was developed closely with adolescents [35]. [PERSON] and colleagues [35] concluded that _EpApp_'s use improved epilepsy knowledge and medication management. This highlights the importance of such apps in the lives of young people with epilepsy, hence the need for broadening the target audience to include younger people. In our review, _EpApp_ was in the top of the MARS scale (Figure 4); however, this app was only possible to test by one rater before becoming inaccessible. Regarding young people with epilepsy, current applications are not designed for engaging continuous use [40]. [PERSON] [39] and colleagues surveyed adolescents with epilepsy and their parents. While parents were more focused on accurate seizure management and emergency information, adolescents expected daily life related contents and tools for anti-seizure medication (ASM) compliance. This article emphasisises the need for customization and tailoring for each adolescent's needs, in order to increase adherence over time. Another work, by [PERSON] and colleagues [40] interviewed patients and relatives of patients with epilepsy, concerning the design of a mobile health system towards adolescents and young adults. Participants described wanting an easy and fast access to safety procedures upon seizure, through audio or video output. Moreover, concerning the use of current applications, they mentioned alarm fatigue and the \"burden of having to manually record multiple entries\" [40]. These two concerns are related to our assessment in MARS since seizure procedures are part of information, and alarm fatigue reduces engagement over time. Thus, new ways of engaging are necessary to improve adherence over time. [PERSON] and coworkers [41] suggested the use of gamification to improve medication adherence in epilepsy through several ideas stated, such as being associated to a social network or having a virtual reward system (this idea was also prompted by one adolescent interviewed in the previous study [40]).  
On a different note, recent studies are dedicated to forecasting seizure risk by using seizure's cyclic behaviour, sleep rhythms and weather data, as examples [42; 43]. Hence, self-management apps could be an important ally for seizure prediction, in collecting relevant data for algorithm development and in displaying results to patients', who, in turn, could reply with feedback. This engagement loop could benefit both patients and research, bringing an additional layer of purpose to such m-health solutions.