The self-reinforcing cycle of financial toxicity in Epilepsy: an evolutionary concept analysis

Epilepsy is a neurological condition that affects the entire household through its chronic course, lifelong medication requirements, and intensive caregiving demands. Financial toxicity, a concept originating in oncology, describes the harm that arises when the costs of care extend beyond the depletion of household resources to affect patients' and families' quality of life, psychological wellbeing, and treatment decisions. Despite these characteristics, financial toxicity in epilepsy has not yet been conceptualized as a unified clinical phenomenon; instead, research has remained fragmented across conceptual silos shaped by disciplinary and methodological differences. This study aims to examine and map the concept of financial toxicity in epilepsy using Rodgers' Evolutionary Concept Analysis framework. A literature search conducted across four databases (PubMed, Web of Science, CINAHL, and Scopus) identified 34 studies offering meaningful conceptual contributions to the understanding of financial toxicity in epilepsy, which were included in the final conceptual synthesis. Findings reveal that financial toxicity in epilepsy comprises three interconnected dimensions: material strain, characterized by catastrophic out-of-pocket expenditures and opportunity costs that deplete household income; psychosocial distress, manifested through caregiver burnout, depression, and social isolation; and cost-related nonadherence, expressed as skipping medication doses and turning to traditional healers. These dimensions are not independent: cost-related nonadherence increases seizure frequency, more frequent seizures drive up costs, deepening financial deprivation fuels further non-adherence, and the cycle self-reinforces with each iteration. This reinforcing mechanism, together with the household-centred distribution of burden, is prominent in the epilepsy literature reviewed here. The proposed conceptual framework offers healthcare professionals a foundation for early identification of financial toxicity and the development of integrated interventions, while underscoring the urgent need for a validated, epilepsy-specific financial toxicity measure.