This is a well-written and valuable manuscript providing insight into real-world clinical management of epilepsy with concomitant anxiety and depression symptoms. The authors examined interventions offered to epilepsy patients who screened positive for anxiety and/or depression, including pharmacologic, psychosocial, referral-based and educational. Notably, the article suggests epileptologist discomfort or perceived role limitation to manage symptoms directly via antidepressant prescribing, ^{Reference Injar, Keezer, Lapalme-Remis, Chamelian, Bou Assi and Nguyen1} and it highlights areas for system improvement and opportunities to enhance training of epileptologists to assess and manage comorbid psychiatric conditions.

This manuscript aligns with prior literature demonstrating the challenges of implementing psychiatric screening in epilepsy clinics. ^{Reference Ongchuan Martin2} For example, studies implementing even a structured, electronic health record-based screening strategy report only about 30% of visits meeting the screening quality measure. ^{Reference Munger Clary3,Reference Fox, Wood and Phillips4} Similarly, although Injar et al. implemented routine paper-based screening with validated instruments (Neurological Disorders Depression Inventory for Epilepsy, Generalized Anxiety Disorder-7 and Beck Anxiety Inventory), only 36% who screened positive received any intervention. A majority (59%) had no follow-up, and 5% declined care. These findings emphasize the consistent gap across studies that merely integrating validated screening into standard clinic workflow does not ensure patients receive treatment.

Additionally, while Injar et al. found that epileptologists frequently adjusted antiseizure medications, none prescribed antidepressants, even when screening results were directly provided. This is consistent with global International League Against Epilepsy Psychology Task Force survey, which showed uncertainty among epilepsy clinicians regarding responsibility for screening and managing depression and anxiety. Less than half of survey respondents felt adequately resourced, over 50% cited insufficient time as a barrier to screening and many relied on watchful waiting despite recognizing the need for treatment. ^{Reference Gandy, Modi and Wagner5} The importance of addressing the treatment gap is also emphasized in a tertiary epilepsy clinic survey, demonstrating nearly 70% of epilepsy clinic patients who screened positive for anxiety and/or depression preferred neurologist antidepressant prescribing over psychiatry referral, with an almost 5:1 preference ratio among those who expressed a choice. ^{Reference Munger Clary, Croxton and Snively6} This finding suggests many patients may want their neurologists to manage these symptoms directly.

Study limitations include lack of data on the proportion of clinic patients screened and lack of clarity on how many individuals were screened repeatedly during the study period. Overall, this manuscript lays the groundwork for future quality improvement initiatives by demonstrating that screening alone does not close gaps in care for anxiety and depression in epilepsy. The study may encourage other epilepsy clinics to evaluate and enhance their own approaches to integrating psychiatric screening and interventions.