Suicide in epileptic patients

Suicide and attempted suicide occur with above-average frequency in patients with epilepsy. The proportion of suicide in the overall mortality of epilepsy patients is about 8% and thus about four times more frequent than in the general population. Affective disorders may be contemporaneous with epileptic attacks, or they may occur interictally. The affective disorders leading to suicide may be caused reactively, pharmacogenically, or by the epileptic function disorder itself or by an underlying cerebral disease. For prophylaxis of suicide, it is especially important to be informed about pharmacogenic depressive moods, which evidently occur above all in phenobarbital treatment. Rapid help is often possible by change of medication. Otherwise, the rules of therapy in epilepsy patients in danger of suicide correspond to those of crisis intervention in suicidal individuals in general.     

Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy

Studies of causes of death among people with epilepsy suggest that the lifetime prevalence rate of suicide is elevated. Although not all of the studies have reported an increased risk for suicide, the collective data yield an average rate of approximately 12% among people with epilepsy, compared with 1.1-1.2% in the general population. The increased risk for suicide appears to affect children and adolescents as well as adults. Rates of suicide attempts have also been reported to be elevated among people with epilepsy. A suicide attempt is a significant risk factor for completed suicide. Certain psychiatric disorders, including primary mood disorders, also increase the risk for suicide. Among people with epilepsy, psychiatric comorbidity is common, and rates of mood disorders, particularly major depression, have consistently been reported to be elevated. Other potential risk factors are family issues, physical health, personality, life stress, previous suicidal behavior, and access to firearms. Assessing severity of risk helps to determine the appropriate level of intervention. The suicidality module of the Mini-International Neuropsychiatric Interview is a practical tool to help quantify current suicide risk.     

Electroconvulsive therapy for bipolar depressive and mixed episode with high suicide risk after epilepsy surgery

Mood disturbance is a common comorbid condition of temporal lobe epilepsy before and after surgery. Suicide is more frequent in patients with epilepsy than in the general population. As suicide is a major issue in both epileptic and depressive patients, it is critical to treat aggressively any psychiatric illness with suicidal ideation. We describe two patients who, after temporal lobe surgery, developed a serious bipolar disorder that necessitated electroconvulsive therapy (ECT), despite better seizure control. Unfortunately they were not able to commit to a regular treatment plan with their psychiatrists to prevent a suicide. These patients underwent a course of ECT treatments. After the ECT regimen, acute suicidal intent remitted and was replaced by chronic suicidal ideation without active intent or plan. The patients were then able to commit to a treatment plan regarding their medications and control visits. These cases represent the safe utilization of ECT as a rapid and effective treatment option for bipolar disorder with suicide ideation following epilepsy surgery. Patients and parents should be advised about possible psychiatric disturbances and suicide risk after epilepsy surgery, especially in the presence of a temporal lobe epilepsy, even when seizure control is achieved postoperatively.     

Ictal and psychiatric aspects of suicide in epileptic patients.

OBJECTIVE: To evaluate the ictal and psychiatric aspects underlying the high risk of suicide among epileptic patients. METHOD: We surveyed the records of 1611 epileptic patients seen in a neurology clinic during an eight-year period, found four who died by suicide, and characterized their ictal and psychiatric features. RESULTS: All four epileptic patients had partial complex seizures and temporal lobe foci. Two had an associated paranoid schizophrenia with suicidal ideation, and good or improving seizure control at the time of their deaths. Another patient killed himself during a brief psychotic episode associated with increasing epileptiform discharges. The fourth patient had ictal depression and committed suicide during a flurry of partial complex seizures. CONCLUSIONS: These findings suggest that the high suicide rate among epileptic patients has a greater association with psychotic behaviors and psychic auras than with major depression or the psychosocial burden of being epileptic. We further review other reported risk factors for suicide in epilepsy.     

Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms, and treatment.

Depression is the most frequent comorbid psychiatric disorder in epilepsy. Its lifetime prevalence has been estimated at between 6% and 30% in population-based studies and up to 50% among patients followed in tertiary centers. The risk of suicide has been estimated to be 10 times higher than that in the general population. Although no one questions that epilepsy is a risk for depression, recent studies have also revealed that a history of depression is associated with a 4- to 6-fold greater risk of developing epilepsy. These data suggest either a possible "bi-directional" relationship between these two disorders or the presence of common pathogenic mechanisms that facilitate the occurrence of one in the presence of the other. The clinical presentation of depressive disorders in epilepsy can be identical to that of nonepileptic patients and can include major depression, bipolar and dysthymic disorders, and minor depression. In a significant percentage of cases, however, the clinical features of depression in epilepsy fail to meet any of the DSM-IV Axis I categories. Depression in epilepsy may be iatrogenically induced with various antiepileptic drugs used to treat the seizure disorder or after surgical treatment of intractable epilepsy. Despite its relatively high prevalence, depression remains unrecognized and untreated, and unfortunately its treatment is based on empirical and uncontrolled data.     

Bipolar disorders and suicidal behaviour

Rihmer Z, Kiss K. Bipolar disorders and suicidal behaviour. Bipolar Disord 2002: 4(Suppl. 1): 21–25. © Blackwell Munksgaard, 2002
Major depressive disorder is the leading cause of suicide, particularly in the absence of adequate treatment. The aim of this paper is to analyse the relationship between different forms of major mood disorders and suicidal behaviour. Population-based epidemiological surveys as well as clinical studies on the clinically explorable suicide risk factors in bipolar and unipolar depressive disorders are reviewed. The present literature shows that patients with bipolar disorders are at higher risk of attempted and completed suicide than that of patients with unipolar major depression. Contrasting only bipolar I and bipolar II patients, current findings indicate that the rate of prior suicide attempt is higher in bipolar II patients, and bipolar II disorder is overrepresented in depressed suicide victims. Among patients with different clinical manifestations of major mood disorders (unipolar major depression, bipolar I and bipolar II disorder), bipolar patients in general, and bipolar II subjects in particular carry the highest risk of suicide.     

Causative factors for suicide attempts by overdose in epileptics

We investigated possible causative factors for the high epileptic suicide rate by reviewing the cases of 22 patients with idiopathic epilepsy found among 711 patients hospitalized for a suicide attempt by overdose. Suicide attempts occurred with increased seizure activity in one epileptic; otherwise, no relationships were found with seizure-related variables. When matched by age, sex, and race with 44 nonepileptic controls from the same population, the epileptics had more borderline personality disorders with multiple impulsive suicide attempts (45.5% vs 13.6%), more psychotic disturbances, including command hallucinations (31.8% vs 9.1%), fewer adjustment disorders (18.2% vs 45.5%), and a comparable frequency of depression (13.6% vs 25%). We conclude that suicide attempts in epileptics are primarily associated with interictal psychopathologic factors, such as borderline personality disorder and psychosis, rather than with specific psychosocial stressors, seizure variables, or anticonvulsant medications.     

Depressive disorders among epileptic patients attending a specialised outpatient clinic

The overall prevalence of psychiatric disorders in epileptic patients is estimated between 19 and 62%. Depressive disorders may be the most common psychiatric disorders and the main reason for psychiatric hospitalisation and taking psychotropic drugs. The underdiagnosis and undertreatment of depressive disorders among epileptic patients represent a problem of considerable magnitude. The aim of the present study was to evaluate the prevalence of depressive disorders among patients with primary epilepsy and to determine the risk factors of the occurrence of the depressive illness. The survey was conducted in a outpatient epilepsy clinic in the Ibn Rochd University Hospital Centre in Casablanca. All patients with idiopathic or cryptogenic epilepsy aged 15 Years and above, were eligible, except for patients with severe physical and mental disabilities. Neurologists diagnosed the epilepsy based on clinical criteria with electroencephalograms data. The depressive disorders met a psychiatrist's evaluation of an ICD-10 criterion. Ninety-two subjects participated in the survey, 57.6% were men and the mean age was 30.3 +/- 10.8 Years. The epilepsy age of onset was 16.3 +/- 11.4 Years with an average duration of 14.1 +/- 9.2 Years. The prevalence of depressive disorders among epileptic patients in our survey was 18.5%. According to sex, the prevalence was 23.1% in women and 15.1% in men. The depressed patients were compared with the remaining patients without depression with regard to seizure variables and sociodemographic characteristics. The epilepsy-depression and epilepsy-control groups did not differ significantly in the duration of epilepsy or in the type of anticonvulsant therapy (mono versus polytherapy). Three variables were significantly different between the two groups. The mean age in the epilepsy-depression group was significantly higher (34.4 +/- 9.6 Years versus 29.4 +/- 10.9, p<0.03), the mean age of epilepsy age of onset was also higher in the epilepsy-depression group than in the epilepsy-control group (21.8 +/- 11.9 Years versus 15.04 +/- 11.0, p<0.03) and the seizure frequency per week was more important among depressed epileptic patients (2.4 + 5.2 seizures versus 0.4 + 1.5, p<0.007). The present survey confirms the findings of previous studies that the prevalence of the comorbidity between epilepsy and depression is common in specialised outpatient units. The detection and the treatment of depressive disorders among the epileptic patients remains a very great challenge in the management of the epileptic illness. It will improve the quality of life of these patients. A closer involvement of psychiatric and psychological treatment in patient management is necessary.     

Epilepsy and anxiety: epidemiology, classification, aetiology, and treatment

Anxiety in epilepsy has recently become a focus of interest for a number of reasons. Epidemiological studies have established that anxiety disorders are twice as common in patients with epilepsy compared to the general population, while in referral centres their prevalence is even higher. In addition, it has been recently appreciated that anxiety exerts a significant negative impact on the quality of life of patients with epilepsy of any age. With regard to the pathogenesis of anxiety in epilepsy, a number of theories have been put forward including those based on psychodynamics, learning-cognition, and neurobiology. From a clinical point of view, anxiety may occur as a comorbid disorder with epilepsy or be directly linked with epilepsy as a preictal, ictal, postictal or interictal phenomenon. The treatment of anxiety in patients with epilepsy requires a comprehensive, multidisciplinary, clinical assessment. Regarding pharmacological therapies, it should be recognised that some drugs prescribed for anxiety disorders are associated with a high risk of seizures, whereas some antiepileptic drugs possess anxiolytic properties that could be of use in the management of epileptic patients with anxiety. The correct diagnosis and successful treatment of anxiety is expected to have significant benefits for the quality of life of epileptic patients.     

Atypical antipsychotics and suicide in mood and anxiety disorders

Abstract:  Globally, a million people commit suicide every year, and 10–20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.     

Risk for suicide in schizophrenia and other psychotic and nonpsychotic disorders

To determine the rate of suicide in young, early phase schizophrenics and other psychotic disorders, and to analyze risk factors for suicide, a large sample of patients was prospectively assessed at index hospitalization and then followed up systematically after discharge. Thirty-six patients committed suicide and these patients were compared with those who did not commit suicide for major diagnostic and prognostic factors. Results indicated the following: a) During early years, schizophrenics and other types of psychotic patients were more likely to commit suicide than nonpsychotic patients. b) Similarly, among depressives, psychotic depressed patients were more likely to commit suicide than nonpsychotic depressed patients. c) Schizophrenics and other psychotic patients were especially vulnerable to suicide within the first 6 years of their first hospitalization. d) Among the combined sample of psychotic patients (schizophrenic and other psychotic patients), those at greater risk for suicide were unmarried, white, high IQ, male patients with a more gradual onset of disorder and were of "chronic" Research Diagnostic Criteria subtypes.     

Epilepsy and risk of suicide: a population-based case-control study

BACKGROUND: Studies have linked epilepsy with an increased suicide risk, but the association might be modified by psychiatric, demographic, and socioeconomic factors. METHODS: Suicide cases were identified in the Cause of Death Register in Denmark from 1981 to 1997. Up to 20 controls, matched by sex, birth year, and calendar date, were assigned to each suicide case. FINDINGS: We identified 21 169 cases of suicide and 423 128 controls. 492 (2.32%) individuals who committed suicide had epilepsy compared with 3140 (0.74%) controls, corresponding to a three times higher risk (rate ratio [RR] 3.17 [95% CI 2.88-3.50]; p<0.0001). The RR remained high after excluding those with a history of psychiatric disease and adjusting for socioeconomic factors (1.99, 1.71-2.32; p<0.0001). The highest risk of suicide was identified in patients with epilepsy and comorbid psychiatric disease, even after adjusting for socioeconomic factors (13.7, 11.8-16.0; p<0.0001). In individuals with epilepsy, the highest risk of suicide was found during the first half year after diagnosis was made (5.35, 3.43-8.33; p<0.0001), and was especially high in those with a history of comorbid psychiatric disease (29.2, 16.4-51.9; p<0.0001). INTERPRETATION: Individuals with epilepsy have a higher risk of suicide, even if coexisting psychiatric disease, demographic differences, and socioeconomic factors are taken into account. Our study identifies people with newly diagnosed epilepsy as a vulnerable group that require special attention.     

Rates of DSM-IV mood,anxiety disorders,and suicidality in Australian adult epilepsy outpatients: A comparison of well-controlled versus refractory epilepsy

Despite recent research into the impact of seizure control on mood disorders in epilepsy, it is often assumed that rates of psychiatric disorders are higher in people with refractory rather than well-controlled epilepsy. We assessed the point prevalence of mood and anxiety disorders and suicide risk using the Mini International Neuropsychiatric Interview (MINI) in a consecutive sample of epilepsy outpatients from a tertiary referral center. One hundred and thirty patients, whose epilepsy was categorized as well-controlled versus drug-treatment-refractory epilepsy (69; 53% well-controlled epilepsy) were recruited. High rates of mood disorders (n = 34; 26%), anxiety disorders (n = 37; 29%) and suicide risk (n = 43; 33%) were found. However, there was no difference in rates of disorders or suicide risk for those with refractory versus well-controlled epilepsy. These results underscore the importance of assessment and management of psychopathology in all people with epilepsy, regardless of their seizure control.     

癫痫共病偏头痛患者血清中C反应蛋白水平及其他相关因素分析

目的 调查癫痫共病偏头痛患者的相关危险因素。方法 选择确诊为癫痫的患者93例为实验组,再根据偏头痛的诊断标准,将93例癫痫患者分为癫痫共病偏头痛组及癫痫不伴偏头痛组(单纯癫痫组),记录患者年龄、性别、民族、工作强度、癫痫家族史和癫痫发作频率等。结果 93例癫痫患者中癫痫共病偏头痛患者占总数的19.35%。癫痫共病偏头痛组患者血清CRP水平明显高于正常对照组(P<0.05)及单纯癫痫组(P<0.05),单纯癫痫组CRP水平明显高于正常对照组(P<0.05)。夜间睡眠状况、脑部外伤史、新生儿疾病史、平素情绪状态及癫痫发作频率与癫痫共病偏头痛的发生有关系(P<0.05),其中癫痫共病偏头痛患者血清中CRP水平与癫痫发作频率呈正相关(r=0.47,P<0.05)。结论 夜间睡眠不佳、存在脑部外伤史及新生儿疾病史、平素情绪差及癫痫发作频繁与癫痫共病偏头痛的发生有关,其中夜间睡眠状况、癫痫发作频率为癫痫共病偏头痛的独立危险因素。癫痫共病偏头痛患者血清CRP水平与癫痫发作频率呈正相关。     

Fever, genes, and epilepsy

About 13% of patients with epilepsy have a history of febrile seizures (FS). Studies of familial forms suggest a genetic component to the epidemiological link. Indeed, in certain monogenic forms of FS, for which several loci have been reported, some patients develop epilepsy with a higher risk than in the general population. Patients with generalised epilepsy with febrile seizures plus (GEFS+) can have typical and isolated FS, FS lasting more beyond age 6 years, and subsequent afebrile (typically generalised) seizures. Mutations associated with GEFS+ were identified in genes for subunits of the voltage-gated sodium channel and the gamma2 subunit of the ligand-gated GABAA receptor. Screening for these genes in patients with severe myoclonic epilepsy in infancy showed de novo mutations of the alpha1 subunit of the voltage-gated sodium channel. Antecedent FS are commonly observed in temporal-lobe epilepsy (TLE). In sporadic mesial TLE-characterised by the sequence of complex FS in childhood, hippocampal sclerosis, and refractory temporal-lobe seizures-association studies suggested the role of several susceptibility genes. Work on some large pedigrees also suggests that FS and temporal-lobe seizures may have a common genetic basis, whether hippocampus sclerosis is present or not. The molecular defects identified in the genetic associations of FS and epileptic seizures are very attractive models to aid our understanding of epileptogenesis and susceptibility to seizure-provoking factors, especially fever.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: the need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Suicidal and violent behaviour in mood disorders: A major public health problem. A review for the clinician

Abstract

Suicide attempt, and particularly completed suicide are relatively rare events in the community, but they are very common among psychiatric patients. Since over 90% of suicide victims suffer from (mostly untreated) current major mental disorders (particularly from major depressive episode), psychiatric risk factors are the clinically most useful predictors, especially if psychosocial and demographic risk factors are also pesent. Violent behaviours associated with mood disorders constitute a related yet independently also important aspect of this illness, and assessment and management of violence is a key component of everyday psychiatric practice. While most people with current mental disorder are not violent, violence is more common among seriously mentally ill individuals than in healthy persons. This is particularly true for untreated schizophrenics and untreated patients with major mood disorders, first of all in the cases of comorbid substance use disorders, mainly among those with current mania or postpartum depression. Although specific clinical studies are lacking, it is very lilely that successful acute and long-tem treatment of mood disorders can reduce the risk of violent behaviour in this patient population.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: The need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Characteristics of suicide attempters with depressive disorders

Abstract   Attempted suicide is known to be an important risk factor of committed suicide. Past studies of the relationship of attempted suicide with mental disorders have shown that it is most closely related to depression. The objective of the present study was to clarify characteristics of depression and measures to prevent committed suicide by comparing depression with other mental disorders. The patients with depression were significantly more often aged, males, married, and used methods other than poisoning by solids or liquids compared with patients with other mental disorders. Particularly, the major risk factors of attempted suicide (i.e. a younger age and the female gender), did not apply to our depressed patients. These results suggest that approaches such as intensive psychiatric treatment may lead to the prevention of committed suicide in older male patients with depression who have attempted suicide.     

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.