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.     

Antiepileptic drugs and suicidality: An expert consensus statement from the Task Force on Therapeutic Strategies of the ILAE Commission on Neuropsychobiology

In 2008, the U.S. Food and Drug Administration (FDA) issued an alert to health care professionals about an increased risk of suicide ideation and suicide behavior in people treated with antiepileptic drugs (AEDs). Since then, a number of retrospective cohort and case–control studies have been published that are trying to address this issue, but gathered results are contradictory. This report represents an expert consensus statement developed by an ad hoc task force of the Commission on Neuropsychobiology of the International League Against Epilepsy (ILAE). Although some (but not all) AEDs can be associated with treatment‐emergent psychiatric problems that can lead to suicidal ideation and behavior, the actual suicidal risk is yet to be established, but it seems to be very low. The risk of stopping AEDs or refusing to start AEDs is significantly worse and can actually result in serious harm including death to the patient. Suicidality in epilepsy is multifactorial, and different variables are operant. Clinicians should investigate the existence of such risk factors and adopt appropriate screening instruments. If necessary, patients should be referred for a psychiatric evaluation, but AED treatment should not be withheld, even in patients with positive suicidal risks. When starting an AED or switching from one to other AEDs, patients should be advised to report to their treating physician any change in mood and suicidal ideation. Data on treatment‐emergent psychiatric adverse events need to be collected, in addition to general safety information, during controlled studies in order to have meaningful information for patients and their relatives when a new drug is marketed.     

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.     

An Update on Antiepileptic Drugs and Suicide: Are There Definitive Answers Yet?

In 2008, the Food and Drug Administration (FDA) issued a warning that any and all antiepileptic drugs (AEDs) might increase the risk of suicidal ideation, suicide attempt, and completed suicide. Considerable confusion and concern followed regarding the use of these drugs, in general, and specifically for people with epilepsy. Recently, four publications examined suicidality and AED use among several databases and illustrated how biases affect the findings. None of the studies was able to control completely for the indication for which the AEDs were prescribed or to account for the varying intensities with which different specialists monitoring patients for suicidality. Though multiple analyses were conducted for many AEDs, no study controlled for the numerous comparisons made. The result is a multitude of contradictions in the findings across studies and even within studies, with no study providing clear or convincing support for the FDA conclusions. This review attempts to clarify the methodological issues in assessing potential associations between AED use and suicidality.The lifetime prevalence of suicide is estimated to be around 1.1 to 1.2 percent in the general population of the United States (1), while the prevalence of suicide attempts ranges between 1.1% and 4.6% (2,3). Primary mood disorders, schizophrenia, antisocial and borderline personality disorders, as well as substance abuse are the psychiatric disorders most commonly associated with completed suicide risk (4,5). The relationship between suicidal risk and individual psychiatric comorbidities is a complex one. For example, the relation between suicidality and bipolar disorders includes: 1) the phase of the illness, with almost 80% of suicide attempts occurring in the midst of a major depressive episode; 2) younger age of onset of the bipolar disorder, defined as a younger age at the first episode of depression or mania; 3) development of rapid cycling bipolar illness, defined as four or more depressive and/or manic (or hypomanic) episodes in a 12-month period; 4) other comorbid psychiatric disorders, including a history of alcohol or substance abuse, anxiety disorders, and personality disorders (6). Furthermore, suicidality is not a onetime event. Following a first episode, the risk is substantially increased for subsequent episodes, including completed suicide. For example, one study found that 10 to 20 percent of patients who report a suicide attempt successfully committed suicide within 10 years (7).Several AEDs (e.g., valproic acid, carbamazepine, oxcarbazepine, and lamotrigine) have been extensively used as mood stabilizing agents for patients with bipolar disease. Yet, the prophylactic efficacy of these AEDs specifically for prevention of suicidality has been limited to comparing valproic acid and carbamazepine against the gold standard, which is lithium (8,9). In these studies, valproic acid and carbamazepine were not as efficacious as lithium for preventing suicide. This finding does not mean that they are ineffective as mood stabilizers, nor does it mean that they act to increase the risk of suicidality relative to no treatment or to other treatments.Epilepsy, itself, is also associated with a relatively high suicide risk (10). One meta-analysis of 21 reports of death among epilepsy patients found that 11.5% of the deaths were attributed to suicide (11). As in the case of bipolar disorder, the relationship between epilepsy and suicidal risk is complex. The operant variables include: 1) the existence of a current and/or past psychiatric disorder, particularly affective disorder, which raises the risk of completed suicide by 19-fold (12); 2) a history of suicide attempt (13); 3) the type of epilepsy (i.e., higher frequency in temporal lobe epilepsy); 4) the existence of postictal psychiatric disturbances (10,14); 5) an increased risk for psychosis following acute withdrawal of AEDs (15); and 6) exposure to some AEDs that can trigger psychiatric disturbances, facilitating the development of suicidal behavior (15). Individuals who have attempted suicide in the past have a five-fold higher risk of developing epilepsy (16). The complex relation between epilepsy and suicidal risk was reviewed previously in this journal (17).Despite the relatively high prevalence of psychiatric comorbidities, and in particular, the increased suicidal risks associated with epilepsy, clinicians seldom identify and refer these patients for psychiatric treatment. It is also rare for patients and family members to spontaneously report the existence of psychiatric disturbances. This pattern appears to have changed since 2008, when the Food and Drug Administration (FDA) issued a warning that any and all AEDs might increase the risk of suicidal ideation, suicide attempt, and completed suicide (suicidality) (18). The warning resulted in considerable confusion and concern about the use of these drugs for the general population but particularly for people with epilepsy. The methodological inadequacies of the FDA analysis previously have been discussed (19).Surprisingly, little data exist in the literature on the association between AEDs and suicidality. Psychiatric adverse events that can lead to an increased suicidal risk have been identified more frequently with AEDs that have GABAergic properties, particularly in vulnerable patients, such as those with a psychiatric history or a family psychiatric history (20–23). The AEDs with GABAergic properties include the barbiturates, the benzodiazepines, tiagabine, vigabatrin, topiramate, zonisamide, and gabapentin. The rise in depression and, in particular, in suicidal behavior has been attributed to a GABAergic-mediated decrease in serotonin secretion at the raphe nuclei (24–26). Other AEDs without known GABAergic effects, such as levetiracetam, have also been associated with an augmented incidence of psychiatric adverse events that can lead to increased suicidality, but the potential pathogenic mechanisms remain to be established (21).Recently, four publications have examined suicidality and AED use in epidemiological analyses of administrative databases (27–30). The following review presents a methodological analysis and critique of these studies, a summary of the conclusions that might be drawn from the four together, and some thoughts on how the findings might or might not influence clinical practice. Before discussing specific aspects and results of these studies, however, a summary of key methodological considerations that need to be taken into account when reading this literature is delineated.     

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.     

Risk factors for psychogenic nonepileptic seizures in children and adolescents with epilepsy

There is evidence that psychogenic nonepileptic seizures (PNES) remain underdiagnosed, especially in children and adolescents. Diagnosis of such events is even more difficult in patients that do have epilepsy, leading to delayed diagnosis and treatment and, consequently, iatrogenic complications. This study aimed to evaluate possible risk factors in children with epilepsy who had PNES. Seizures and epileptic syndromes were classified according to International League Against Epilepsy guidelines. Patients were evaluated with a structured psychiatric anamnesis and classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research; and Schedule for Affective Disorders and Schizophrenia for School-Age Children--Epidemiological Version. Risk factors such as head trauma, physical, sexual and psychological abuse, and psychiatric diagnoses, among others, were investigated. Family history of epilepsy and psychiatric illness were detected by review of medical records and/or follow-up interviews. Gender was not a predictive factor, and although older children had a higher risk for PNES, younger children also presented truly psychogenic events mimicking epileptic seizures. The most common associated psychiatric diagnosis was depression. Family histories for epilepsy and psychiatric illness were a frequent finding. An inadequate family environment was more common than sexual or physical abuse. Current knowledge obtained from adults with PNES has been used to understand children with PNES. However, this study of children with epilepsy revealed some similarities and many differences. These features may help to identify predictive factors in a population in need of adequate diagnosis of and therapy for this long-lasting pathology.     

Differential effects of executive functioning on suicide attempts

Suicide is common among individuals with psychiatric illness; executive functioning may be associated with suicide risk. The authors examined demographic, clinical, and executive-functioning variables in suicide ideators and suicide attempters, hypothesizing that attempters would demonstrate poorer executive-functioning skills. Seventy-seven participants with psychiatric illness completed a neuropsychological battery while hospitalized or residing in crisis-houses after expressing suicidal ideation (N=40) or making a suicide attempt (N=37). Logistic regression predicted suicide Ideator versus suicide Attempter status; suicide Attempters exhibited poorer inhibition but better problem-solving ability than suicide Ideators. Suicide attempt risk may be associated with better problem-solving skills, but worse inhibitory control.     

Psychogenic nonepileptic seizures: Should we use response to AEDS as a red flag for the diagnosis?

PurposeLack of response to anti-epileptic drugs (AEDS) is considered a “red flag” pointing to a diagnosis of Psychogenic Nonepileptic Seizures (PNES). On the other hand, placebo effects are relevant in any medical condition with a complex psychosocial component. We aimed to evaluate the presence and frequency of a placebo response in patients with sole PNES and explore its impact on diagnostic delay.MethodsWe reviewed the medical records of 102 patients referred for video EEG monitoring and diagnosed with PNES. Patients with PNES and epilepsy were excluded. The response to AEDs was analyzed according to patients’ reports and medical records. Patients were classified, according to the response to AEDs, in two groups: responders (patients achieving remission) and non-responders. Then, we compared the diagnostic delay from the first event to the final diagnosis between these groups.ResultsForty-seven patients (79.7%) with sole PNES who were using AEDs were identified. Twenty-two patients (46.8%) had reported complete or partial remission of PNES with mean response duration of 7.2 months (SD + 9.6 months). The time delay of the diagnosis in the AED responder group was 10.6 years; the delay in non-responders was 5.6 years (p = 0.035).ConclusionPatients with sole PNES receiving AEDs can go into PNES remission. A favorable response to AEDs is likely to be interpreted as supporting a diagnosis of epilepsy and is associated with diagnostic delay. Physicians should bear in mind that patients with PNES may be particularly vulnerable to placebo effects.     

Examination of volunteer bias in research involving patients diagnosed with psychogenic nonepileptic seizures

There is some evidence to suggest that the same personality and emotional features observed in patients diagnosed with psychogenic nonepileptic seizures (PNES) may be related to nonparticipation in studies aimed at determining the most effective interventions for treating this patient population. This study aimed to document the frequency with which patients referred to an epilepsy monitoring unit (EMU) for video/EEG telemetry who are diagnosed with PNES or epileptic seizures (ES) participate in survey research. Of the 139 patients approached, 16 patients declined and 23 produced invalid or incomplete surveys. There was no significant difference in participation rates between patients diagnosed with PNES and those diagnosed with ES. These findings argue against a volunteer bias in research involving PNES and suggest that the results of other studies with these patients generalize to the population as a whole.     

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.     

Suicidal ideation and suicide attempts in a sample of homeless people with mental illness

This study utilized data from the national ACCESS program (N = 7224) to investigate the prevalence of suicidal ideation and suicide attempts in a sample of homeless people with mental illness. The prevalence of suicidal ideation in this sample was high (66.2% lifetime prevalence). In addition, 51.3% of the sample reported that they had ever attempted suicide, 26.9% reported an attempt that resulted in a nonpsychiatric hospitalization, and 8% reported an attempt in the previous 30 days. Youth, substance abuse, and psychiatric symptoms were all significantly associated with suicide attempts. Those who reported a recent attempt also reported higher rates of mental health care utilization, particularly inpatient care. The authors conclude that homeless people with mental illness are at particularly high risk for suicidal behavior, however, only in part because of the high prevalence of traditional risk factors.     

Familial clustering of suicidal behaviour and psychopathology in young suicide attempters

Introduction Familial clustering of suicidal behaviour and psychopathology has been reported in young suicide attempters. Most of these studies were predominantly carried out in clinical treatment settings and lacked statistical power to assess the independent and modifying influences of own and familial psychopathology and suicidal behaviour. Methods We carried out a population-based record-linkage study with a nested case control design. The 14,440 individuals hospitalised due to suicide attempt (cases) and 144,400 matched controls were born in Sweden between 1968 and 1980 and followed up till December 31, 1999. Results Among the strongest independent familial risk factors for youth suicide attempt were siblings’ (OR 3.4; 2.8–4.1), maternal (OR 2.7; 2.5–3.1) and paternal (OR 1.9; 1.7–2.1) suicide attempt. Other important risk factors were familial personality and substance abuse disorders, maternal schizophrenia, non-affective psychoses and organic disorders and parental neurotic, stress-related and somatoform disorders (1.9–3.2 fold increase), and paternal (OR 1.9; 1.6–2.3) and maternal (OR 1.8; 1.3–2.4) suicide completion. Mental illnesses in index subjects, particularly substance abuse, affective and personality disorders, were the dominant determinants of suicide attempt. Strong interactions were observed between psychopathology in index subjects and familial suicidality. Familial suicide completion had a stronger effect on suicide attempt of earlier onset and on boys. Nearly half (47%) of all suicide attempts could be attributed to familial psychopathology (13%), family suicide attempt (7%) and suicide completion (1%) and own psychopathology (25%). Conclusion Early recognition and adequate treatment of individual mental illness contribute to prevent youth suicide attempts. Children of parents with psychopathology and suicidal behaviour should receive early support and attention. Evaluation of familial suicidal behaviour seems to be vital for suicide risk assessment in young psychiatric inpatients. There appears to be an independent effect of familial suicidal behaviour as well as familial psychopathology on youth suicide attempt beyond the transmission of mental illness.     

Suicidality in Epilepsy and Possible Effects of Antiepileptic Drugs

Suicide is an important cause of premature death, and people with epilepsy are thought to be at increased risk for suicide. Antiepileptic drugs (AEDs) continue to be the mainstay of epilepsy treatment, but the benefits of seizure control must be balanced with their psychotropic potential. In recent years, suicidality has been recognized as a complication of several groups of drugs and, most recently, AEDs were implicated in an alert by the US Food and Drug Administration. The risk of suicidal ideation and behavior as side effects of AED treatment is low, and in people with epilepsy, such a risk must be balanced against the risk of not treating the seizures.     

Risk factors for suicide in epilepsy: a case control study

PURPOSE: Suicide is considered to be one of the most important causes of death contributing to the increased mortality of persons with epilepsy. We investigated the association between the risk of suicide in persons with epilepsy and clinical factors that might increase or have been suggested to increase the risk of suicide. METHODS: A case-control study was nested within a cohort of 6,880 patients registered in the Stockholm County In-Patient Register with a diagnosis of epilepsy. The study population was followed up through the National Cause of Death Register. Twenty-six cases of suicide, 23 cases of suspected but not proven suicide, and 171 controls, living epilepsy patients, were selected from the cohort. Clinical data were collected through medical record review. RESULTS: There was a ninefold increase in risk of suicide with mental illness and a 10-fold increase in relative risk (RR) with the use of antipsychotic drugs. The estimated RR of suicide was 16.0 [95% confidence interval (CI), 4.4-58.3] for onset of epilepsy at younger than 18 years, compared with onset after 29 years. The risk of suicide seemed to increase with high seizure frequency and antiepileptic drug (AED) polytherapy, although the estimates were imprecise and the associations not statistically significant. Insufficient data on seizure frequency and changes in AED dosage due to incomplete case records were associated with high RRs. We found no association between risk of suicide and any particular AED, with type of epilepsy, or localization or lateralization of epileptogenic focus on EEG [RR = 0.3 (95% CI, 0.1-1.7)]. CONCLUSIONS: The profile of the epilepsy patient who commits suicide that emerges from our study is a patient with early onset (particularly onset during adolescence) but not necessarily severe epilepsy, psychiatric illness, and perhaps inadequate neurologic follow-up. Previous reports of an association with temporal lobe epilepsy could not be confirmed.     

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.     

Pseudosleep events in patients with psychogenic non-epileptic seizures: prevalence and associations

OBJECTIVES: To determine the prevalence and clinical associations of a history of events during sleep in patients with psychogenic non-epileptic seizures (PNES, pseudoseizures), and to compare the prevalence of a history of sleep events with that in poorly controlled epilepsy. METHODS: Prospective study by semistructured interview of the history of event patterns and their clinical associations in 142 patients with video EEG confirmed PNES, and 100 patients with poorly controlled epilepsy. RESULTS: 84/142 patients with PNES (59%) and 47/100 with epilepsy (47%) gave a history of events during sleep (p = 0.062). In patients with PNES, significant associations were found between a history of sleep events and: convulsive clinical semiology, antiepileptic drug treatment, fatigue, suicide attempts, mood disorder, and physical abuse. A particularly strong association with social security benefit was also found (odds ratio 4.0, p<0.001). CONCLUSIONS: The prevalence of a history of sleep events is similar in PNES and epilepsy, and is of no value in discriminating between the two, although a history of events occurring exclusively during sleep does suggest epileptic seizures. The clinical associations found indicate that a combination of psychopathological and external influences may be important in determining whether or not a patient with PNES gives a history of events during sleep.     

Body dissatisfaction and suicidal ideation among psychiatric inpatients with eating disorders

The current study the relationship between eating disorders (EDs) and suicidal ideation and suicide attempt in adult inpatients. In particular, the present study investigated one potential mechanism, body dissatisfaction (BD), which may contribute to increased risk for suicide in adult ED patients. A sample of 432 psychiatric inpatients ranging from 18 to 65 years of age participated in the current study. Findings indicated that patients who have higher levels of BD also had higher levels of passive and active suicidal ideation and previous suicide attempts. Higher levels of BD were also related to increased suicidal ideation after controlling for depression and emotion dysregulation. Although additional risk factors for suicide should be investigated in adults with EDs, this study provides evidence regarding the relationship between BD and risk for suicide ideation and attempt.     

Age and attempted suicide

Clinical and demographic factors associated with suicide attempts admitted to the West Midlands Poisons Unit over a 2-year period were compared by age group. Risk factors for future suicide (living alone, physical illness, psychiatric illness and high suicidal intent in the attempt) were significantly more common among elderly patients (65 years and over) than middle-aged patients (35-64 years) and significantly less common among young patients (under 35 years) than middle-aged patients. Elderly patients that attempted suicide resemble elderly patients that completed suicide and should be considered at high risk of future suicide.     

Suicidality and Its Risk Factors in Korean People with Epilepsy: A MEPSY Study

Background and Purpose

People with epilepsy (PWE) are more likely to experience suicidality, with suicidal ideation and attempts, than people without epilepsy (PWoE). The aims of the present study were to determine 1) the characteristics of suicidality in Korean PWE, 2) whether PWE with suicidality receive psychiatric intervention, and 3) the risk factors for suicidality.

Methods

Patients who consecutively visited epilepsy clinics at secondary- and tertiary-care hospitals were recruited (n=684), along with age- and sex-matched PWoE (n=229). The presence of current major depressive disorder (MDD), generalized anxiety disorder (GAD), and/or suicidality was established using the Mini International Neuropsychiatric Interview-Plus Version 5.0.0. The Korean version of the Liverpool Adverse Events Profile (K-LAEP) was applied to detect adverse effects of antiepileptic drugs (AEDs).

Results

Suicidality was present in 208 (30.4%) of the 684 PWE. The rate of suicidality was 4.6 times higher among PWE than PWoE, and 108 (15.7%) PWE had suicidal ideation and had attempted suicide. Among those who had attempted suicide, 40.7% had made at least two attempts. The most common method of suicide attempt was drug overdose (34.9%). Unfortunately, of the 208 PWE with suicidality, 136 (65.4%) did not receive psychiatric intervention. The risk factors for suicidality were MDD [odds ratio (OR)=6.448, 95% confidence interval (CI)=3.739-11.120, p<0.001], GAD (OR=3.561, 95% CI=1.966-6.452, p<0.001), item scores of 3 or 4 on the K-LAEP (OR=2.688, 95% CI=1.647-4.387, p<0.001), and a history of febrile convulsion (OR= 2.188, 95% CI=1.318-3.632, p=0.002).

Conclusions

Suicidality is more prevalent in PWE than in PWoE. Clinicians should monitor psychiatric disorders and the adverse effects of AEDs in PWE in an attempt to reduce the incidence of suicidal ideation or suicide attempts in this patient population.     

Recognition of psychogenic nonepileptic seizures diminishes acute care utilization

Patients with psychogenic nonepileptic seizures (PNES) frequently use acute health care resources including emergency departments (EDs), resulting in redundant efforts. We asked whether establishing the diagnosis of PNES via video/EEG telemetry reduces subsequent ED use. Twenty-three patients with PNES were studied over a 48-month period surrounding the diagnosis using a provincewide database. There was a 39% reduction in total ED visits and a 51% reduction in ED visits for neurological causes during the 24 months following the diagnosis, and decreased ED use persisted throughout the follow-up period. There was no significant change in ED utilization for psychiatric causes. The proportion of patients with PNES who used ED services once or not at all per year increased from 26% in the 2 years prior to the diagnosis to 57% following the diagnosis. These findings suggest that a definitive, telemetry-based diagnosis relieves diagnostic uncertainties for the patient and physician, but also has quantifiable economic benefits.