Seizure freedom reduces illness intrusiveness and improves quality of life in epilepsy

BACKGROUND: Chronic illnesses are associated with multiple stressors that compromise quality of life (QOL). Implicit in many of these stressors is the concept of illness intrusiveness: the disruption of lifestyles, activities, and interests due to the constraints imposed by chronic disease and its treatment. The purpose of this study was to examine illness intrusiveness and QOL in epilepsy in patients with different levels of seizure control. METHODS: Cross-sectional data were obtained and compared between two groups of patients categorized by presence of seizures: seizure freedom or continued seizures (N = 145). Standard instruments measured the following variables: illness intrusiveness, perceived personal control, subjective well-being, and disease specific QOL. RESULTS: Illness intrusiveness varied inversely and significantly with seizure control. Complete seizure freedom, whether achieved by pharmacological or surgical treatment, was associated with the lowest levels of illness intrusiveness. Seizure freedom was also associated with increased perceived control, positive affect, self-esteem and QOL in epilepsy. CONCLUSIONS: The most robust benefits of decreased illness intrusiveness in epilepsy occur when treatment leads to complete seizure control. Therefore every effort should be made by health care providers to achieve seizure freedom to reduce illness intrusiveness and improve QOL in epilepsy.     

The dynamics of drug treatment in epilepsy: an observational study in an unselected population based cohort with newly diagnosed epilepsy followed up prospectively over 11-14 years

OBJECTIVES: To study prospectively long term dynamics and patterns of treatment in a population based cohort of patients with newly diagnosed epilepsy. METHODS: 564 patients with definite epilepsy entered the UK National General Practice Study of Epilepsy (NGPSE), between 1984 and 1987, and were prospectively followed up for between 11-14 years. RESULTS: Treatment was started in 433 (77%) patients. Only 15% of single seizure patients had medication prescribed initially, although due to high seizure recurrence, more than 70% ultimately received antiepileptic medication. 209/564 patients (37%) were on drug therapy for epilepsy at the time of last follow up. 168/564 patients (30%) have stayed continuously on medication and another 41/564 patients (7%) restarted drug therapy because of seizure recurrence, having withdrawn medication. 98/209 (47%) of those on treatment are known to be in 5 year terminal remission. Phenytoin (29%) and carbamazepine (27%) were the most commonly preferred first line drugs followed by valproate (15%). Less than half of treated patients with partial seizures received carbamazepine as a first line drug and less than a third with generalised seizures were prescribed valproate as first choice drug. Nine out of 31 (29%) patients with one or more seizures a week at last follow up had never tried a second drug and only seven (23%) had tried four or more drugs. 11% of all treatment changes involved a new antiepileptic drug. Treatment changes were associated with low terminal remission rates. CONCLUSIONS: Out of 30 000 patients with newly diagnosed epilepsy every year in the United Kingdom, about 6000 have inadequate seizure control in the long term. About a third of the patients in this group have one or more seizures every month. Only two thirds of these patients with frequent seizures are likely to switch medication to try and achieve better seizure control. There is probably still considerable room for improvement in prescribing practice in the United Kingdom.     

Changes in serum anticonvulsant levels with febrile illness in children with epilepsy

Changes in anticonvulsant serum levels during intercurrent illness may cause toxicity or decreased seizure control in children with epilepsy. We studied prospectively the effect of intercurrent illness and its treatment in 111 children being treated with AC monotherapy. Free fraction and total serum AC levels were determined when the child was well, on the fifth day of any illness with fever and one month after recovery. There were 55 episodes of febrile illness in 39 children during the study period. Twelve illnesses were associated with significant increases or decreases in serum AC levels; 7 children became clinically toxic; 1 child had increased seizures during illness. The mechanisms of AC level changes appeared to include interaction with antibiotics, with antipyretics or with viral illness. Amoxycillin and acetaminophen did not appear to interact with the AC's used. Physicians caring for children with epilepsy should be aware of the frequency and complexity of potential interactions between intercurrent febrile illness and anticonvulsant medication.     

Prevalence and correlates of major depressive disorder (MDD) among adolescent patients with epilepsy attending a Nigerian neuropsychiatric hospital

BackgroundA high prevalence of mood disorders exists in patients with epilepsy. In most cases, this is not detected and, consequently, not treated. This study aimed to determine the prevalence and correlates of major depressive disorder (MDD) among adolescents with epilepsy attending a child and adolescent clinic in Nigeria.MethodsWe recruited 156 participants consecutively for the study. Adherence was assessed using the 8-item Morisky Medication Adherence Questionnaire, while the K-SADS was used to assess the presence of major depressive disorder. Seizure control was evaluated by the frequency of seizures within a year.ResultsMajor depressive disorder (DSM-IV criteria) was diagnosed in 28.2% of the participants. The age of participants (p = 0.013), seizure control (p = 0.03), medication adherence (p = 0.045), frequency of seizures in the preceding 4 weeks (p < 0.001), and duration of illness (p < 0.001) were all significantly associated with the presence of MDD. Participants with seizures occurring more than once weekly in the preceding 4 weeks were 16 times more likely to have a MDD compared with those with no seizures in the preceding 4 weeks (p < 0.001, 95% C.I. [4.13, 65.43]), while participants with a duration of illness more than 10 years were more than four times likely to have MDD compared with those with an illness duration of 5–10 years (p < 0.01, 95% C.I. [0.07, 0.70]).ConclusionThe prevalence of MDD among patients with epilepsy was high. Poor seizure control, poor medication adherence, and long duration of illness were associated with the presence of MDD among such patients. Intervention should focus on ensuring good seizure control and optimal adherence in order to mitigate the impact of MDD in patients with epilepsy.     

Predictors of seizure control in patients with juvenile myoclonic epilepsy (JME)

PurposeJuvenile myoclonic epilepsy (JME) is a widely accepted epilepsy syndrome. Factors that are potentially predictive for seizure outcome in JME are not entirely clear yet. In the current study, we tried to identify factors that are potentially predictive for seizure outcome in patients with JME.MethodIn this case–control study all patients with a clinical diagnosis of JME were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences from 2008 to 2012. All patients were followed for at least 18 months. We divided the patients into two groups: patients who were seizure free in the last 12 months of their follow-up period and those who had any seizures (i.e., generalized tonic-clonic (GTC), myoclonic or absences).Results116 patients were studied. Sixty-eight patients were seizure free in the last 12 months of their follow-up and 48 patients had at least one seizure of any type. Shorter follow-up period, drugs other than valproate in the drug regimen, and poor drug adherence were significantly more frequent among those who were not seizure free.ConclusionA correct diagnosis of JME does not guarantee an optimal response to therapy. Poorer drug adherence might result in more seizures; this should be highlighted for patients in every single visit. Longer follow-up gives the treating physician more time to adjust the drug(s) and formulate a plan that is appropriate for patients with difficult to treat seizures. We recommend valproate if seizure control is the main objective.     

Drug treatment-related factors of inadequate seizure control

To optimize seizure control it is important to identify modifiable factors. We conducted a case-control study to explore to what extent drug treatment-related factors are associated with seizures. Eighty-six patients with epilepsy were evaluated: 45 cases (recently experienced a seizure) and 41 controls (seizure-free for at least 2 months). There was a significant association between low AED serum concentration and seizures (odds ratio (OR)=8.9, 95% confidence interval (CI)=1.7-47.8), compliance was not associated with seizures (OR=0.9, 95% CI=0.2-4.0), and changes in medication (mainly non-AEDs) were more frequently observed in the case group than in the control group (OR=4.1, 95% CI=0.9-18.3). These findings indicate that patients with low AED serum levels have a nine times higher risk of seizures compared with patients with therapeutic AED levels and that changes in medication regimens in patients with epilepsy should be made with care.     

Childhood absence epilepsy requiring more than one medication for seizure control

INTRODUCTION: Absence epilepsy is the most common primary generalized epilepsy syndrome encountered in pediatric practice. Treatment is pharmacologically specific and usually successful with a single medication. The objective of this study was to identify any clinical or electroencephalographic features at initial presentation in a consecutive cohort of children with absence epilepsy that may be associated with the need for a second medication. METHODS: A computerized pediatric neurology database (1991-2007 inclusive) was retrospectively searched for all patients with typical absence seizures, 3 Hz spike and wave on EEG and no apparent symptomatic etiology who were over the age of two years at seizure onset with at least one year of follow-up. All such children were then divided into two groups; a) those requiring a single medication for seizure control (Group 1), and b) those requiring two medications for seizure control despite optimal management with the initial medication as determined by serum drug monitoring (Group 2). Clinical and electrographic features evident at diagnosis were then contrasted between Group 1 and 2. RESULTS: Seventy-five children with absence seizures were initially identified with 52 meeting the study's inclusion and none of the exclusion criteria. Of these 52 children, 43 required a single medication for seizure control (Group 1), while 9 required two or more medications for seizure control (Group 2). A significant difference (p < 0.05) was apparent between Group 1 and 2 with respect to gender (16/43 males vs 8/9 males) and mean age of diagnosis (8.19 years +/- 3.00 vs 6.06 years +/- 2.22). Age of onset of seizures, interval duration of seizures prior to treatment initiation, duration of seizures, presence of automatisms, family history, presence of co-morbid conditions and EEG findings were not found to be significantly different between the two Groups. CONCLUSIONS: Male gender and an earlier age of diagnosis is associated with the need for two medications for seizure control in children with absence epilepsy. This observation may suggest the need for more intensive early programmatic follow-up for young male children with newly diagnosed absence epilepsy to effect more rapid attainment of seizure control.     

The Use of Antiepileptic Drugs—Principles and Practice

Summary:  Up to 70% of people developing epilepsy may expect to become seizure free with optimum antiepileptic drug (AED) therapy. The remaining 30% are the most difficult to treat. Most patients are controlled on a single AED, but a small proportion requires a combination of two agents. Add-on therapy with a second drug, rather than substitution, may be a viable and rational approach in some patients, particularly if the first drug is relatively well tolerated. Precise classification of the type of seizures, as well as the epilepsy syndrome, together with careful recording of both seizures and adverse effects, are essential if rational management decisions are to be made. The goal of therapy should be complete seizure freedom with a single drug taken once or twice a day and without adverse effects. If control is difficult to achieve, the maximum tolerated dose of each drug should be explored, but a balance needs to be struck between adverse effects and control of seizures. In patients in whom treatment appears to be ineffective, the diagnosis of epilepsy and adherence to therapy should be reviewed. Drugs used in combination must be carefully selected, as poor adherence, drug interactions, and toxicity are more likely if more than one drug is prescribed. Agents are usually chosen according to seizure type, patient characteristics, and often by clinician preference. Those that are better tolerated have a low potential for pharmacokinetic and pharmacodynamic interactions, and those that can be easily introduced without any complicated titration schedule have an advantage.     

EEG Changes and Seizure Exacerbation in Young Children Treated with Carbamazepine

Summary: Carbamazepine (CBZ) has been reported to exacerbate some seizure types in children. We studied the correlation between CBZ-associated EEG changes and seizure exacerbation in 59 children aged <6 years treated with CBZ. All patients had EEGs before and after initiation of treatment; initial EEGs were not significantly different among the patients. In 33 children (56%), the subsequent EEGs were either unchanged or improved or demonstrated minor changes (Group I), and excellent to complete seizure control was achieved in 67% of patients. In 26 children (44%), the EEG became significantly more abnormal and was characterized predominantly by new appearance of generalized spikelpolyspike-and-wave discharges (group 11). The majority of these patients (65%) experienced seizure exacerbation (p <0.001). For group I, symptomatic partial epilepsy, idiopathic focal epilepsy, and complex febrile seizures were significantly more common; in group 11, cryptogenic seizure disorders were more common (p < 0.005). Children in group I were more likely to remain on CBZ or to be weaned from medication after successful treatment, whereas children in group II required additional medication(s) or complete discontinuation of CBZ. Our results suggest that new appearance of generalized paroxysmal discharges after treatment is highly correlated with seizure exacerbation or suboptimal control as well as with adverse outcome. Conversely, absence of significant EEG deterioration on CBZ is usually associated with good seizure control.     

Atypical benign epilepsy of childhood with rolandic spikes: features of a subset requiring more than one medication for seizure control

The objective of this study was to compare the clinical and electroencephalographic features of two groups of children with benign epilepsy of childhood with rolandic spikes: those in whom seizure control was attained either without the use of medication or with a single medication (group 1) and those requiring two medications for seizure control (group 2). A consecutive series of children with benign epilepsy of childhood with rolandic spikes was identified in a single pediatric neurology practice. Medical charts were then systematically retrospectively reviewed. A total of 66 children with benign epilepsy of childhood with rolandic spikes was identified; 52 (78.8%) required either no medication (n = 7) or a single medication (n = 45) for seizure control, whereas 14 (21.2%) required two medications. The two groups did not differ with respect to gender, age of onset, type (generalized or partial) of initial seizure, or whether EEG abnormalities were unilateral or bilateral. They did differ significantly with respect to the mean number of seizures experienced prior to initiating treatment (group 1, 2.06, versus group 2, 4.36; t = 3.40, P = .005). In those treated (n = 59), the initial medication selected (carbamazepine versus noncarbamazepine) in the two groups was significantly different: group 1, 40 (carbamazepine)/45, versus group 2, 9 (carbamazepine)/14; chi2 = 4.59; P = .03. The difference in frequency between the two groups of associated comorbid conditions (tics, attention-deficit hyperactivity disorder [ADHD], learning disability) almost reached the threshold of statistical significance: group 1, 7/52, versus group 2, 5/14 (chi2 = 3.67, P = .06). A subset of children with benign epilepsy of childhood with rolandic spikes may require more than one medication for effective seizure control. This subset experiences more seizures prior to the initiation of treatment, is more likely to be treated initially with a noncarbamazepine medication, and tends to have a higher frequency of associated conditions.     

Parents' and physicians' perceptions of childhood epilepsy.

STATEMENT OF THE PROBLEM: There is increasing interest in reducing burden of illness in families with childhood epilepsy. Evidence suggests that burden of illness is more related to parents' perception of seizure control than actual seizure control. This study examined the extent to which parents could describe their children's epilepsy and its impact. The degree of concordance between parents' and physicians' perceptions of epilepsy, and its effect on parents' satisfaction with care was also examined. METHOD: The study involved 37 parents and 1 paediatric neurologist. A questionnaire measured parents' perceptions of seizures and satisfaction with care. A physician questionnaire was piloted for comparison with parent responses. RESULTS: Parents were able to describe and distinguish seizure types, characteristics and impact of epilepsy. Results indicate a low degree of concordance between parents' and physician's perceptions for global, medical and everyday aspects of epilepsy. Preliminary evidence suggests that satisfaction with care may be positively related to degree of concordance. CONCLUSIONS: It is feasible to examine burden of illness from the parents' perspective. More attention should be paid to the parent-physician relationship in order for physicians to appreciate parents' perceptions. Future research is needed to replicate the findings in a larger sample of parents and paediatric neurologists.     

Illness perceptions of neurologists and psychiatrists in relation to epilepsy and nonepileptic attack disorder

Previous studies have demonstrated that the illness perceptions of doctors can affect treatment outcomes. This is likely to be particularly relevant in chronic disorders such as epilepsy or nonepileptic attack disorder (NEAD) in which treatment success depends on adherence to tablet treatments with significant side effects or a potentially difficult process of engagement in psychological treatment. This study describes the illness perceptions of neurologists and psychiatrists to epilepsy and NEAD. 85 doctors (45 neurologists and 40 psychiatrists) completed the adapted Illness Perception Questionnaire-Revised (IPQ-R) and the Symptom Attribution Question for epilepsy and NEAD. Both groups of doctors thought that patients with NEAD had greater personal control over their condition than patients with epilepsy (p<.02) and that NEAD was a more cyclical condition than epilepsy (p<.001). Both groups of doctors professed a greater understanding of epilepsy than NEAD (p<.001). Psychiatrists alone believed epilepsy to be more chronic than NEAD (p=.002). Psychiatrists felt that epilepsy had less of an emotional impact on patients (p=.004) and were more likely to endorse psychological causes for epilepsy (p=.008) when compared to neurologists. Psychiatrists felt that NEAD had less negative consequences (p=.014) and were more likely to endorse nonpsychological causes for NEAD (p=.020) when compared to neurologists. The IPQ-R and Symptom Attribution Question demonstrated important differences in attitudes of neurologists and psychiatrists towards epilepsy and NEAD. Different attitudes towards the two seizure disorders may cause problems with communication and treatment if patients are referred from one speciality to the other.     

Social support and locus of control as predictors of adherence to antidepressant medication in an elderly population.

OBJECTIVE: The authors examined whether social support and locus of control (LOC), either individually or jointly, would be associated with subsequent self-reported medication adherence and treatment barriers in a sample of depressed elderly patients. METHODS: A group of 85 elderly patients with major depression was enrolled in the Mental Health Clinical Research Center for the Study of Depression in Later Life at Duke University and treated with a standardized algorithm. During the course of the study, participants completed measures of social support and internal locus of control (LOC). A little more than 1 year later, they completed general measures of medication adherence and treatment barriers. RESULTS: Increasing subjective and instrumental social support and non-family interaction were associated with greater adherence among patients high in internal LOC but not among patients low in internal LOC. Less instrumental social support was associated with more treatment barriers among patients low in internal LOC but not among patients high in internal LOC. CONCLUSION: The relationship between social support and antidepressant medication adherence is moderated by beliefs about control over one's illness.     

Adherence to Treatment in Children With Epilepsy: Who Follows "Doctor's Orders"?

PURPOSE: The goal of the present study was to examine sociocultural, medical, family environment, and individual cognitive factors that predict adherence to treatment in children with epilepsy. METHODS: The study subjects (4-13 years old) were enrolled in a longitudinal seizure study at the first visit to the seizure clinic, attended at least 6 months, and had at least two appointments. Baseline predictors, which were obtained by interview, chart review, and psychometric testing, included sociocultural and family environment, seizure and previous treatment history, child behavior, cognitive functioning (IQ), and family stress. Four latent factors tapping these indicators of risk (acculturative risk, seizure severity, behavior problems, family environment) and two measured variables (IQ and life events) were hypothesized. Outcomes were visit adherence (proportion of scheduled appointments kept, plus proportion without unscheduled contacts), medication report (proportion of visits at which parent report of medication agreed with records), and medication levels (proportion of serum anticonvulsant levels within expected range for dosage). Two-step analytic procedure included confirmatory factor analysis to validate the hypothetical structure of the baseline risk indicators, followed by structural equation modeling to examine longitudinal relations between baseline risk and subsequent adherence outcomes. RESULTS: Significant prospective relationships included acculturative risk associated positively with visit adherence and medication levels, behavior problems associated negatively with visit adherence and medication levels, family environment associated negatively with medication report, life events associated positively with medication levels and visit adherence, and cognitive functioning (IQ) associated positively with medication levels. Seizure severity was not associated significantly with any adherence outcome. There also were no significant within-time associations between adherence outcomes. CONCLUSIONS: Contrary to clinical expectations, families at higher acculturative risk and with higher life events reported greater adherence. Seizure severity did not influence adherence. The three adherence measures were statistically independent of each other.     

Advances in the Assessment of Refractory Epilepsy

Summary: The assessment of patients with refractory epilepsy presents both a challenge and an opportunity. The use of appropriate instruments to carefully and consistently measure a patient's seizure type and frequency, hormonal function, and medication side effects and the impact of those variables on quality of life ensures consistent, standardized assessment. A patient's epilepsy then can be classified as refractory based on any combination of factors that preclude a reasonably normal life-style by current practice standards, given the person's capabilities. Diagnostic studies and treatment strategies should address all significant adverse findings resulting from the assessment process. Accurate diagnosis of seizure type usually requires electroencephalographic (EEG) monitoring. Postictal hormonal assays and periodic measurements of estrogen and progesterone may be useful diagnostically in a selected group of patients. Awareness of a patient's compliance history, environmental stressors, and seizure triggers may reduce seizure frequency without a change in medication. For patients with medication intolerance, the usual strategy is to modify the medication regimen or treatment schedule to minimize side effects while maximizing seizure control and compliance. For most patients, monotherapy provides a greater therapeutic window than combination therapy. Devising an effective and safe therapeutic regimen is an ongoing process and can be lengthy depending on seizure type(s), frequency, and temporal pattern; anticonvulsant pharmacokinetics; drug interactions and side effects; patient's life-style; and other factors. Serial measurements of quality-of-life variables may assist in the process. Rapid strides have been recently made, and as the pace of new antiepileptic drug development quickens and surgical centers become more widely available, clinicians will need to redefine refractoriness as the expectations improve for patients with epilepsy.     

Long-term outcome of nonsurgical candidates with medically refractory localization-related epilepsy

PURPOSE: Epilepsy surgery can result in complete seizure remission rates of upto 80% in patients with mesial temporal sclerosis and unilateral seizures. The seizure-free rate after surgery for patients with extratemporal nonlesional epilepsy has ranged between 30% and 40%. Some patients with medically refractory localization-related epilepsy cannot be offered surgical resection because of inadequate localization of the epileptogenic zone, documentation of bilateral ictal onsets, or functionally important areas of cortex that prohibit resection. The short-term rate of complete remission with medications in temporal lobe epilepsy is poor. Less is known about remission rates in patients who are not surgical candidates. In this study, we evaluated the outcome of medical treatment in patients with medically refractory partial epilepsy who were evaluated for possible epilepsy surgery but deemed to be inadequate surgical candidates. METHODS: A retrospective chart review and telephone survey with a self-rating questionnaire were completed for all patients who underwent epilepsy surgery evaluation but were not ultimately offered surgical treatment at the University of Michigan from 1990 through 1998. We assessed changes in seizure frequency and type, imaging characteristics, ictal recordings, interim medication history, and subjective changes in quality of life. RESULTS: Thirty-four subjects were available for follow-up study, at an average of >4 years after surgical evaluation. A significant reduction in seizure frequency was noted at the time of follow-up compared with that at the time of surgical evaluation. Of patients, 21% achieved seizure remission and remained seizure free for an average of 2.5 years. Four of the seven seizure-free patients attributed their remission to new antiepileptic drugs (AEDs). On a global self-rating item, 15 of 34, or 44%, felt more or much more satisfied with their lives, and 41% felt their quality of life was stable. CONCLUSIONS: A surprisingly large number of patients we surveyed, with refractory partial epilepsy not eligible for surgical management, reported reduced seizure frequency at follow-up, and 21% were seizure free. Our findings suggest that the long-term prognosis in patients with refractory partial epilepsy who are not surgical candidates may be more positive than might be generally expected.     

The association of stigma with self-management and perceptions of health care among adults with epilepsy

OBJECTIVE: The purpose of this study was to examine the perception of stigma among adults with epilepsy including its association with epilepsy self-management and perceptions of health care. METHODS: Participants for the study were recruited from two epilepsy centers and a neurology clinic. Individuals agreeing to participate in the study were asked to complete three assessments each 3 months apart. Data were collected from 320 adult men and women with epilepsy; 314 provided responses on stigma and were included in this analysis. RESULTS: Participants ranged in age from 19 to 75 years (mean=43). Fifty percent of the sample was female, and 80% was white. The mean age of seizure onset was 22 years, and 76% of participants reported having had a seizure within the past year. Analysis suggests levels of perceived stigma are similar for men and women and across ethnic and age groups. However, participants who were not married or living with a partner, were not working for pay, and had limited income reported higher levels of stigma than did married participants, those working for pay, and those in higher income brackets. Participants reporting higher levels of stigma included those who had their first seizure before the age of 50 and a seizure in the last year. Participants whose seizures interfered more with activities, who rated their seizures as under less control, and who were not legally able to drive also reported higher levels of stigma. Tests of association between stigma and health-related variables revealed that participants reporting higher levels of perceived stigma also reported lower levels of self-efficacy to manage epilepsy; more negative outcome expectancies related to treatment and seizures; and lower levels of medication management, medication adherence, and patient satisfaction. However, they also reported greater management of information related to seizures. In regression analysis, income, age at first seizure, seizures during the past year, lower self-efficacy, negative outcome expectancies for seizures, and less patient satisfaction explained 54% of the variance in perceived stigma. CONCLUSIONS: The results of the study suggest that perceived stigma is significant for people with epilepsy and is associated with factors that are known to be important in the management of epilepsy. Understanding who is at greatest risk for feeling stigmatized could lead to the development of preventive measures.     

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.