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Is antiepileptic-induced suicidality a data-based class effect or an exaggeration? A comment on the literature. Harv Rev Psychiatry 2014; 22:379-81. [PMID: 25377614 DOI: 10.1097/hrp.0000000000000039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A few years ago the Food and Drug Administration, based on a meta-analysis, issued a warning stating that antiepileptic drugs (AEDs) are associated with an increased risk of suicidal ideation, suicide attempts, and completed suicide. This warning generated significant concern about the use of AEDs, especially in patients with epilepsy and affective disorders. Following the FDA report, several studies addressed this issue but only served to generate further concern and confusion. There seems to be no convincing data concerning a "class effect" of AEDs in inducing any type of suicide-related behaviors. Some data suggest a possible association of lamotrigine, levetiracetam, and topiramate with suicidality, but further research is needed. In any case, clinicians need to carefully assess suicidality in all patients treated with AEDs and inform them and their families on the possible increased risk of suicidality, though preferably in a way that keeps open the continuing use of AEDs.
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French JA, Gazzola DM. New generation antiepileptic drugs: what do they offer in terms of improved tolerability and safety? Ther Adv Drug Saf 2014; 2:141-58. [PMID: 25083209 DOI: 10.1177/2042098611411127] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Over the last two decades a total of 11 antiepileptic drugs (AEDs) have been introduced to the US market. Randomized, placebo-controlled trials have yielded information about each drug's efficacy, tolerability, and safety profile; however, few studies have compared the newer generation AEDs directly with the older generation. Comparative studies are not always straightforward in their interpretation, as many characteristics of drugs, both favorable and unfavorable, may not be highlighted by such studies. In general, findings from the literature suggest that the newer generation AEDs (including vigabatrin, felbamate, gabapentin, lamotrigine, tiagabine, topiramate, levetiracetam, oxcarbazepine, zonisamide, pregabalin, rufinamide, and lacosamide) enjoy both improved tolerability and safety compared with older agents such as phenobarbital, phenytoin, carbamazepine, and valproate. This is partially supported by some of the findings of the QSS and the TTA Committee of the American Academy of Neurology (AAN), whose review of four AEDs (gabapentin, lamotrigine, topiramate, and tiagabine) is discussed. Briefly, when compared with carbamazepine, lamotrigine was better tolerated; topiramate adverse events (AEs) were fairly comparable to carbamazepine and valproate; and tiagabine compared with placebo was associated with a higher discontinuation rate due to AEs. The findings of the SANAD trial are also presented; when administered to patients with partial epilepsy, carbamazepine was most likely to fail due to AEs, and lamotrigine and gabapentin were least likely to fail due to AEs. When administered to patients with idiopathic generalized epilepsy, topiramate was most frequently associated with AE-related discontinuation, followed by valproate; and while valproate was the most efficacious drug in this arm of the study, lamotrigine was more tolerable. What makes the SANAD study valuable and somewhat unique is its head-to-head comparison of one drug with another. Such comparative trials are overall lacking for new AEDs, although some conclusions can be drawn from the available data. In the end, however, AED selection must be based on individual patient and drug characteristics.
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Affiliation(s)
- Jacqueline A French
- New York University School of Medicine, NYU Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, USA
| | - Deana M Gazzola
- New York University School of Medicine, NYU Comprehensive Epilepsy Center, New York, NY, USA
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Anger with murderous impulse induced by lamotrigine. Gen Hosp Psychiatry 2014; 36:451.e1-2. [PMID: 24736088 DOI: 10.1016/j.genhosppsych.2014.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 03/07/2014] [Accepted: 03/11/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report two cases of major depressive disorder in which lamotrigine (LTG) induced anger with murderous impulse. PATIENTS Case 1 was a 22-year-old man with symptoms of obsessive-compulsive disorder who developed major depressive disorder with antidepressant-induced hypomanic episodes. Case 2 was a 23-year-old woman experiencing an antidepressant-refractory depressive episode for whom remission was achieved by switching to a mood stabilizer and antipsychotics. In both cases LTG was started to treat the depressive episode. RESULTS Case 1 manifested with anger and murderous impulse when taking 125 mg/day of LTG. A reduction to 75 mg/day calmed this anger. Case 2 manifested with the same symptom when taking 25 mg/day of LTG, and the symptom immediately disappeared upon stopping LTG. CONCLUSIONS Use of LTG for epilepsy in intellectually disabled patients was reported to be associated with onset or exacerbation of aggressive or violent behavior. The two cases would suggest that LTG may cause anger so severe as to be accompanied with murderous impulse when administered to patients with mood disorders. Physicians should be cognizant of this possible, albeit infrequent, adverse effect even in use of LTG for mood disorders.
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Mittal M, Harrison DL, Miller MJ, Farmer KC, Thompson DM, Ng YT. Have antiepileptic drug prescription claims changed following the FDA suicidality warning? An evaluation in a state Medicaid program. Epilepsy Behav 2014; 34:109-15. [PMID: 24739448 DOI: 10.1016/j.yebeh.2014.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 03/18/2014] [Accepted: 03/21/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In January 2008, the Food and Drug Administration (FDA) communicated concerns and, in May 2009, issued a warning about an increased risk of suicidality for all antiepileptic drugs (AEDs). This research evaluated the association between the FDA suicidality communications and the AED prescription claims among members with epilepsy and/or psychiatric disorder. METHODS A longitudinal interrupted time-series design was utilized to evaluate Oklahoma Medicaid claims data from January 2006 through December 2009. The study included 9289 continuously eligible members with prevalent diagnoses of epilepsy and/or psychiatric disorder and at least one AED prescription claim. Trends, expressed as monthly changes in the log odds of AED prescription claims, were compared across three time periods: before (January 2006 to January 2008), during (February 2008 to May 2009), and after (June 2009 to December 2009) the FDA warning. RESULTS Before the FDA warning period, a significant upward trend of AED prescription claims of 0.01% per month (99% CI: 0.008% to 0.013%, p<0.0001) was estimated. In comparison to the prewarning period, no significant change in trend was detected during (-20.0%, 99% CI: -70.0% to 30.0%, p=0.34) or after (80.0%, 99% CI: -20.0% to 200.0%, p=0.03) the FDA warning period. After stratification, no diagnostic group (i.e., epilepsy alone, epilepsy and comorbid psychiatric disorder, and psychiatric disorder alone) experienced a significant change in trend during the entire study period (p>0.01). CONCLUSIONS During the time period considered, the FDA AED-related suicidality warning does not appear to have significantly affected prescription claims of AED medications for the study population.
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Affiliation(s)
- Manish Mittal
- Health Economics and Outcomes Research, AbbVie, North Chicago, IL, USA.
| | - Donald L Harrison
- Department of Pharmacy, Clinical and Administrative Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Michael J Miller
- Department of Pharmacy, Clinical and Administrative Sciences, The University of Oklahoma Health Sciences Center, Tulsa, OK, USA.
| | - Kevin C Farmer
- Department of Pharmacy, Clinical and Administrative Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - David M Thompson
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Yu-Tze Ng
- Department of Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Schnelle Erkennung einer depressiven Störung bei Menschen mit Epilepsie. DER NERVENARZT 2014; 85:1151-5. [DOI: 10.1007/s00115-013-3982-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mula M, Sander JW. Antiepileptic drugs and suicide risk: could stopping medications pose a greater hazard? Expert Rev Neurother 2014; 10:1775-6. [DOI: 10.1586/ern.10.165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mumoli L, Ciriaco M, Gambardella A, Bombardiere GN, Valentino P, Palleria C, Labate A, Russo E. A possible case of natalizumab-dependent suicide attempt: A brief review about drugs and suicide. J Pharmacol Pharmacother 2013; 4:S90-3. [PMID: 24347991 PMCID: PMC3853678 DOI: 10.4103/0976-500x.120974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
β-Interferon therapy is known to be a potential trigger of suicidal behavior, but this effect has not been previously reported for other multiple sclerosis (MS) treatments, such as, natalizumab. Here we report the case history of a 32-year-old woman affected by relapsing-remitting MS, who attempted suicide during natalizumab treatment. This case suggests that a suicidal ideation might be a rare side effect of natalizumab. Nevertheless, this case represents the first evidence of the new adverse drug reaction related to natalizumab treatment. We should alert clinicians to be aware of the possibility of paradoxical activation of suicidality during its therapeutic use. The main purpose of the present article is to use this case to review the possible relationship between suicidal behavior and drugs.
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Affiliation(s)
- Laura Mumoli
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, Italy ; Pharmacovigilance's Center Calabria Region, University Hospital Mater Domini, Italy ; Institute of Neurology, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Miriam Ciriaco
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, Italy ; Pharmacovigilance's Center Calabria Region, University Hospital Mater Domini, Italy
| | - Antonio Gambardella
- Institute of Neurology, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | | | - Paola Valentino
- Institute of Neurology, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Caterina Palleria
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, Italy ; Pharmacovigilance's Center Calabria Region, University Hospital Mater Domini, Italy
| | - Angelo Labate
- Institute of Neurology, School of Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine, University of Catanzaro, Catanzaro, Italy ; Pharmacovigilance's Center Calabria Region, University Hospital Mater Domini, Italy
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Pugh MJV, Hesdorffer D, Wang CP, Amuan ME, Tabares JV, Finley EP, Cramer JA, Kanner AM, Bryan CJ. Temporal trends in new exposure to antiepileptic drug monotherapy and suicide-related behavior. Neurology 2013; 81:1900-6. [PMID: 24174583 DOI: 10.1212/01.wnl.0000436614.51081.2e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Because some recent studies suggest increased risk for suicide-related behavior (SRB; ideation, attempts) among those receiving antiepileptic drugs (AEDs), we examined the temporal relationship between new AED exposure and SRB in a cohort of older veterans. METHODS We used national Veterans Health Administration databases to identify veterans aged ≥65 years who received a new AED prescription in 2004-2006. All instances of SRB were identified using ICD-9-CM codes 1 year before and after the AED exposure (index) date. We also identified comorbid conditions and medication associated with SRB in prior research. We used generalized estimating equations with a logit link to examine the association between new AED exposure and SRB during 30-day intervals during the year before and after the index date, controlling for potential confounders. RESULTS In this cohort of 90,263 older veterans, the likelihood of SRB the month prior to AED exposure was significantly higher than in other time periods even after adjusting for potential confounders. Although there were 87 SRB events (74 individuals) the year before and 106 SRB events (92 individuals) after, approximately 22% (n = 16) of those also had SRB before the index date. Moreover, the rate of SRB after AED start was gradually reduced over time. CONCLUSIONS The temporal pattern of AED exposure and SRB suggests that, in clinical practice, the peak in SRB is prior to exposure. While speculative, the rate of gradual reduction in SRB thereafter suggests that symptoms may prompt AED prescription.
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Affiliation(s)
- Mary Jo V Pugh
- From the South Texas Veterans Health Care System (VERDICT) (M.J.V.P., C.-P.W., J.V.T., E.P.F.), San Antonio; Department of Epidemiology & Biostatistics (M.J.V.P., C.-P.W.), University of Texas Health Science Center at San Antonio; Department of Medicine (M.J.V.P.), Texas A & M University, College Station; Mailman School of Public Health (D.H.), Sergievsky Center, The Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY; Edith Nourse Rogers Memorial Hospital (The Center for Health Quality, Outcomes and Economic Research [CHQOER]) (M.E.A.), Bedford, MA; Yale University School of Medicine (J.A.C.), New Haven, CT; Epilepsy Therapy Project (J.A.C.), Houston, TX; Rush University Medical Center (A.M.K.), Chicago, IL; and National Center for Veterans Studies (C.J.B.), University of Utah, Salt Lake City
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Epps SA, Kahn AB, Holmes PV, Boss-Williams KA, Weiss JM, Weinshenker D. Antidepressant and anticonvulsant effects of exercise in a rat model of epilepsy and depression comorbidity. Epilepsy Behav 2013; 29:47-52. [PMID: 23933912 PMCID: PMC3783960 DOI: 10.1016/j.yebeh.2013.06.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 06/18/2013] [Accepted: 06/20/2013] [Indexed: 11/25/2022]
Abstract
The bidirectional comorbidity between epilepsy and depression is associated with severe challenges for treatment efficacy and safety, often resulting in poor prognosis and outcome for the patient. We showed previously that rats selectively bred for depression-like behaviors (SwLo rats) also have increased limbic seizure susceptibility compared with their depression-resistant counterparts (SwHi rats). In this study, we examined the therapeutic efficacy of voluntary exercise in our animal model of epilepsy and depression comorbidity. We found that chronic wheel running significantly increased both struggling duration in the forced swim test and latency to pilocarpine-induced limbic motor seizure in SwLo rats but not in SwHi rats. The antidepressant and anticonvulsant effects of exercise were associated with an increase in galanin mRNA specifically in the locus coeruleus of SwLo rats. These results demonstrate the beneficial effects of exercise in a rodent model of epilepsy and depression comorbidity and suggest a potential role for galanin.
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Affiliation(s)
- S. Alisha Epps
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322
| | - Alexa B. Kahn
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322
| | | | | | - Jay M. Weiss
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA 30322
| | - David Weinshenker
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322,Address correspondence to: David Weinshenker, PhD, Department of Human Genetics, Emory University School of Medicine, Whitehead 301, 615 Michael St., Atlanta, GA 30322, Phone: (404) 727-3106, Fax: (404) 727-3949,
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Bell SG, Matsumoto M, Shaw SJ, Brandt J, Krauss GL. New antiepileptic drug safety information is not transmitted systematically and accepted by U.S. neurologists. Epilepsy Behav 2013; 29:36-40. [PMID: 23933628 DOI: 10.1016/j.yebeh.2013.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/03/2013] [Accepted: 06/08/2013] [Indexed: 11/29/2022]
Abstract
We surveyed U.S. neurologists in order to evaluate their knowledge of, and sources for, recent FDA safety warnings regarding antiepileptic drugs (AEDs) and whether they incorporate this information into their practices. Survey respondents (N=505) were predominantly board-certified American Academy of Neurology members. Approximately 20% of respondent neurologists were not aware of warnings about four drug safety risks: suicidality with newer AEDs, increased birth defect risks from in utero divalproex exposure, impaired cognitive development from in utero divalproex exposure, and the requirement of haplotype screening in patients of Asian descent starting carbamazepine. Most respondents were aware of a recommendation for haplotype screening, yet did not routinely perform the safety screening, and 18 reported patients that had hypersensitivity reactions to carbamazepine. Respondents learned about drug safety risks from varied sources; only notifications from specialty organizations were associated with accurate knowledge of drug safety warnings. Most surveyed neurologists would prefer implementing "a formal warning process via specialty organizations" with e-mails of updated product insert warnings.
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Affiliation(s)
- Sarah G Bell
- Johns Hopkins University, Department of Neurology, 600 N. Wolfe St., Meyer 2-147, Baltimore, MD 21287, USA
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Korczyn AD, Schachter SC, Brodie MJ, Dalal SS, Engel J, Guekht A, Hecimovic H, Jerbi K, Kanner AM, Landmark CJ, Mares P, Marusic P, Meletti S, Mula M, Patsalos PN, Reuber M, Ryvlin P, Štillová K, Tuchman R, Rektor I. Epilepsy, cognition, and neuropsychiatry (Epilepsy, Brain, and Mind, part 2). Epilepsy Behav 2013; 28:283-302. [PMID: 23764496 PMCID: PMC5016028 DOI: 10.1016/j.yebeh.2013.03.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 12/13/2022]
Abstract
Epilepsy is, of course, not one disease but rather a huge number of disorders that can present with seizures. In common, they all reflect brain dysfunction. Moreover, they can affect the mind and, of course, behavior. While animals too may suffer from epilepsy, as far as we know, the electrical discharges are less likely to affect the mind and behavior, which is not surprising. While the epileptic seizures themselves are episodic, the mental and behavioral changes continue, in many cases, interictally. The episodic mental and behavioral manifestations are more dramatic, while the interictal ones are easier to study with anatomical and functional studies. The following extended summaries complement those presented in Part 1.
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Affiliation(s)
- Amos D. Korczyn
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv 69978, Israel
| | - Steven C. Schachter
- Center for Integration of Medicine and Innovative Technology, Harvard Medical School, Boston, MA, USA
| | | | - Sarang S. Dalal
- Zukunftskolleg & Department of Psychology, University of Konstanz, Germany
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | | | - Alla Guekht
- Russian National Research Medical University, Moscow City Hospital No. 8 for Neuropsychiatry, Moscow, Russia
| | - Hrvoje Hecimovic
- Zagreb Epilepsy Center, Department of Neurology, University Hospital, Zagreb, Croatia
| | - Karim Jerbi
- Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, University Lyon I, Brain Dynamics and Cognition Team, Lyon, France
| | - Andres M. Kanner
- Department of Neurology, University of Miami, Miller School of Medicine, Miami FL, USA
| | - Cecilie Johannessen Landmark
- Department of Pharmacy and Biomedical Science, Oslo, Norway
- Akershus University College of Applied Sciences, Oslo, Norway
| | - Pavel Mares
- Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Petr Marusic
- Department of Neurology, Charles University in Prague, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Stefano Meletti
- Department of Biomedical Sciences, Metabolism, and Neuroscience, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Mula
- Amedeo Avogadro University, Novara, Italy
| | - Philip N. Patsalos
- Department of Clinical and Experimental Epilepsy, UCL-Institute of Neurology, London and Epilepsy Society, Chalfont St Peter, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Philippe Ryvlin
- Service de neurologie fonctionnelle et d’épileptologie, Hôpital Neurologique, HCL TIGER, CRNL, INSERM U1028, UMR-CNRS 5292, Université Lyon-1, Lyon, France
| | - Klára Štillová
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
| | - Roberto Tuchman
- Autism and Neurodevelopment Program, Miami Children’s Hospital Dan Marino Center, Departments of Neurology and Psychiatry, Herbert Wertheim College of Medicine, Florida International University, FL, USA
| | - Ivan Rektor
- Masaryk University, Brno Epilepsy Center, St. Anne’s Hospital and School of Medicine, and Central European Institute of Technology (CEITEC), Brno, Czech Republic
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Mula M, Sander JW. Suicide risk in people with epilepsy taking antiepileptic drugs. Bipolar Disord 2013; 15:622-7. [PMID: 23755740 DOI: 10.1111/bdi.12091] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 03/10/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The standardized mortality ratio for suicide in people with epilepsy is reported as 5.1 [95% confidence interval (CI): 3.9-6.6], but this is only partially explained by the high rates of psychiatric comorbidity. This issue was revived when, in 2008, the Food and Drug Administration (FDA) issued an alert on an increased risk of suicide in people taking antiepileptic drugs (AEDs). We discuss and elaborate on available evidence on the interplay among epilepsy, suicide, and AEDs, taking into account the phenomenology of mood disorders in people with epilepsy and the psychotropic potential of AEDs. METHODS Articles were identified by searches of Medline/PubMed using the terms epilepsy, antiepileptic drugs, and suicide. Only papers published in English in international peer-reviewed journals were considered. The reference lists of relevant articles were hand-searched for additional publications (e.g., book chapters or review papers) if relevant to the discussion. RESULTS The results of studies supporting or opposing the FDA conclusions have been inconsistent. This may be due to a number of methodological limitations, such as the failure to adjust for past suicidality and the confounding effect of epilepsy. CONCLUSIONS A subgroup of people with epilepsy appears to be at risk of developing treatment-emergent psychiatric adverse effects of AEDs independently of the specific mechanism of action of the drug. Clinicians need to pay attention not only to seizure patterns when choosing the appropriate AED but also to a number of different parameters, not least the mental state of the individual patient.
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Affiliation(s)
- Marco Mula
- Division of Neurology, Trinity Hospital, Borgomanero, Italy
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Abstract
Antiepileptic drugs (AEDs) are used by millions of people worldwide for the treatment of epilepsy, as well as in many other neurological and psychiatric conditions. They are frequently associated with adverse effects (AEs), which have an impact on the tolerability and success of treatment. Half the people who develop intolerable AEs discontinue treatment early on after initiation, while the majority of people will continue to be exposed to their effects for long periods of time. The long-term safety of AEDs reflects their potential for chronic, cumulative dose effects; rare, but potentially serious late idiosyncratic effects; late, dose-related effects; and delayed, teratogenic or neurodevelopmental effects. These AEs can affect every body system and are usually insidious. With the exception of delayed effects, most other late or chronic AEs are reversible. To date, there is no clear evidence of a carcinogenic effect of AEDs in humans. While physicians are aware of the long-term AEs of old AEDs (the traditional liver enzyme-inducing AEDs and valproate), information about AEs of new AEDs (such as lamotrigine, levetiracetam, oxcarbazepine, topiramate or zonisamide), particularly of their teratogenic effects, has emerged over the years. Sporadic publications have raised issues about AEs of the newer AEDs eslicarbazepine, retigabine, rufinamide, lacosamide and perampanel but their long-term safety profiles may take years to be fully appreciated. Physicians should not only be aware of the late and chronic AEs of AEDs but should systematically enquire and screen for these according to the individual AED AE profile. Care should be taken for individuals with comorbid conditions that may render them more susceptible to specific AEs. Prevention and appropriate management of long-term AED AEs is expected to improve adherence to treatment, quality of life and control of epilepsy.
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Pereira A, Gitlin MJ, Gross RA, Posner K, Dworkin RH. Suicidality associated with antiepileptic drugs: implications for the treatment of neuropathic pain and fibromyalgia. Pain 2013; 154:345-349. [PMID: 23375513 DOI: 10.1016/j.pain.2012.12.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 12/28/2012] [Accepted: 12/31/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Anthony Pereira
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
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Gandy M, Sharpe L, Perry KN, Miller L, Thayer Z, Boserio J, Mohamed A. Rates of DSM-IV mood, anxiety disorders, and suicidality in Australian adult epilepsy outpatients: a comparison of well-controlled versus refractory epilepsy. Epilepsy Behav 2013. [PMID: 23201610 DOI: 10.1016/j.yebeh.2012.10.023] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Milena Gandy
- The School of Psychology, University of Sydney, Australia.
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Caplan R. Psychopathology in pediatric epilepsy: role of antiepileptic drugs. Front Neurol 2012; 3:163. [PMID: 23233847 PMCID: PMC3516700 DOI: 10.3389/fneur.2012.00163] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 10/24/2012] [Indexed: 01/17/2023] Open
Abstract
Children with epilepsy are usually treated with antiepileptic drugs (AEDS). Some AEDs adversely affect behavior in susceptible children. Since psychiatric comorbidity is prevalent in pediatric epilepsy, this paper attempts to disentangle these AED side effects from the psychopathology associated with this illness. It first outlines the clinical and methodological problems involved in determining if AEDs contribute to the behavior and emotional problems of children with epilepsy. It then presents research evidence for and against the role AEDs play in the psychopathology of children with epilepsy, and outlines how future studies might investigate this problem. A brief description of how to clinically separate out AED effects from the complex illness-related and psychosocial factors that contribute to the behavior difficulties of children with epilepsy concludes the paper.
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Affiliation(s)
- Rochelle Caplan
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles Los Angeles, CA, USA
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Epps SA, Tabb KD, Lin SJ, Kahn AB, Javors MA, Boss-Williams KA, Weiss JM, Weinshenker D. Seizure susceptibility and epileptogenesis in a rat model of epilepsy and depression co-morbidity. Neuropsychopharmacology 2012; 37:2756-63. [PMID: 22871911 PMCID: PMC3499730 DOI: 10.1038/npp.2012.141] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Although a strong co-morbidity exists clinically between epilepsy and depression, the cause of this co-morbidity remains unknown, and a valid animal model is crucial for the identification of underlying mechanisms and the development of a screening tool for novel therapies. Although some rodent models of epilepsy have been reported to display behaviors relevant to affective disorders, the seizure susceptibility of animals prone to depression-like behavior has not been characterized. Toward this end, we assessed several forms of seizure sensitivity and epileptogenesis in rats selectively bred for vulnerability (Swim Lo-Active; SwLo) or resilience (Swim High-Active; SwHi) to depression-like phenotypes. The SwLo rats exhibit decreased motor activity in a swim test and other depression-like phenotypes, whereas the SwHi rats display increased motor activity in a swim test. SwLo rats exhibited a decreased latency to limbic motor seizures following acute pilocarpine administration in the absence of differences in pilocarpine pharmacokinetics, and also had a decreased threshold to tonic seizures induced by electroshock. Approximately half of the SwLo rats, but none of the SwHi rats, had spontaneous limbic motor seizures 5 weeks following pilocarpine-induced status epilepticus. While the number of stimulations required to achieve full amygdala and hippocampal electrical kindling were similar in the two rat lines, SwLo rats had a lower final hippocampal kindling threshold and more wet dog shakes during both amygdala and hippocampal kindling. Combined, these results indicate that SwLo rats are a model of epilepsy and depression co-morbidity that can be used for investigating underlying neurobiological and genetic mechanisms and screening novel therapeutics.
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Affiliation(s)
- S Alisha Epps
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Kroshona D Tabb
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharon J Lin
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Alexa B Kahn
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - Martin A Javors
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | | | - Jay M Weiss
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - David Weinshenker
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA,Department of Human Genetics, Emory University School of Medicine, Whitehead 301, 615 Michael St, Atlanta, GA 30322, USA, Tel: +404 727 3106, Fax: +404 727 3949, E-mail:
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68
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Fountoulakis KN, Gonda X, Samara M, Siapera M, Karavelas V, Ristic DI, Iacovides A. Antiepileptic drugs and suicidality. J Psychopharmacol 2012; 26:1401-7. [PMID: 22402242 DOI: 10.1177/0269881112440514] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The current study is a systematic review of the literature concerning the possible relationship of antiepileptics and suicide-related clinical features and behaviours. A MEDLINE search returned 863 papers but only five were chosen as relevant. A critical analysis of the Food and Drug Administration report is also included. Overall, the current review suggests there are no convincing data concerning a 'class effect' of antiepileptics in inducing any type of suicide-related behaviours. Further research is needed concerning topiramate, lamotrigine and maybe leviracetam. Clinicians are expected to inform patients and their families on the possible increased risk but it is important not to overemphasise the issue, since stopping or refusing to start antiepileptics may result in serious harm, including death of the patient. Future randomised controlled trials should specifically focus on issues concerning depression and suicidal thoughts in patients with epilepsy.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 13rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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69
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Pugh MJV, Copeland LA, Zeber JE, Wang CP, Amuan ME, Mortensen EM, Tabares JV, Van Cott AC, Cooper TL, Cramer JA. Antiepileptic drug monotherapy exposure and suicide-related behavior in older veterans. J Am Geriatr Soc 2012; 60:2042-7. [PMID: 23110401 DOI: 10.1111/j.1532-5415.2012.04207.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the association between antiepileptic drug (AED) receipt and suicide-related behavior (SRB) in older veterans. DESIGN Retrospective database analysis. SETTING Veterans Health Administration (VHA) inpatient and outpatient care. PARTICIPANTS Veterans aged 65 and older in 2004 to 2006. MEASUREMENTS SRB was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes, and new AED monotherapy was identified using the VHA product variable in pharmacy data. Comorbid conditions and medications were also identified as potential confounders using previously validated algorithms. Cox proportional hazards models controlling for the propensity to receive AEDs examined the association between any AED exposure, specific AEDs, and time to SRB. RESULTS Within the eligible sample of 2.15 million individuals, 332 cases of SRB were found. Overall, 98% of participants were male, and 67% were non-Hispanic white. Affective disorders and severe psychiatric conditions were strongly associated with SRB and were included in the propensity score. AED exposure displayed a significant association with SRB (odds ratio = 4.10, 95% confidence interval (CI) = 3.85-6.63) after adjusting for propensity to receive AEDs. Stratified analyses found similar results for those with (hazard ratio (HR) = 4.00, 95% CI = 2.9-5.5) and without (HR = 4.57, 95% CI = 1.15-18.20) mental health comorbidities. Gabapentin, phenytoin, lamotrigine, levetiracetam, topiramate, and valproate were significantly associated with SRB. CONCLUSION Exposure to five common AEDs was associated with SRB in older VHA beneficiaries. Given the strong associations between psychiatric comorbidity and SRB, clinicians treating elderly adults should weigh this potential adverse effect into their consideration for treatment of those receiving AEDs. Particular attention should be given to depression and suicidality screening in people prescribed AEDs.
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Affiliation(s)
- Mary Jo V Pugh
- South Texas Veterans Health Care System (VERDICT), Audie L. Murphy Division, San Antonio, Texas 78229, USA.
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70
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Aurlien D, Larsen JP, Gjerstad L, Taubøll E. Comorbid and underlying diseases—Major determinants of excess mortality in epilepsy. Seizure 2012; 21:573-7. [DOI: 10.1016/j.seizure.2012.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/24/2012] [Accepted: 05/27/2012] [Indexed: 10/28/2022] Open
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Mula M, Kanner AM, Schmitz B, Schachter S. Antiepileptic drugs and suicidality: an expert consensus statement from the Task Force on Therapeutic Strategies of the ILAE Commission on Neuropsychobiology. Epilepsia 2012; 54:199-203. [PMID: 22994856 DOI: 10.1111/j.1528-1167.2012.03688.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Marco Mula
- Amedeo Avogadro University, Novara, Italy.
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72
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Epps SA, Weinshenker D. Rhythm and blues: animal models of epilepsy and depression comorbidity. Biochem Pharmacol 2012; 85:135-46. [PMID: 22940575 DOI: 10.1016/j.bcp.2012.08.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 08/16/2012] [Accepted: 08/17/2012] [Indexed: 12/12/2022]
Abstract
Clinical evidence shows a strong, bidirectional comorbidity between depression and epilepsy that is associated with decreased quality of life and responsivity to pharmacotherapies. At present, the neurobiological underpinnings of this comorbidity remain hazy. To complicate matters, anticonvulsant drugs can cause mood disturbances, while antidepressant drugs can lower seizure threshold, making it difficult to treat patients suffering from both depression and epilepsy. Animal models have been created to untangle the mechanisms behind the relationship between these disorders and to serve as screening tools for new therapies targeted to treat both simultaneously. These animal models are based on chemical interventions (e.g. pentylenetetrazol, kainic acid, pilocarpine), electrical stimulations (e.g. kindling, electroshock), and genetic/selective breeding paradigms (e.g. genetically epilepsy-prone rats (GEPRs), genetic absence epilepsy rat from Strasbourg (GAERS), WAG/Rij rats, swim lo-active rats (SwLo)). Studies on these animal models point to some potential mechanisms that could explain epilepsy and depression comorbidity, such as various components of the dopaminergic, noradrenergic, serotonergic, and GABAergic systems, as well as key brain regions, like the amygdala and hippocampus. These models have also been used to screen possible therapies. The purpose of the present review is to highlight the importance of animal models in research on comorbid epilepsy and depression and to explore the contributions of these models to our understanding of the mechanisms and potential treatments for these disorders.
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Affiliation(s)
- S Alisha Epps
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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73
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Hesdorffer DC, Ishihara L, Mynepalli L, Webb DJ, Weil J, Hauser WA. Epilepsy, suicidality, and psychiatric disorders: A bidirectional association. Ann Neurol 2012; 72:184-91. [DOI: 10.1002/ana.23601] [Citation(s) in RCA: 370] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 02/11/2012] [Accepted: 03/23/2012] [Indexed: 11/08/2022]
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74
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Kanner AM, Schachter SC, Barry JJ, Hesdorffer DC, Mula M, Trimble M, Hermann B, Ettinger AE, Dunn D, Caplan R, Ryvlin P, Gilliam F, LaFrance WC, LaFrance WC. Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives. Epilepsy Behav 2012; 24:169-81. [PMID: 22632407 DOI: 10.1016/j.yebeh.2012.01.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2012] [Indexed: 12/11/2022]
Abstract
The clinical manifestations of depression in people with epilepsy (PWE) are pleomorphic, often associated with anxiety symptoms and anxiety disorders. The ongoing debate of whether the clinical presentation of depression in PWE is unique to this neurologic disorder is reviewed. Comorbid depression can impact the recruitment of PWE for pharmacologic trials with antiepileptic drugs (AEDs). Yet, the impact of depression on the response of the seizure disorder to pharmacotherapy with AEDs and its impact on worse adverse events may bias the interpretation of the trial findings, particularly when depressed patients are included in the AED trials. PWE have a greater suicidal risk than the general population. This risk is mediated by multiple factors, and recent data from the FDA have imputed a potential pathogenic role to all AEDs. The recognition of patients at risk is reviewed. Yet, the validity of the FDA data has been questioned, and the status of this controversial question is analyzed. As in the case of epilepsy, depression and pain syndromes have a relatively high comorbidity. The negative impact of depression on pain is reminiscent of that of depression in PWE; furthermore, the high comorbidity may be also associated with the existence of common pathogenic mechanisms. Neurologists and in particular, epileptologists establish the diagnosis of psychogenic non-epileptic seizures (PNES) in whom a comorbid depressive disorder is very often identified. The role of depression in the course of PNES and its treatment are discussed. Scarce data are available on the treatment of depression in PWE. Thus, clinicians have had to adopt data from patients with primary depressive disorders. We outline a consensus strategy on the identification and treatment of depressive disorders in adult and pediatric patients with epilepsy.
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Affiliation(s)
- Andres M Kanner
- Department of Neurological Sciences, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612, USA.
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75
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76
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Kanner AM, Hesdorffer DC. Neuropsychiatric complications of epilepsy. HANDBOOK OF CLINICAL NEUROLOGY 2012; 107:461-82. [PMID: 22938989 DOI: 10.1016/b978-0-444-52898-8.00037-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Andres M Kanner
- Department of Neurological Sciences, Rush University, Chicago, IL, USA.
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77
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Elger CE, Hoppe C. What is Depression in Epilepsy? Front Neurol 2011; 2:79. [PMID: 22162974 PMCID: PMC3232452 DOI: 10.3389/fneur.2011.00079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 11/21/2011] [Indexed: 12/02/2022] Open
Affiliation(s)
- Christian E Elger
- Department of Epileptology, University of Bonn Medical Centre Bonn, Germany
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78
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Schumock GT, Lee TA, Joo MJ, Valuck RJ, Stayner LT, Gibbons RD. Association between leukotriene-modifying agents and suicide: what is the evidence? Drug Saf 2011; 34:533-44. [PMID: 21663330 DOI: 10.2165/11587260-000000000-00000] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The US FDA has issued safety alerts and required manufacturers of leukotriene-modifying agents (LTMAs), including montelukast, zafirlukast and zileuton, to include suicide and neuropsychiatric events as a precaution in the drug label. This paper reviews the existing evidence on the potential association between the LTMAs and suicidal behaviour. We conducted a literature search of MEDLINE, EMBASE and International Pharmaceutical Abstracts from 1995 to 2010 (inclusive) to identify pertinent studies and reports. We also examined data obtained from the FDA adverse event reporting system. To date, there are no well conducted, comparative, observational studies of this association, and the safety alerts are based primarily on case reports. While the FDA safety alerts apply to all three LTMAs, montelukast (known by its trade name Singulair®) is by far the most widely used of these drugs and most of the reports to date regarding suicide pertain to montelukast. From 1998 to 2009 there were 838 suicide-related adverse events associated with leukotrienes reported to the FDA, of which all but five involved montelukast. Nearly all cases were reported in 2008 and 2009 (96.1%) after the FDA warnings. LTMAs are approved for use in asthma and allergic rhinitis, and are effective drugs. Both of these diseases are also associated with suicide, making confirmation of the association more difficult. Given the lack of good evidence, we recommend that a large observational cohort or case-control study be conducted to quantify the association between LTMAs and suicide. Until then, when prescribing LTMAs, clinicians should consider the potential for suicide and monitor patients who may be at elevated risk carefully for suicidal ideation or psychiatric symptoms associated with suicidal behaviour.
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Affiliation(s)
- Glen T Schumock
- Center for Pharmacoeconomic Research, University of Illinois at Chicago, USA.
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79
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Hecimovic H, Salpekar J, Kanner AM, Barry JJ. Suicidality and epilepsy: a neuropsychobiological perspective. Epilepsy Behav 2011; 22:77-84. [PMID: 21620772 DOI: 10.1016/j.yebeh.2011.04.059] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Abstract
People with epilepsy (PWE) are at increased risk of experiencing suicidal ideation, displaying suicidal behavior, and committing suicide than the general population. The relationship between suicidality and epilepsy is complex and multifactorial in which operant pathogenic mechanisms include epilepsy-related variables, personal and familial psychiatric history, and iatrogenic effects. Furthermore, a bidirectional relationship between suicidality and epilepsy has suggested the existence of common neurobiological pathogenic mechanisms operant in both conditions and including disturbances of several neurotransmitters, in particular, serotonin (5HT), norepinephrine (NE), glutamate (GTE), and γ-aminobutyric acid (GABA), and disturbances of the hypothalamic-pituitary-adrenal axis (HPAA), which, in turn, can result in abnormal secretion of some of these neurotransmitters. The purpose of this article is to review these common neurobiological pathogenic mechanisms.
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Affiliation(s)
- Hrvoje Hecimovic
- Zagreb Epilepsy Center, Department of Neurology University Hospital, Zagreb, Croatia
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80
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Chien J. Ethosuximide-induced mania in a 10-year-old boy. Epilepsy Behav 2011; 21:483-5. [PMID: 21689989 DOI: 10.1016/j.yebeh.2011.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/05/2011] [Accepted: 05/06/2011] [Indexed: 11/25/2022]
Abstract
Psychosis and suicidal ideation have been reported as side effects of ethosuximide treatment, but previous reports seldom place these symptoms in the context of mania. Given the recent renewed interest in ethosuximide as first-line therapy in children and adolescents, it is important for clinicians to be aware of the potential psychiatric complication of mania with this medication. Described here is the case of a 10-year-old boy who developed acute mania, as well as psychotic symptoms and suicidal ideation, on ethosuximide.
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Affiliation(s)
- Joseph Chien
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
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81
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Hesdorffer DC, Berg AT, Kanner AM. An update on antiepileptic drugs and suicide: are there definitive answers yet? Epilepsy Curr 2011; 10:137-45. [PMID: 21157540 DOI: 10.1111/j.1535-7511.2010.01382.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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82
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Hoppe C, Elger CE. Depression in epilepsy: a critical review from a clinical perspective. Nat Rev Neurol 2011; 7:462-72. [PMID: 21750525 DOI: 10.1038/nrneurol.2011.104] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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83
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Marc Testa S, Lesser RP, Krauss GL, Brandt J. Personality Assessment Inventory among patients with psychogenic seizures and those with epilepsy. Epilepsia 2011; 52:e84-8. [DOI: 10.1111/j.1528-1167.2011.03141.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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84
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Mula M, Hesdorffer DC. Suicidal behavior and antiepileptic drugs in epilepsy: analysis of the emerging evidence. DRUG HEALTHCARE AND PATIENT SAFETY 2011; 3:15-20. [PMID: 21753899 PMCID: PMC3132858 DOI: 10.2147/dhps.s13070] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Indexed: 11/23/2022]
Abstract
Two years after the warning issued by the Food and Drug Administration on an increased risk of suicide for people taking antiepileptic drugs (AEDs), a number of pharmacoepidemiologic studies have been published but the scientific community is far from definitive answers. The present paper is aimed at reviewing available evidence on the association between AEDs and suicidal behavior, discussing major variables involved such as the relationship between epilepsy, depression, and suicide and the psychotropic potential of AEDs. All studies published so far show a lack of concordance and are constrained by various methodological limitations. What seems to be established is that mood disorders represent a frequent comorbidity in epilepsy and suicide is a serious complication more frequently encountered in epilepsy rather than in the general population. Moreover, a subgroup of patients appears to be at risk of developing treatment-emergent psychiatric adverse effects of AEDs independently of the specific mechanism of action of the drug. The prior history of suicide attempt, especially preceding the onset of the epilepsy, may represent a key element explaining why what is observed is independent of the specific mechanism of the drug. In general terms, risks associated with stopping, or not even starting, AEDs in epilepsy might well be in excess of the risk of suicide in epilepsy, as deaths due to accident and epilepsy itself may predominate. Clinicians need to pay attention not only to seizure patterns when choosing the appropriate AED but also to a number of different parameters (eg, age, gender, working needs, medical comorbidities, history of psychiatric disorders, and suicidality before epilepsy onset) and not the least the mental state of the patient. Missing severe complications such as suicidal behavior or delaying its treatment may worsen the prognosis of epilepsy.
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Affiliation(s)
- Marco Mula
- Department of Clinical and Experimental Medicine, Amedeo Avogadro University and Division of Neurology, University Hospital Maggiore della Carità, Novara, Italy
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Abstract
PURPOSE OF REVIEW The risk of suicide is thought be increased in epilepsy. Antiepileptic drugs (AEDs) remain the primary treatment. An FDA alert in 2008 raised concerns that AEDs may increase the risk of suicidal thoughts and behaviour. The risk profile for suicide in epilepsy is examined in the context of recent reports investigating the risk of suicide and the reported association between AEDs and risk of suicide. RECENT FINDINGS Following a diagnosis of epilepsy the risk of completed suicide is increased (standardized mortality ratio 2-3.5); although the causes remain poorly understood, co-morbid depression and the first 6 months after epilepsy surgery seem to be particular risk factors. The evidence for AEDs increasing risk for suicide remains mixed and is based on retrospective data. SUMMARY The identification of risk factors such as mood or anxiety disorders in patients with epilepsy should not delay AED treatment as the risks associated with seizures far outweigh the current research evidence for increased AED-related suicide risk. A pragmatic approach to clinical assessment and management is suggested. Prospective AED trials should include validated scales to systematically identify neuropsychiatric complications of AEDs.
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86
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Russo E, Citraro R, Scicchitano F, De Fazio S, Perrota I, Di Paola ED, Constanti A, De Sarro G. Effects of early long-term treatment with antiepileptic drugs on development of seizures and depressive-like behavior in a rat genetic absence epilepsy model. Epilepsia 2011; 52:1341-50. [DOI: 10.1111/j.1528-1167.2011.03112.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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87
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Kanner AM. Are Antiepileptic Drugs Used in the Treatment of Migraine Associated with an Increased Risk of Suicidality? Curr Pain Headache Rep 2011; 15:164-9. [DOI: 10.1007/s11916-011-0199-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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88
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Machado RA, Espinosa AG, Melendrez D, González YR, García VF, Rodríguez YQ. Suicidal risk and suicide attempts in people treated with antiepileptic drugs for epilepsy. Seizure 2011; 20:280-4. [PMID: 21269844 DOI: 10.1016/j.seizure.2010.12.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 12/14/2010] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine whether antiepileptic drugs constitute in themselves an independent risk factor for suicidality in patients with epilepsy. METHODS One hundred and thirty one patients with epilepsy were recruited and followed-up during 5 years. A detailed medical history, neurological examination, EEGs, Mini-International Neuropsychiatric Interview, executive function, and MRI were assessed. Systematically collected data were used to assess suicidality. Multiple regression analysis was carried out to examine predictive associations between clinical variables, psychiatric disorders, antiepileptic drugs and suicidality. RESULTS We identified two AEDs related with suicide attempts (PHB and LTG) and four with suicidal risk: PHB, PRM, PHT and LTG, but the increased of risk diminished or disappeared when psychiatric comorbidity and other well established risk factors for suicidality were analyzed. We found a significant proportion of patients with depressive episodes associated with Topiramate, Phenitoin, Phenobarbital and Lamotrigine. CONCLUSION Antiepileptic drugs probably do not have an impact on suicidality.
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Affiliation(s)
- René Andrade Machado
- National Neurology Institute, 29 street e/t D and E, Vedado, Plaza, Havana City, Cuba.
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89
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Redden L, Pritchett Y, Robieson W, Kovacs X, Garofalo M, Tracy K, Saltarelli M. Suicidality and divalproex sodium: analysis of controlled studies in multiple indications. Ann Gen Psychiatry 2011; 10:1. [PMID: 21244672 PMCID: PMC3032763 DOI: 10.1186/1744-859x-10-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 01/18/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent analyses of antiepileptic drugs have indicated an increase in the risk of suicidality. The objective of this report was to provide clinical information and an independent meta-analysis of divalproex sodium and suicidality events by analyzing data from 13 placebo-controlled studies and 1 low-dose controlled study. METHODS Adverse events considered to be possibly suicide related were identified using the Columbia Classification Algorithm of Suicide Assessment (C-CASA) methodology. Indications included epilepsy, bipolar disorder, migraine prophylaxis, impulsive aggression, and dementia. Narratives were produced for every event, and suicidality event ratings were performed by a third party blinded to treatment assignment. Statistical analyses were conducted using methodology similar to that reported by the US Food and Drug Administration (FDA). RESULTS Suicidality events were identified in 5 of the 13 placebo-controlled studies. Of the 1,327 (0.83%) subjects taking divalproex sodium, 11 had suicidality events: 2 suicide attempts and 9 suicidal ideation. Of 992 (0.91%) subjects taking placebo, 9 had suicidality events: 1 preparatory act toward suicide, 2 suicide attempts, and 6 suicidal ideation. Across placebo-controlled studies, the overall estimated odds ratio (OR) of suicidal behavior or ideation was 0.72 (95% CI 0.29 to 1.84). The OR for suicidal behavior was 0.37 (95% CI 0.04 to 2.58), and the OR for suicidal ideation was 0.90 (95% CI 0.31 to 2.79). CONCLUSIONS In this meta-analysis, divalproex sodium does not appear to increase the risk of suicide-related adverse events relative to placebo in the populations studied. Clinicians should nonetheless remain vigilant in assessing suicidality, not only in patients treated for mental disorders with inherently high suicide risk, but also in patients taking antiepileptic medications.
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90
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Araújo Filho GMD, Mazetto L, Yacubian EMT. Efeitos psiquiátricos e comportamentais das drogas antiepilépticas e sua ação como moduladores de humor. ACTA ACUST UNITED AC 2011. [DOI: 10.1590/s1676-26492011000200006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUÇÃO: Um dos aspectos mais estudados da epileptologia atual é a associação existente entre os transtornos psiquiátricos (TP) e as drogas antiepilépticas (DAE). De acordo com dados recentes na literatura, as DAE podem exercer um papel protetor ou de predisposição ao aparecimento de TP. OBJETIVO: O presente trabalho tem como objetivo fazer uma revisão dos efeitos psiquiátricos e comportamentais das DAE e de sua ação como estabilizadores do humor, bem como de relacionar seu papel protetor ou de predisposição ao aparecimento de TP com seus respectivos mecanismos de ação. CONCLUSÃO: As DAE não apresentam apenas propriedades antiepilépticas, possuindo também efeitos comportamentais positivos ou negativos. O aparecimento de TP, no entanto, está associado tanto ao mecanismo de ação da DAE como à predisposição individual e à condição emocional preexistente do paciente.
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91
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92
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Taylor FR, Landy SH, Kaniecki RG. Abstracts and Citations. Headache 2010. [DOI: 10.1111/j.1526-4610.2010.01784.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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93
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Wen X, Meador KJ, Loring DW, Eisenschenk S, Segal R, Hartzema AG. Is antiepileptic drug use related to depression and suicidal ideation among patients with epilepsy? Epilepsy Behav 2010; 19:494-500. [PMID: 20880757 DOI: 10.1016/j.yebeh.2010.08.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 08/23/2010] [Accepted: 08/24/2010] [Indexed: 11/28/2022]
Abstract
Depression and suicide are increased in patients with epilepsy. The U.S. Food and Drug Administration warns that antiepileptic drugs (AEDs) are associated with increased risk of suicidality. This study examines the relationship among depression, suicidal ideation, and AEDs in a prospective cohort of 163 patients with epilepsy from a registry at the University of Florida (January 2006 to August 2008). The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was used to measure mood and suicidal ideation across two time points (median = 154 days). Groups included: (1) No AED Change, (2) New AED Added, (3) AED Dose Increased, (4) AED Reduced/Stopped, (5) Multiple AED Changes, and (6) Combined Any AED Change (groups 2-5 combined). No group had worsening mood or suicidal ideation. Significant improvements in proportions of depression and suicidal ideation were seen only for the No AED Change group, which differed only with the AED Dose Increased group with respect to suicidal ideation.
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Affiliation(s)
- X Wen
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
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94
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Schmitz B, Montouris G, Schäuble B, Caleo S. Assessing the unmet treatment need in partial-onset epilepsy: Looking beyond seizure control. Epilepsia 2010; 51:2231-40. [DOI: 10.1111/j.1528-1167.2010.02759.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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95
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Abstract
Recently, the US Food and Drug Administration issued an alert about an increased risk for suicidality during treatment with antiepileptic drugs (AEDs) for different indications, including epilepsy. We discuss the issue of suicide in epilepsy with special attention to AEDs and the assessment of suicide in people with epilepsy. It has been suggested that early medical treatment with AEDs might potentially reduce suicide risk of people with epilepsy, but it is of great importance that the choice of drug is tailored to the mental state of the patient. The issue of suicidality in epilepsy is likely to represent an example of how the underdiagnosis of psychiatric symptoms, the lack of input from professionals (eg, psychologists, social workers, and psychiatrists), and the delay in an optimized AED therapy may worsen the prognosis of the condition with the occurrence of severe complications such as suicide.
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Affiliation(s)
- Marco Mula
- Department of Clinical and Experimental Medicine, Division of Neurology, Amedeo Avogadro University, University Hospital Maggiore della Carità, Novara, Italy
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96
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Britton JW, Shih JJ. Antiepileptic drugs and suicidality. DRUG HEALTHCARE AND PATIENT SAFETY 2010; 2:181-9. [PMID: 21701630 PMCID: PMC3108698 DOI: 10.2147/dhps.s13225] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Indexed: 11/23/2022]
Abstract
The risk of suicide in patients with epilepsy is significantly higher than the general population. There are many hypotheses as to the reasons for this, but the potential role of anti-epileptic drugs (AEDs) in increasing suicidality has recently been brought into question. In 2008, the U.S. Food and Drug Administration (FDA) published a warning after a meta-analysis of data from all clinical trials involving AEDs found a suicidality risk of 0.43 per 1000 patients in active drug arms of these clinical trials compared to a rate in the placebo arm of 0.22. While an increased risk for individual AEDs was found in two, the FDA decided to issue a warning for the entire AED class. While this decision and the meta-analysis findings have been considered controversial, and have created concern that this stated risk may dissuade use of AEDs by patients who would benefit from them, it has led to increased awareness of the risk of suicidality and psychiatric co-morbidity in this patient group. In this article, the association of epilepsy and AEDs with psychiatric disease and suicidality are reviewed, perspective as to the significance and limitations of the FDA’s findings are discussed, and some options for suicidality screening and their potential utility in clinical care are evaluated.
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97
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St. Louis EK. The Art of Managing Conversions between Antiepileptic Drugs: Maximizing Patient Tolerability and Quality of Life. Pharmaceuticals (Basel) 2010; 3:2956-2969. [PMID: 27713385 PMCID: PMC2946260 DOI: 10.3390/ph3092956] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 08/12/2010] [Accepted: 09/02/2010] [Indexed: 11/16/2022] Open
Abstract
Conversion between anti-epilectic drugs (AEDs) is frequently necessary in epilepsy care, exposing patients to a risk of incurring adverse effects and reduced quality of life. Little practical guidance is available to practitioners to guide conversions between AED monotherapies, or in adding a new adjunctive AED into a polytherapy regimen. This article reviews the impact of adverse effects of AEDs on quality of life in epilepsy patients, then reviews several important patient-related factors such as age, gender, medical and psychiatric co-morbidities, and co-medications that must be considered when selecting AEDs and ensuring tolerable and safe AED conversions. Practical strategies for transitional polytherapy AED conversion are then considered in different commonly encountered clinical scenarios in newly diagnosed and refractory epilepsy care, including inadequate seizure control, intolerable adverse effects, or idiosyncratic safety hazards. Successful conversion between AEDs requires regular monitoring for patient-reported adverse effects and appropriately reactive adjustment of AED therapy to maximize patient quality of life.
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Affiliation(s)
- Erik K. St. Louis
- Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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98
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Do Antiepileptic Drugs Increase the Risk of Suicidality in Adult Patients With Epilepsy? Neurologist 2010; 16:325-8. [DOI: 10.1097/nrl.0b013e3181f79f37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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99
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Abstract
In 2009, the US Food and Drug Administration approved three medications for the treatment of epilepsy: rufinamide, lacosamide, and vigabatrin. In addition, extended-release formulations of lamotrigine and levetiracetam were approved recently. When added to the dozen medications for treating epilepsy, the choice is a luxury in terms of additional options, but also a challenge for practitioners to use them all with expertise. Recently, there has been much interest surrounding medications for epilepsy and their possible association with osteoporosis, safety during pregnancy, biological equivalence to generic versions, and possible association with higher rates of suicidality. This review discusses these issues and provides a current overview for the medical management of epilepsy.
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100
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Kanner AM. Advances in epilepsy: new perspectives on new-onset epilepsy, comorbidities, and pharmacotherapy. F1000 MEDICINE REPORTS 2010; 2:51. [PMID: 21173849 PMCID: PMC2990413 DOI: 10.3410/m2-51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The purpose of this brief article is to review old concepts of the significance of acute symptomatic seizures, the impact of psychiatric comorbidities on the response of pharmacologic and surgical treatments of the seizure disorder, and the importance of factoring comorbid medical comorbidities into the choice of antiepileptic drugs (AEDs). In addition, this article provides an update on the latest data on the teratogenic effects of AEDs and reviews the most relevant results of a recent practice guideline on pregnancy issues in women with epilepsy. The article closes with a review of the latest advances in the therapeutic effects of first- and second-generation AEDs.
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Affiliation(s)
- Andres M Kanner
- Rush Medical College at Rush University, Laboratory of Electroencephalography and Video-EEG-Telemetry, Section of Epilepsy and Rush Epilepsy Center, Rush University Medical Center 1653 West Congress Parkway, Chicago, IL 60612 USA
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