Prevalence of suicide attempts and their risk factors in school-aged patients with epilepsy: a population-based study

Psychiatric Comorbidities in Persons With Epilepsy Compared With Persons Without Epilepsy: A Systematic Review and Meta-Analysis

Importance

Several psychiatric disorders have been found to occur more frequently in persons with epilepsy (PWE) than in persons without epilepsy.

Objective

To summarize the prevalence of 20 psychiatric disorders in PWE compared with persons without epilepsy.

Data Sources

The search included records from inception to February 2024 in Ovid, MEDLINE, Embase, and PsycINFO.

Study Selection

Published epidemiological studies examining the prevalence of psychiatric disorders among PWE compared with persons without epilepsy were systematically reviewed. There were no restrictions on language or publication date.

Data Extraction and Synthesis

Abstracts were reviewed in duplicate, and data were extracted using a standardized electronic form. Descriptive statistics and meta-analyses are presented.

Main Outcomes and Measures

Data were recorded on the prevalence of 20 psychiatric disorders among PWE compared with persons without epilepsy. Meta-analyses were performed along with descriptive analyses.

Results

The systematic search identified 10 392 studies, 27 of which met eligibility criteria. The meta-analyses included 565 443 PWE and 13 434 208 persons without epilepsy. The odds of most psychiatric disorders studied were significantly increased in PWE compared with those without epilepsy, including anxiety (odds ratio [OR], 2.11; 95% CI, 1.73-2.58); depression (OR, 2.45; 95% CI, 1.94-3.09); bipolar disorder (OR, 3.12; 95% CI, 2.23-4.36); suicidal ideation (OR, 2.25; 95% CI, 1.75-2.88) but not suicide attempt (OR, 3.17; 95% CI, 0.49-20.46); psychotic disorder (OR, 3.98; 95% CI, 2.57-6.15); schizophrenia (OR, 3.72; 95% CI, 2.44-5.67); obsessive-compulsive disorder (OR, 2.71; 95% CI, 1.76-4.15); posttraumatic stress disorder (OR, 1.76; 95% CI, 1.14-2.73); eating disorders (OR, 1.87; 95% CI, 1.73-2.01); alcohol misuse (OR, 3.64; 95% CI, 2.27-5.83) and alcohol dependence (OR, 4.94; 95% CI, 3.50-6.96) but not alcohol abuse (OR, 2.10; 95% CI, 0.60-7.37); substance use disorder (OR, 2.75; 95% CI, 1.61-4.72); autism spectrum disorder (OR, 10.67; 95% CI, 6.35-17.91); and attention-deficit/hyperactivity disorder (OR, 3.93; 95% CI, 3.80-4.08).

Conclusions and Relevance

In this comprehensive study, most psychiatric comorbidities examined were significantly more prevalent in PWE than in those without epilepsy. These findings show the high burden of psychiatric comorbidities in PWE. This, in turn, underscores the need for appropriately identifying and treating psychiatric comorbidity in epilepsy to manage patients effectively and improve quality of life.

Prevalence of Suicidality in Adolescents With Newly Diagnosed Focal Epilepsy at Diagnosis and Over the Following 36 Months

BACKGROUND AND OBJECTIVES

Individuals with epilepsy have increased risk of suicidal ideation (SI) and behaviors when compared with the general population. This relationship has remained largely unexplored in adolescents. We investigated the prevalence of suicidality in adolescents with newly diagnosed focal epilepsy within 4 months of treatment initiation and over the following 36 months.

METHODS

This was a post hoc analysis of the enrollment and follow-up data from the Human Epilepsy Project, an international, multi-institutional study that enrolled participants between 2012 and 2017. Participants enrolled were 11-17 years of age within 4 months of treatment initiation for focal epilepsy. We used data from the Columbia Suicide Severity Rating Scale (C-SSRS), administered at enrollment and over the 36-month follow-up period, along with data from medical records.

RESULTS

A total of 66 adolescent participants were enrolled and completed the C-SSRS. At enrollment, 14 (21%) had any lifetime SI and 5 (8%) had any lifetime suicidal behaviors (SBs). Over the following 36 months, 6 adolescents reported new onset SI and 5 adolescents reported new onset SB. Thus, the lifetime prevalence of SI within this population increased from 21% to 30% (14-20 adolescents), and the lifetime prevalence of SB increased from 8% to 15% (5-10).

DISCUSSION

The prevalence of suicidality in adolescents with newly diagnosed focal epilepsy reported in our study is consistent with previous findings of significant suicidality observed in epilepsy. We identify adolescents as an at-risk population at the time of epilepsy diagnosis and in the following years.

Experience sampling methodology study of anxiety and depression in adolescents with epilepsy: The role of metacognitive beliefs and perseverative thinking

Emotional distress is common in young people with epilepsy (YPwE). According to the Self-Regulatory Executive Function (S-REF) model, maladaptive metacognitive beliefs and perseverative thinking are fundamental in the development and maintenance of emotional distress. As emotional distress and perseverative thinking can highly fluctuate over short intervals in YPwE, it is important to account for this variability when testing the utility of psychological models. Experience sampling methodology (ESM) was therefore used to explore the momentary relationship between metacognitive beliefs, perseverative thinking, and emotional distress in YPwE. Eighteen participants diagnosed with epilepsy (aged 12-17 years) completed the 10-day ESM period. Participants were prompted to complete the ESM assessment five times daily. The ESM assessment assessed participant's momentary levels of metacognitive beliefs, perseverative thinking (i.e., worry and rumination), and emotional distress (i.e., anxiety and depression). A series of multilevel regression analyses indicated that metacognitive beliefs were significantly positively associated with worry, rumination, anxiety and depression. After controlling for worry and rumination, respectively, metacognitive beliefs did not account for additional variance in anxiety or depression. Findings provide preliminary support for the utility of the S-REF model for emotional distress in YPwE. Metacognitive therapy, which is underpinned by the S-REF model, may be an appropriate intervention for emotional distress in YPwE. Future studies should assess the mediational relationship between metacognitive beliefs, perseverative thinking, and emotional distress using time-lagged models.

Prevalence of suicidality in children and adolescents with depressive disorders with and without epilepsy

OBJECTIVE

Children with epilepsy (CWE) are at risk for a range of adverse emotional, behavioral, and social outcomes. Approximately one-third of CWE experience depressive disorders, and up to 20% of children and adolescents with epilepsy may experience suicidality, suggesting that epilepsy increases the risk for suicidality among children and adolescents with depressive disorders. Consequently, the goal of the present study is to compare rates of suicidality in children and adolescents diagnosed with depressive disorders with or without co-morbid epilepsy.

PARTICIPANTS AND METHODS

A retrospective chart review was conducted for 100 pediatric patients with a history of both seizures and depressive disorders and 100 patients with a history of depressive disorders only. Cases were coded for depression diagnosis, suicidality, suicidal ideation, suicide attempts, psychiatric hospitalizations, and self-injury. The distributions of these variables for the two groups were compared.

RESULTS

The age and sex distributions of the two groups were comparable. Patients with co-morbid depressive disorders and epilepsy found a high rate of suicidal ideation (69%) but did not differ from those with depressive disorders without epilepsy on any of the suicidality variables (all p > 0.20), with the exception of self-injury, which was higher in those without epilepsy.

CONCLUSIONS

CWE and co-morbid depression are at significant risk for suicidality, including ideation, attempts, and hospitalizations, but at rates that are comparable to those with depressive disorders without seizures. However, patients with co-morbid epilepsy are less likely to engage in other self-injurious behaviors. These findings support the need for careful monitoring of the psychiatric status of children and adolescents with epilepsy.

Severity features of suicide attempters with epilepsy

BACKGROUND

After the Food and Drug Administration alert about antiepileptic medication and suicide, incident epilepsy has been associated with first or recurrent suicide attempts independently of psychiatric comorbidities and antiepileptic treatment. Following this thread, the aim of this study was to analyze if epilepsy was associated with a higher severity of lifetime suicide attempts (SAs).

METHODS

Analyses were carried out on 1677 adults hospitalized between 1999 and 2012 after a SA in a specialized ward for affective episodes. Five severity features were studied: frequent SAs (>2), early onset of first SA (≤26 years), history of violent SA, high suicide intent and high lethality of the SA. Adjusted logistic regression models were used to estimate the association between the lifetime diagnosis of epilepsy and the severity features.

RESULTS

Among suicide attempters, ninety-three patients reported a lifetime diagnosis of epilepsy (5.5%). Epileptic patients diagnosed after the first SA were more likely to be frequent suicide attempters than non-epileptic ones. They showed also higher SA planification scores.

LIMITATIONS

Diagnosis accuracy is limited by the use of self-reports for epilepsy. The lack of precise information about the disease course and treatment have not allowed for further statistical analysis. With regard to psychiatric comorbidities, personality disorders could not be taken into account.

CONCLUSIONS

Suicide attempters with epilepsy present an increased severity in some aspects of their suicidal behavior regardless of demographic and clinical variables. Our results give support to the existence of a bidirectional association between epilepsy and suicidal behavior.

Indicators of suicidal outcomes among 6- to 12-year-old treatment seeking youth

Suicide among elementary school-age youth is vastly understudied despite being a major health concern. This study utilized mediation and moderation models to elucidate the nature of risk factors for suicide by examining the effect emotion dysregulation (of anger, sadness, and worry) has on the relation between ADHD symptoms (hyperactivity/impulsivity and inattention) and suicidal outcomes (suicidal behavior and risk for suicide) in children ages 6 to 12. When accounting for sex, age, depressive symptoms, and emotion dysregulation, hyperactivity/impulsivity was positively associated with suicidal behavior; however, inattention was negatively associated with suicidal behavior. After accounting for the variance associated with sex, age, and depressive symptoms, two interaction effects were evident. At low levels of sadness and worry dysregulation, hyperactivity was positively associated with suicide risk. However, at high levels of sadness and worry dysregulation, hyperactivity was not related to suicide risk. Findings support moderation over mediation.

Suicide and Epilepsy

PURPOSE OF REVIEW

Epilepsy has a bidirectional association with suicidality, and epilepsy patients are at much higher risk for suicide than the general population. This article reviews the recent literature on suicide risk factors, assessments, and management as they pertain specifically to suicidality in people with epilepsy, a population that requires unique considerations.

RECENT FINDINGS

Risk factors for suicidality include younger age (independent of comorbid psychiatric disorders), poor social support, psychiatric comorbidity (depression, anxiety, obsessive-compulsive symptoms, and alcohol use), and epilepsy-related factors (more frequent seizures, temporal lobe epilepsy, and drug-resistant epilepsy). Most clinicians agree with the need for addressing suicidality; however, there is inconsistency in the approach to caring for these patients. An example neurology clinic-based approach is outlined. Although PWE are at risk for suicide and risk factors have been characterized, care gaps remain. Screening strategies may help close these gaps.

Adolescence and Epilepsy: The Perfect Storm for Suicidal Behavior

Self-Injurious and Suicidal Behavior in Young Adults, Teens, and Children With Epilepsy: A Population-Based Study

Wirrell EC, Bieber EW, Vanderwiel A, et al. Epilepsia. 2020;61(9):1919-1930. doi:10.1111/epi.16618

Objective:

Whereas studies in adult epilepsy patients have shown higher rates of suicidal ideation and attempt, such studies in children are limited. Using the Rochester Epidemiology Project database, we compared the risk of self-injurious behavior and suicidal ideation in a population-based cohort of childhood epilepsy to controls.

Methods:

We studied 339 cases with epilepsy and 678 age- and sex-matched controls followed to a median age of 24.7 and 23.4 years and identified 98 patients with self-injurious behavior or suicidal ideation (43 with epilepsy and 55 controls). All behaviors were categorized using the Columbia Suicide Severity Rating Scale.

Results:

Those with epilepsy had a significantly higher rate of any self-injurious behavior and suicidal ideation (hazard ratio [HR] = 1.56, 95% CI = 1.04-2.35) and tended to have an increased risk of suicidal ideation and attempt (HR = 1.48, 95% CI = 0.93-2.37). The prevalence of preceding mood and substance abuse disorders was similarly high in both cases and controls with self-injurious behavior or suicidal ideation; however, preceding attention-deficit/hyperactivity disorder was more than twice as common in the epilepsy cases. Among cases with epilepsy, we did not identify any specific epilepsy-related variable that was significantly correlated with risk of self-injurious behavior or suicidal ideation.

Significance:

Children, teens, and young adults with a history of childhood epilepsy are at greater risk of self-injurious behavior, highlighting the need for careful screening of mental health concerns as part of routine epilepsy care.

Self-injurious and suicidal behavior in young adults, teens, and children with epilepsy: A population-based study

OBJECTIVE

Whereas studies in adult epilepsy patients have shown higher rates of suicidal ideation and attempt, such studies in children are limited. Using the Rochester Epidemiology Project database, we compared the risk of self-injurious behavior and suicidal ideation in a population-based cohort of childhood epilepsy to controls.

METHODS

We studied 339 cases with epilepsy and 678 age- and sex-matched controls followed to a median age of 24.7 and 23.4 years, and identified 98 subjects with self-injurious behavior or suicidal ideation (43 with epilepsy and 55 controls). All behaviors were categorized using the Columbia Suicide Severity Rating Scale.

RESULTS

Those with epilepsy had a significantly higher rate of any self-injurious behavior and suicidal ideation (hazard ratio [HR] = 1.56, 95% confidence interval [CI] = 1.04-2.35) and tended to have an increased risk of suicidal ideation and attempt (HR = 1.48, 95% CI = 0.93-2.37). The prevalence of preceding mood and substance abuse disorders was similarly high in both cases and controls with self-injurious behavior or suicidal ideation; however, preceding attention-deficit/hyperactivity disorder was more than twice as common in the epilepsy cases. Among cases with epilepsy, we did not identify any specific epilepsy-related variable that was significantly correlated with risk of self-injurious behavior or suicidal ideation.

SIGNIFICANCE

Children, teens, and young adults with a history of childhood epilepsy are at greater risk of self-injurious behavior, highlighting the need for careful screening of mental health concerns as part of routine epilepsy care.

Digital conversations about suicide among teenagers and adults with epilepsy: A big-data, machine learning analysis

Objective

Digital media conversations can provide important insight into the concerns and struggles of people with epilepsy (PWE) outside of formal clinical settings and help generate useful information for treatment planning. Our study aimed to explore the big data from open‐source digital conversations among PWE with regard to suicidality, specifically comparing teenagers and adults, using machine learning technology.

Methods

Advanced machine‐learning empowered methodology was used to mine and structure open‐source digital conversations of self‐identifying teenagers and adults who endorsed suffering from epilepsy and engaged in conversation about suicide. The search was limited to 12 months and included only conversations originating from US internet protocol (IP) addresses. Natural language processing and text analytics were employed to develop a thematic analysis.

Results

A total of 222 000 unique conversations about epilepsy, including 9000 (4%) related to suicide, were posted during the study period. The suicide‐related conversations were posted by 7.8% of teenagers and 3.2% of adults in the study. Several critical differences were noted between teenagers and adults. A higher percentage of teenagers are: fearful of “the unknown” due to seizures (63% vs 12% adults), concerned about social consequences of seizures (30% vs 21%), and seek emotional support (29% vs 19%). In contrast, a significantly higher percentage of adults show a defeatist (“given up”) attitude compared to teenagers (42% vs 4%). There were important differences in the author's determined sentiments behind the conversations among teenagers and adults.

Significance

In this first of its kind big data analysis of nearly a quarter‐million digital conversations about epilepsy using machine learning, we found that teenagers engage in an online conversation about suicide more often than adults. There are some key differences in the attitudes and concerns, which may have implications for the treatment of younger patients with epilepsy.

A Meta-Analysis of the Rates of Suicide Ideation, Attempts and Deaths in People with Epilepsy

This meta-analysis aimed to evaluate the association between epilepsy and suicide. We systematically searched PubMed, PsycINFO, Embase and Web of Science for studies that reported the prevalence of suicidality in the form of suicide ideation, attempts and deaths among people with epilepsy (PWE). Studies were included if they reported the numbers of patients who died by suicide and concurrently suffered from epilepsy, assessed suicide ideation, or studied suicide attempts in PWE by validated instruments or diagnostic interviews. We used the random effects model to calculate the pooled odds ratios (OR) and standard mean differences (SMDs). We performed subgroup analyses. Seven case-control studies were included in the comparison of rates of suicide attempts between PWE and controls, with a total of 821,594 participants. Our analyses demonstrated a positive association between epilepsy and suicide attempts (pooled OR = 3.25, 95% confidence interval (CI): 2.69–3.92, p < 0.001), indicating that PWE have an elevated risk of suicide. The pooled prevalence for suicide ideation (24 studies) and suicide attempts (18 studies) were 23.2% (95% CI: 0.176–0.301) and 7.4% (95% CI: 0.031–0.169) respectively. The pooled rate of death due to suicide (10 studies) was 0.5% (95% CI: 0.002–0.016). Meta-regression showed that mean age and proportion of male gender were significant moderators for prevalence of suicide attempts and death due to suicide in PWE. Young PWE could be triggered by relationship problems and male PWE might use more lethal methods to attempt suicide. This meta-analysis provides the most up-to-date information on the prevalence of suicide among people with epilepsy and guidance on strategies to improve current psychiatric services provided for this population.