Evaluating clinical risk factors for suicide attempts in patients with epilepsy

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.

The neuropsychological presentation of women with epilepsy: Clinical considerations and future directions

Objective: Cognitive, mood, and behavioral changes are common among persons with epilepsy (PWE), resulting in a complex neuropsychological presentation. Women with epilepsy (WWE) represent a distinct cohort within the broader epilepsy population due to sex and gender-specific factors impacting epilepsy semiology and treatment. However, unique neuropsychological profiles among WWE have not been established. This narrative review aims to further define neuropsychological correlates in WWE and promote meaningful discussion related to enhancing the provision of neuropsychological care within this clinical population. Method: Current literature in PWE examining differences in cognitive function, mental health, and quality of life (QoL) between women and men was critically reviewed, emphasizing considerations for neuropsychological practice. Results: WWE demonstrate a preservation of verbal learning and memory compared to men both pre- and post-surgically, with sex-based, neurobiological mechanisms likely contributing to this association. WWE also have elevated risk for affective disorder psychopathology, suicidality, and traumatic experiences. Epidemiology related to psychotic and bipolar spectrum disorders is less clear, and findings are mixed regarding sex-specific behavioral side effects of antiseizure and psychotropic medication. Finally, hormonal and obstetric factors are highlighted as important contributors to neuropsychological symptoms in WWE, with elevated risk for low QoL and increased stigma associated with greater medical and psychiatric comorbidities compared to men. Conclusions: While emerging literature has begun to characterize the neuropsychological presentation of WWE, future research is needed to define sex and gender differences in neuropsychological sequalae among PWE to ensure consistency and quality of care for WWE.

Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity

BACKGROUND AND OBJECTIVES

Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts.

METHODS

The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses.

RESULTS

A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts.

DISCUSSION

In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.

Suicidality and epilepsy: A systematic review and meta-analysis

Background

We aimed to evaluate the association between epilepsy and suicidality, including suicidal ideation, attempts and completed suicide.

Methods

We systematically searched PubMed, Embase, Cochrane Online Library, and Clinicaltrials.gov from 1946 to June 21, 2021 and assessed the quality of the studies using the Newcastle-Ottawa Scale. We calculated the pooled OR and the crude rate for suicidal ideation, suicide attempts and completed suicide in patients with epilepsy (PWE).

Results

We screened 2,786 studies and included 88 articles with 1,178,401 PWE and 6,900,657 participants as controls. Search terms included epilepsy and suicide. The pooled rates of suicidal ideation, suicide attempts and completed suicide in PWE were 19.73% (95% CI: 17.00-22.62%), 5.96% (95% CI: 4.82-7.20%), and 0.24% (95% CI: 0.11-0.42%), respectively. Compared to the control group, PWE were at a significantly higher risk of total suicidality (pooled OR, 2.60; 95%: 2.13-3.18), including suicidal ideation (pooled OR, 2.70; 95% CI, 2.21-3.30), suicide attempts (pooled OR, 2.74; 95% CI, 2.08-3.61) and completed suicide (pooled OR, 2.36; 95% CI, 1.45-3.83). Subgroup analyses showed significant differences in the subgroups of the measurement of suicidality.

Conclusion

The rate of suicidal ideation, suicide attempts and completed suicide in PWE were about 19.73, 5.96, and 0.24%. And there was an increased risk of suicidality in PWE especially temporal lobe epilepsy and drug-resistant epilepsy. Clinicians need to be aware of this risk in PWE with early identification and prevention at the time of diagnosis.Protocol Registration: PROSPERO CRD42021278220.

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.

I would be better off dead: investigating suicidal ideation in people with epilepsy

BACKGROUND

It is known that the risk of suicidal behavior in adult people with epilepsy (PWEs) is high. However, the associated clinical and psychosocial factors are still being discussed.

OBJECTIVE

To assess the risk of suicide in PWEs and relate it to resilience and quality of life (QoL) as well as with clinical variables.

METHODS

The item "I'd be better off dead" of the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) was related to the resilience scale, clinical aspects, the presence of depression, and the Quality of Life in Epilepsy Inventory (QOLIE-31) scores of PWEs, with a p < 0.05.

RESULTS

A total of 271 PWEs were assessed, 50.6% were female, with a mean age of 46.6 (± 15.8) years, and a mean age at 1st seizure of 24.1 (± 18.5) years. Risk for suicide occurred in 50 (19.3%) cases. In multiple logistic regression, the factors that explain the risk of suicide were female sex, depression, and lower scores on the QOLIE-31 and on the resilience scale. In the classification and regression trees, the order of importance of the variables was depression > resilience > age > QoL > age at 1st seizure.

CONCLUSION

The risk of suicide was high, and it was associated with demographic aspects, clinical variables, QoL, and resilience. A higher risk of suicide was associated with lower resilience regardless of the presence or absence of depression. In the presence of depression, a higher risk of suicide was associated with the early onset of epilepsy. In the absence of depression, the risk of suicide was associated with low QoL in young adults.

Suicidality in Patients With Epilepsy: Why Should Neurologists Care?

Suicidality is a relatively common comorbidity in patients with epilepsy (PWE). Population-based studies have revealed lifetime prevalence rates of 25% of suicidal ideation (SI). In addition, PWE without comorbid psychiatric disorders has two to three higher risk of committing suicide and this risk increases by 12- to 32-fold in the presence of various psychiatric disorders. Risk factors are multiple and include socio-demographic, genetic, age and gender, and psychiatric comorbidities. Among the latter, mood, anxiety, and psychotic disorders have been found to be common risk factors for suicidality in PWE, but iatrogenic causes resulting from pharmacotherapy with antiseizure drugs or epilepsy surgery can also cause SI and behavior. Suicidality and epilepsy have a complex bidirectional relation, whereas PWE are at increased risk of suicidality and vice-versa. Common pathogenic mechanisms operant in both conditions may explain this bidirectional relation. SI can be easily identified in outpatient epilepsy clinics with screening instruments and can be treated and thus prevent its escalation to suicidal attempts and completed suicide. The aim of this manuscript is to review these data in detail.

Risk factors for suicidal tendency in people with epilepsy in China: a case-control study

People with epilepsy (PWE) have an increased suicide prevalence. This study aimed to identify the risk factors for suicidal tendency among PWE in West China. A nested case–control study was designed in a cohort of patients with epilepsy (n = 2087). In total, 28 variates were calculated. In the univariate analysis, unemployment, low income, seizure frequency, seizure-free time, infectious or structural etiology, levetiracetam or phenobarbital use, anxiety, depression, and stigma were associated with suicidal tendency. A multivariate analysis indicated that unemployment (odds ratio [OR] 5.74, 95% confidence interval [CI] 2.13–15.48), levetiracetam use (OR 2.80, 95%CI 1.11–7.05), depression (C-NDDI-E score ≥ 13; OR 3.21, 95%CI 1.26–8.21), and stigma (SSCI score ≥ 16; OR 6.67, 95%CI 1.80–24.69) were independently associated with suicidal tendency. Conditional inference tree analysis indicated that SSCI and C-NDDI-E scores could effectively identify patients with suicidal tendency. Thus, this study suggests that unemployment, levetiracetam use, depression, and stigma are independent risk factors for suicidal tendency in PWE in China.

Association between depression risk and polycystic ovarian syndrome in young women: a retrospective nationwide population-based cohort study (1998-2013)

STUDY QUESTION

Is polycystic ovarian syndrome (PCOS) in women associated with the increasing incidence of depression in an East Asian population?

SUMMARY ANSWER

Younger PCOS patients (aged 15-29 years), but not middle-aged patients, have an increased risk of depression in Taiwan.

WHAT IS KNOWN ALREADY

During reproductive age, 6-10% of women have PCOS. Among them, ~40% experience depression, mostly at young ages.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based cohort study analysing depression risk in Taiwanese women using data from a nationwide database containing 1998-2013 data of nearly 1 million people.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 15- to 50-year-old women newly diagnosed with PCOS during 1998-2013 from the Taiwan National Health Insurance Research Database as the PCOS cohort (n = 7684) and then randomly matched them 4 : 1 by sex, age and index year with women without PCOS as the comparison cohort (n = 30 736). We used multivariable Cox proportional hazard regression analysis to determine the association between PCOS and depression risk [hazard ratio (HR) with 95% confidence interval (CI)].

MAIN RESULTS AND THE ROLE OF CHANCE

The incidence of depression was higher in the PCOS group than in the comparison group (6.67 vs. 4.82 per 1000 person-years; adjusted HR = 1.28, 95% CI = 1.12-1.46). PCOS patients aged 15-29 years had a significantly higher depression risk (adjusted HR = 1.39, 95% CI = 1.18-1.65); no such significant association was noted among patients aged 30-39 years and 40-50 years.

LIMITATIONS, REASONS FOR CAUTION

A history of malignancy, which may increase depression, could not be obtained for our study patients. Moreover, we could not obtain a family history of depression, a relevant risk factor for depression. Finally, the database has no records of body mass index, which may influence depression outcome.

WIDER IMPLICATIONS OF THE FINDINGS

In Taiwan, younger PCOS patients (15-29 years), but not the middle-aged patients, have an increased risk of depression. Our findings provide vital information to patients, clinicians, the Taiwan Government and other developing Asian countries to improve the PCOS treatment strategies in the future. Routine screening for depression in PCOS patients may be implemented into the health practice.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported in part by the Taiwan Ministry of Health and Welfare Clinical Trial Center (MOHW108-TDU-B-212-133 004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 107-2321-B-039 -004-), Tseng-Lien Lin Foundation, Taichung, Taiwan and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. No competing interest existed.

TRIAL REGISTRATION NUMBER

N/A.

Women with polycystic ovary syndrome associated with increased anxiety risk: A population-based cohort study in Taiwan

BACKGROUND

Polycystic ovary syndrome (PCOS) has been associated with developing mental disorders in Western populations, but this association is poorly studied in Asians. Hence, using insurance claims data, this study evaluated the anxiety risk in women with PCOS.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 7026 women aged 15-49 years with newly diagnosed PCOS without anxiety in 1998-2013 as the PCOS cohort. We also randomly selected 28,104 women without PCOS and anxiety as the comparison cohort, which was frequency-matched to cases by age and index year. Determined by incidence and Cox method, the hazard ratio (HR) of anxiety and the 95% confidence interval (CI) for the association with PCOS were estimated after a 16-year follow-up.

RESULTS

The incidence of anxiety was 19.5% higher in the PCOS cohort than in the comparison cohort (15.3 vs. 12.8 per 1000 person-years), with an adjusted HR of 1.18 (95% CI=1.07-1.30). For women with both PCOS and comorbid depression, it was 32.1 per 1000 person-years, with an adjusted HR of 2.24 (95% CI=1.24-4.06), compared with those without PCOS or depression. Moreover, it was 48.0 per 1000 person-years for women with depression alone (adjusted HR=3.46; 95% CI=2.58-4.64).

LIMITATIONS

We used a diagnostic code to identify PCOS cases without reference to pathology records. Miscoding might have occurred in the database.

CONCLUSIONS

PCOS is associated with an increased risk of developing anxiety independently. Comorbid depression could increase the risk further. Our findings provide vital information for Asian women to cope with anxiety.

Differences in Incidence and Risks of Suicide Attempt and Suicidal Drug Overdose between Patients with Epilepsy with and without Comorbid Depression

Objective: To determine the differences in the incidences and risks of suicide attempt (SA) and suicidal drug overdose (SDO) between patients with epilepsy with and without comorbid depression by using data from Taiwan’s National Health Insurance Research Database. Methods: We analyzed data of patients (≥20 years) who had received epilepsy diagnoses between 2000 and 2012; the diagnosis date of epilepsy was defined as the index date. The epilepsy patients were divided into the cohorts, with and without comorbid depression, and compared against a cohort from the non-affected population. We calculated adjusted hazard ratios and the corresponding 95% confidence intervals for SA and SDO in the three cohorts after adjustment for age, sex, and comorbidities. Results: The incidences of SA and SDO in the cohort with epilepsy and depression were 42.9 and 97.4 per 10,000 person-years, respectively. The epilepsy with depression cohort had 21.3 times of SA risk; and 22.9 times of SDO risk than did the comparison cohort had a 6.03-fold increased risk of SA and a 2.56-fold increased risk of SDO than did the epilepsy patients without depression. Moreover, patients’ age <65 years, and female sex would further increase the risk of SA in patients with epilepsy and comorbid depression. Conclusion: Risks of SA and SDO in patients with epilepsy are proportionally increased when depression is coexisted. Our findings provide crucial information for clinicians and the government for suicide prevention and to question whether prescribing a large number of medications to patients with epilepsy and depression is safe.

Etiopathogenesis of Suicide: A Conceptual Analysis of Risk and Prevention Within a Comprehensive, Deterministic Model

Suicide is a rising global health concern receiving disproportionate attention in comparison to other health conditions. In spite of substantial technological and scientific advancements, suicide research has continued to move slowly in terms of clinical translation due to the complexity of neural mechanisms, and subjective experiences that seem to underpin this complex human behavior. This paper analyzes the concepts of risk and prevention in the context of suicide in an attempt to bridge the large methodological and theoretical gaps between the biological, psychological, and sociological dimensions. This paper aims to accomplish the following objectives: (1) operationalize the concepts of suicide risk and prevention as they relate to current knowledge and capabilities; (2) synthesize and integrate suicide research across biological, psychological, and sociological dimensions; (3) discuss limitations of each dimension in isolation; (4) suggest a model of etiopathogenesis that incorporates extant literature and bridges unnecessary gaps between dimensions; and (5) suggest future directions for multidimensional research through the inclusion of principles from the physical sciences. Ultimately, this paper provides a basis for a comprehensive model of suicide within a deterministic, chaotic system.

Risk factors for suicidal tendency in adult patients with epilepsy in China

OBJECTIVE

The major cause of premature mortality in people with epilepsy (PWE) is suicide. Actual data on the risk of suicidal tendency in adult PWE in China are scarce. In our study, associations between possible risk factors and suicidal tendency in adult PWE in China were investigated.

METHODS

People with epilepsy (n = 251) were recruited, and their demographic and clinical characteristics were evaluated. Suicide risk was examined using the suicidality module (SM) of the Mini International Neuropsychiatric Interview (MINI) Plus Chinese Version 5.0.0.

RESULTS

Suicidal tendency was present in 36 (14.3%) of the 251 PWE. On the basis of the results of univariate analyses, family relationship (P < 0.001), age at epilepsy onset (P = 0.037), seizure-free period (P = 0.041), seizures/month (P = 0.015), depressive disorders (P < 0.001), and number of antiepileptic drugs (AEDs) (P = 0.017) were associated with suicidal tendency. Multivariate analysis revealed that moderate or poor family relationships (odds ratio (OR): 6.468, 95% confidence interval (CI): 2.418-17.300) and depressive disorders (OR: 3.548, 95% CI: 1.575-7.995) were associated with high odds of suicidal tendency.

CONCLUSION

Suicidal tendency is common among adult PWE. This study reveals that family relationships and depressive disorders are independent risk factors for suicidal tendency among adult PWE. Therefore, while maintaining treatment of epilepsy, more attention should be directed to the social support and mental state of PWE to prevent suicide.

Suicide attempt in patients with atrial fibrillation - A nationwide cohort study

BACKGROUND AND AIMS

We analyzed the incidence of suicide attempt in a Taiwanese population following admission to hospital between 2000 and 2010 for atrial fibrillation (AF).

METHODS

Using the National Health Insurance Research Database in Taiwan, the study cohort and the comparison cohort were 1-fold matched according to propensity score method. Cox proportion hazard regression models were used to examine the effect of AF on the risk of suicide attempt, and were shown as hazard ratios (HRs) and 95% confidence intervals (CIs). Mortality for patients who have made suicide attempts was subsequently compared between the AF and the non-AF cohorts.

RESULTS

The study included a cohort of 88,259 patients with AF and a non-AF cohort of 88,259 subjects. The overall incidence of suicide attempt for the AF and the non-AF cohorts were 5.75 and 3.97 per 10,000 person-years, respectively. AF patients were associated with an increased risk of suicide attempt compared with the non-AF controls [adjusted HR (aHR) = 1.47, 95% CI = 1.19-1.81] after controlling for the confounders. The incidence of mortality among patients who have made suicide attempts was not significantly higher in the AF cohort than in the non-AF cohort, with an adjusted HR of 1.11 (95% CI = 0.75-1.65).

CONCLUSIONS

We concluded that in this large database AF patients were related with higher incidence of suicide attempt.

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.

[Suicidality in epilepsy: epidemiology and clinical risk factors]

The results of studies on the prevalence of suicidal behavior in patients with epilepsy are discussed in the article. The reasons for the high incidence of suicides among patients with epilepsy are given, with special attention paid to social, demographic, clinical and pathopsychological risk factors. Existing gaps in our knowledge about suicidal behavior in patients with epilepsy are analyzed.