Suicidality and brain volumes in pediatric epilepsy

Structural brain alterations associated with suicidal thoughts and behaviors in young people: results from 21 international studies from the ENIGMA Suicidal Thoughts and Behaviours consortium

Identifying brain alterations associated with suicidal thoughts and behaviors (STBs) in young people is critical to understanding their development and improving early intervention and prevention. The ENIGMA Suicidal Thoughts and Behaviours (ENIGMA-STB) consortium analyzed neuroimaging data harmonized across sites to examine brain morphology associated with STBs in youth. We performed analyses in three separate stages, in samples ranging from most to least homogeneous in terms of suicide assessment instrument and mental disorder. First, in a sample of 577 young people with mood disorders, in which STBs were assessed with the Columbia Suicide Severity Rating Scale (C-SSRS). Second, in a sample of young people with mood disorders, in which STB were assessed using different instruments, MRI metrics were compared among healthy controls without STBs (HC; N = 519), clinical controls with a mood disorder but without STBs (CC; N = 246) and young people with current suicidal ideation (N = 223). In separate analyses, MRI metrics were compared among HCs (N = 253), CCs (N = 217), and suicide attempters (N = 64). Third, in a larger transdiagnostic sample with various assessment instruments (HC = 606; CC = 419; Ideation = 289; HC = 253; CC = 432; Attempt=91). In the homogeneous C-SSRS sample, surface area of the frontal pole was lower in young people with mood disorders and a history of actual suicide attempts (N = 163) than those without a lifetime suicide attempt (N = 323; FDR-p = 0.035, Cohen's d = 0.34). No associations with suicidal ideation were found. When examining more heterogeneous samples, we did not observe significant associations. Lower frontal pole surface area may represent a vulnerability for a (non-interrupted and non-aborted) suicide attempt; however, more research is needed to understand the nature of its relationship to suicide risk.

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.

Increased Amygdala-Paracentral Lobule/Precuneus Functional Connectivity Associated With Patients With Mood Disorder and Suicidal Behavior

Mood disorder patients have greater suicide risk than members of the general population, but how suicidal behavior relates to brain functions has not been fully elucidated. This study investigated how functional connectivity (FC) values between the right/left amygdala and the whole brain relate to suicidal behavior in patients with mood disorder. The participants in this study were 100 mood disorder patients with suicidal behavior (SB group), 120 mood disorder patients with non-suicidal behavior (NSB group), and 138 age- and gender-matched healthy controls (HC group). Whole-brain FC values among the three groups were compared using an analysis of covariance (ANCOVA). Compared to the NSB and HC groups, increased FC values in the right amygdala-bilateral paracentral lobule/precuneus circuit were observed in the SB group (Bonferroni-corrected, p < 0.017). The FC values in the NSB group did not differ significantly from those in the HC group (Bonferroni-corrected, p > 0.017). Moreover, there were no significant differences in FC values between mood disorder patients with suicide attempt (SA group) and mood disorder patients with suicidal ideation (SI group), while the FC values between the right amygdala and bilateral paracentral lobule/precuneus in the SA group were higher than the mean in the SI group. These findings suggest that right amygdala-paracentral lobule/precuneus dysfunction has an important role in patients with mood disorder and suicidal behavior.

Internalizing symptoms in intractable pediatric epilepsy: Structural and functional brain correlates

Internalizing disorders (i.e., depression and anxiety) are common comorbidities in people with epilepsy. In adults with epilepsy, comorbid depression or anxiety is associated with worse seizure control and reduced quality of life, and may be linked to specific neural biomarkers. Less is known about brain correlates of internalizing symptoms in pediatric populations. In the current study, we performed a retrospective analysis of 45 youth between the ages of 6 and 18 years old with intractable epilepsy. Individuals were evaluated for internalizing symptoms on the Child Behavior Checklist (CBCL) and underwent magnetic resonance (MR) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) imaging as part of the clinical evaluation for surgical treatment of epilepsy. Forty-two percent of patients experienced clinically significant internalizing symptoms based on parent report. Compared with individuals who scored in the normal range, youth with clinical levels of internalizing problems showed overall reductions in cortex volume, as well as widespread reductions in cortical thickness and functional activation in the bilateral occipital/parietal lobe, left temporal regions, and left inferior frontal cortex on MR and PET scans. There were no group differences in amygdala or hippocampus volumes, nor other patient- or illness-related variables such as age, sex, or the type, lateralization, or duration of epilepsy. Results suggest that high rates of internalizing disorders are present in youth with refractory epilepsy. Multifocal reductions in cortical thickness and function may be nonspecific risk factors for clinically meaningful internalizing symptoms in youth with chronic epilepsy. As such, the presence of broad cortical thinning and reduced glucose uptake upon radiological examination may warrant more focused clinical evaluation of psychological symptoms.

Multimodal Neuroimaging of Frontolimbic Structure and Function Associated With Suicide Attempts in Adolescents and Young Adults With Bipolar Disorder

OBJECTIVE

Bipolar disorder is associated with high risk for suicidal behavior that often develops in adolescence and young adulthood. Elucidation of involved neural systems is critical for prevention. This study of adolescents and young adults with bipolar disorder with and without a history of suicide attempts combines structural, diffusion tensor, and functional MR imaging methods to investigate implicated abnormalities in the morphology and structural and functional connectivity within frontolimbic systems.

METHOD

The study had 26 participants with bipolar disorder who had a prior suicide attempt (the attempter group) and 42 participants with bipolar disorder without a suicide attempt (the nonattempter group). Regional gray matter volume, white matter integrity, and functional connectivity during processing of emotional stimuli were compared between groups, and differences were explored for relationships between imaging modalities and associations with suicide-related symptoms and behaviors.

RESULTS

Compared with the nonattempter group, the attempter group showed significant reductions in gray matter volume in the orbitofrontal cortex, hippocampus, and cerebellum; white matter integrity in the uncinate fasciculus, ventral frontal, and right cerebellum regions; and amygdala functional connectivity to the left ventral and right rostral prefrontal cortex. In exploratory analyses, among attempters, there was a significant negative correlation between right rostral prefrontal connectivity and suicidal ideation and between left ventral prefrontal connectivity and attempt lethality.

CONCLUSIONS

Adolescent and young adult suicide attempters with bipolar disorder demonstrate less gray matter volume and decreased structural and functional connectivity in a ventral frontolimbic neural system subserving emotion regulation. Among attempters, reductions in amygdala-prefrontal functional connectivity may be associated with severity of suicidal ideation and attempt lethality.

Hospital care for mental health and substance abuse in children with epilepsy

BACKGROUND

Reducing the burden of pediatric mental illness requires greater knowledge of mental health and substance abuse (MHSA) outcomes in children who are at an increased risk of primary psychiatric illness. National data on hospital care for psychiatric illness in children with epilepsy are limited.

METHODS

We used the Kids' Inpatient Database (KID), the Healthcare Cost and Utilization Project (HCUP), and the Agency for Healthcare Research and Quality from 2003 to 2009 to examine MHSA hospitalization patterns in children with comorbid epilepsy. Nonparametric and regression analyses determined the association of comorbid epilepsy with specific MHSA diagnoses and examined the impact of epilepsy on length of stay (LOS) for such MHSA diagnoses while controlling for demographic, payer, and hospital characteristics.

RESULTS

We observed 353,319 weighted MHSA hospitalizations of children ages 6-20; 3280 of these involved a child with epilepsy. Depression was the most common MHSA diagnosis in the general population (39.5%) whereas bipolar disorder was the most common MHSA diagnosis among children with epilepsy (36.2%). Multivariate logistic regression models revealed that children with comorbid epilepsy had greater adjusted odds of bipolar disorder (AOR: 1.17, 1.04-1.30), psychosis (AOR: 1.78, 1.51-2.09), sleep disorder (AOR: 5.90, 1.90-18.34), and suicide attempt/ideation (AOR: 3.20, 1.46-6.99) compared to the general MHSA inpatient population. Epilepsy was associated with a greater LOS and a higher adjusted incidence rate ratio (IRR) for prolonged LOS (IRR: 1.12, 1.09-1.17), particularly for suicide attempt/ideation (IRR: 3.74, 1.68-8.34).

CONCLUSIONS

Children with epilepsy have distinct patterns of hospital care for mental illness and substance abuse and experience prolonged hospitalization for MHSA conditions. Strategies to reduce psychiatric hospitalizations in this population may require disease-specific approaches and should measure disease-relevant outcomes. Hospitals caring for large numbers of children with neurological disease (such as academic centers) may have inaccurate measurements of mental health-care quality unless the impact of key comorbid conditions such as epilepsy is considered.

Cortical thickness and sulcal depth: insights on development and psychopathology in paediatric epilepsy

BACKGROUND

The relationship between cortical thickness (CThick) and sulcal depth (SDepth) changes across brain regions during development. Epilepsy youth have CThick and SDepth abnormalities and prevalent psychiatric disorders.

AIMS

This study compared the CThick-SDepth relationship in children with focal epilepsy with typically developing children (TDC) and the role played by seizure and psychopathology variables.

METHOD

A surface-based, computational high-resolution three-dimesional (3D) magnetic resonance image analytic technique compared regional CThick-SDepth relationships in 42 participants with focal epilepsy and 46 TDC (6-16 years) imaged in a 1.5 Tesla scanner. Psychiatric interviews administered to each participant yielded psychiatric diagnoses. Parents provided seizure-related information.

RESULTS

The TDC group alone demonstrated a significant negative medial fronto-orbital CThick-SDepth correlation. Focal epilepsy participants with but not without psychiatric diagnoses showed significant positive pre-central and post-central CThick-SDepth associations not found in TDC. Although the history of prolonged seizures was significantly associated with the post-central CThick-SDepth correlation, it was unrelated to the presence/absence of psychiatric diagnoses.

CONCLUSIONS

Abnormal CThick-SDepth pre-central and post-central associations might be a psychopathology biomarker in paediatric focal epilepsy.

DECLARATION INTEREST

None.

COPYRIGHT AND USAGE

© 2015 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Are children affected by epileptic neuropsychiatric comorbidities?

Childhood-onset epilepsy is associated with psychiatric and cognitive difficulties and with poor social outcomes in adulthood. Some antiepileptic drugs adversely affect behavior in susceptible children with easy-to-control or refractory epilepsies, contributing to a high risk of psychological and psychiatric disturbance. Studies had demonstrated that patients with benign rolandic epilepsy and absence epilepsy had more aggressive behavior, depression, and anxiety disorders than control children. Psychiatric comorbidities are strongly associated with a poor long-term health-related quality of life in childhood-onset epilepsy, which suggests that comprehensive epilepsy care must include screening and long-term treatment for these conditions, even if seizures remit.

Neurobiological risk factors for suicide: insights from brain imaging

CONTEXT

This article reviews neuroimaging studies on neural circuitry associated with suicide-related thoughts and behaviors to identify areas of convergence in findings. Gaps in the literature for which additional research is needed are identified.

EVIDENCE ACQUISITION

A PubMed search was conducted and articles published before March 2014 were reviewed that compared individuals who made suicide attempts to those with similar diagnoses who had not made attempts or to healthy comparison subjects. Articles on adults with suicidal ideation and adolescents who had made attempts, or with suicidal ideation, were also included. Reviewed imaging modalities included structural magnetic resonance imaging, diffusion tensor imaging, single photon emission computed tomography, positron emission tomography, and functional magnetic resonance imaging.

EVIDENCE SYNTHESIS

Although many studies include small samples, and subject characteristics and imaging methods vary across studies, there were convergent findings involving the structure and function of frontal neural systems and the serotonergic system.

CONCLUSIONS

These initial neuroimaging studies of suicide behavior have provided promising results. Future neuroimaging efforts could be strengthened by more strategic use of common data elements and a focus on suicide risk trajectories. At-risk subgroups defined by biopsychosocial risk factors and multidimensional assessment of suicidal thoughts and behaviors may provide a clearer picture of the neural circuitry associated with risk status-both current and lifetime. Also needed are studies investigating neural changes associated with interventions that are effective in risk reduction.

Functional MRI and structural MRI as tools for understanding comorbid conditions in children with epilepsy

Children with epilepsy are at risk for behavioral and cognitive comorbidities. Potential etiologies can be assessed in part by neuroimaging. Functional magnetic resonance imaging (MRI) has a major role in presurgical evaluation and prediction of postoperative outcome by mapping of language and memory. Structural MRI and functional MRI have shown changes in children and adolescents with attention deficit hyperactivity disorder and disruptive behavior, common comorbidities in children with epilepsy. Neuroimaging has the potential for significantly increasing understanding of the basis of cognitive and behavioral problems in children with epilepsy.

Cerebral microbleeds and suicidality in stroke

OBJECTIVE

Cerebral microbleeds (CMBs) are common in stroke survivors. The clinical significance of CMBs in the development of suicidality (SI) following stroke is unknown. This study examined the association between SI and CMBs. The aim of the study reported here was to determine the relationship between CMBs and SI in ischemic stroke survivors.

METHODS

A cohort of 367 patients with acute ischemic stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. SI was assessed with the geriatric mental state examination at three months following the subjects' index stroke. Depressive symptoms were assessed using the geriatric depression scale (GDS). A qualified psychiatrist administered the Chinese version of the Structured Clinical Interview for DSM-IV to diagnose depressive disorders. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI).

RESULTS

Compared with the non-SI patients, SI patients were more likely to have CMBs in any brain region (36.6% vs. 20.2%, p = 0.017), specifically more lobar (29.3% vs. 13.5%, p = 0.008) and thalamic CMBs (19.5% vs. 7.5%, p = 0.018). Presence of CMBs (odds ratio was 2.5, p = 0.026) and lobar CMBs (odds ratio 2.6, p = 0.034) were independent predictors of SI in the multivariate analysis.

CONCLUSIONS

The results suggest that lobar CMBs may play roles in the development of SI. The importance of CMBs in the pathogenesis of SI in stroke survivors warrants further investigation.

Relationship between suicidality and impulsivity in bipolar I disorder: a diffusion tensor imaging study

BACKGROUND

Impulsivity is characteristic of individuals with bipolar disorder and may be a contributing factor to the high rate of suicide in patients with this disorder. Although white matter abnormalities have been implicated in the pathophysiology of bipolar disorder, their relationship to impulsivity and suicidality in this disorder has not been well-investigated.

METHODS

Diffusion tensor imaging scans were acquired in 14 bipolar disorder patients with a prior suicide attempt, 15 bipolar disorder patients with no prior suicide attempt, and 15 healthy volunteers. Bipolar disorder patients received clinical assessments including measures of impulsivity, depression, mania, and anxiety. Images were processed using the Tract-Based Spatial Statistics method in the FSL software package.

RESULTS

Bipolar disorder patients with a prior suicide attempt had lower fractional anisotropy (FA) within the left orbital frontal white matter (p < 0.05, corrected) and higher overall impulsivity compared to patients without a previous suicide attempt. Among patients with a prior suicide attempt, FA in the orbital frontal white matter region correlated inversely with motor impulsivity.

CONCLUSIONS

Abnormal orbital frontal white matter may play a role in impulsive and suicidal behavior among patients with bipolar disorder.

Child psychiatry

This paper first summarizes the main findings of clinical studies conducted over the past two and a half decades on psychopathology (i.e., psychiatric diagnoses, behavior and emotional problems) in children with new onset and chronic epilepsy both with and without intellectual disability who are treated medically and surgically. Although impaired social relationships are core features of the psychiatric disorders found in pediatric epilepsy, few studies have examined social competence (i.e., social behavior, social adjustment, and social cognition) in these children. There also is a dearth of treatment studies on the frequent psychiatric comorbidities of pediatric epilepsy, attention deficit hyperactivity disorder, anxiety disorders, and depression. Drs. Hamiwka and Jones then describe their current and planned studies on social competence and cognitive behavioral treatment of anxiety disorders, respectively, in these children and how they might mitigate the poor long-term psychiatric and social outcome of pediatric epilepsy.

The suicidal mind and brain: a review of neuropsychological and neuroimaging studies

OBJECTIVES. We aimed at reviewing studies exploring dysfunctional cognitive processes, and their neuroanatomical basis, in suicidal behaviour, and to develop a neurocognitive working model. Methods. A literature search was conducted. RESULTS. Several limitations were found. The main reported neuropsychological findings are a higher attention to specific negative emotional stimuli, impaired decision-making, lower problem-solving abilities, reduced verbal fluency, and possible reduced non-specific attention and reversal learning in suicide attempters. Neuroimaging studies mainly showed the involvement of ventrolateral orbital, dorsomedial and dorsolateral prefrontal cortices, the anterior cingulate gyrus, and, to a lesser extent, the amygdala. In addition, alterations in white matter connections are suggested. CONCLUSIONS. These studies support the concept of alterations in suicidal behaviour distinct from those of comorbid disorders. We propose that a series of neurocognitive dysfunctions, some with trait-like characteristics, may facilitate the development of a suicidal crisis during stressful circumstances: (1) an altered modulation of value attribution, (2) an inadequate regulation of emotional and cognitive responses, and (3) a facilitation of acts in an emotional context. This preliminary model may represent a framework for the design of future studies on the pathophysiology, prediction and prevention of these complex human behaviours.

Structural and functional neuroimaging studies of the suicidal brain

Suicidality is a major challenge for today's health care. Evidence suggests that there are differences in cognitive functioning of suicidal patients but the knowledge about the underlying neurobiology is limited. Brain imaging offers the advantage of a non-invasive in vivo direct estimation of detailed brain structure, regional brain functioning and estimation of molecular processes in the brain. We have reviewed the literature on neuroimaging studies of the suicidal brain. This article contains studies on structural imaging such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) and functional imaging, consisting of Positron Emission Tomography (PET), Single Photon Emission Tomography (SPECT) and functional MRI (fMRI). We classified the results of the different imaging modalities in structural and functional imaging. Within our research, we found no significant differences in the suicidal brain demonstrated by Computed Tomography. Magnetic Resonance Imaging studies in subjects with a history of suicide attempt on the other hand deliver differing results, mostly pointing at a higher prevalence of white (especially deep white matter and periventricular) and grey matter hyperintensities in the frontal, temporal and/or parietal lobe and decreased volumes in the frontal and temporal lobe. There seems to be a trend towards findings of reduced grey matter volume in the frontal lobe. Overall, there is no consensus of opinion on structural imaging of the suicidal brain. Research on functional imaging is further divided into studies in resting state, studies in activation conditions and studies on brain neurotransmitters, transporters and receptors. A common finding in functional neuroimaging in resting conditions is a decreased perfusion in the prefrontal cortex of suicidal patients. During cognitive activation, perfusion deficits in the prefrontal cortex have been observed. After fenfluramine challenge, the prefrontal cortex metabolism seems to be inversely correlated to the lethality of previous suicide attempt. The few studies that examined the serotonin transporter in suicide found no significant differences in binding potential. In suicide attempters there seems to be a negative correlation between impulsivity and SERT binding. Our group found a reduced 5-HT(2A) binding in the frontal cortex in patients with a recent suicide attempt. The binding index was significantly lower in the deliberate self injury patients compared to the deliberate self poisoning patients. The few authors that examined DAT binding in suicide found no significant DAT differences between patients and controls. However they demonstrated significant negative correlations between DAT binding potential and mental energy among suicide attempters, but not in healthy control subjects. We did not find studies measuring the binding potential of the noradrenalin or gamma amino butyric acid transporter or receptor in suicidal subjects. Several reports have suggested abnormalities of GABA neurotransmission in depression. During our literature search, we have focused on neuroimaging studies in suicidal populations, but in the absence of evidence in the literature on this group or when further collateral evidence is appropriate, this overview expands to results in impulsive aggressive or in depressed subjects.