1
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Porwal MH, Razzak AN, Kumar V, Obeidat AZ, Sharma U. An analysis of suicidal and self-injurious behavior reports with antiseizure medications in the FDA adverse event database. Epilepsy Res 2024; 203:107382. [PMID: 38761467 DOI: 10.1016/j.eplepsyres.2024.107382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Pharmacovigilance systems such as the FDA Adverse Event Reporting System (FAERS), are established models for adverse event surveillance that may have been missed during clinical trials. We aimed to analyze twenty-five anti-seizure medications (ASMs) in FAERS to assess for increased reporting of suicidal and self-injurious behavior. METHODS Twenty-five ASMs were analyzed: brivaracetam, cannabidiol, carbamazepine, clobazam, clonazepam, diazepam, eslicarbazepine, felbamate, gabapentin, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, perampanel, phenobarbital, phenytoin, pregabalin, primidone, rufinamide, stiripentol, tiagabine, topiramate, valproate, vigabatrin, zonisamide. Reports of "suicidal and self-injurious behavior" were collected from January 1, 2004, to December 31, 2020, using OpenVigil 2.1 tool with indication as "Epilepsy". Relative reporting ratio, proportional reporting ratio, and reporting odds ratio were calculated utilizing all other drug reports for epilepsy patients as a control. RESULTS Significant relative operating ratio, ROR (greater than 1, p<0.05) were observed for diazepam (2.909), pregabalin (2.739), brivaracetam (2.462), gabapentin (2.185), clonazepam (1.649), zonisamide (1.462), lacosamide (1.333), and levetiracetam (1.286). CONCLUSIONS Of the 25 ASMs that were analyzed in this study, 4 (16%) were identified to have been linked with a likely true adverse event. These drugs included diazepam, brivaracetam, gabapenetin, and pregabalin. Although several limitations are present with the FAERS database, it is imperative to closely monitor patient comorbidities for increased risk of suicidality with the use of several ASMs.
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Affiliation(s)
- Mokshal H Porwal
- Department of Neurosurgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA; Department of Neurology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Abrahim N Razzak
- Department of Neurology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
| | - Vinay Kumar
- Department of Neurology, Temple University, 1801 N Broad St., Philadelphia, PA 19122, USA
| | - Ahmed Z Obeidat
- Department of Neurology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Umesh Sharma
- Department of Neurology, University of Central Florida, 4000 Central Florida Blvd, Orlando, FL 32816, USA
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Kanner AM, Shankar R, Margraf NG, Schmitz B, Ben-Menachem E, Sander JW. Mood disorders in adults with epilepsy: a review of unrecognized facts and common misconceptions. Ann Gen Psychiatry 2024; 23:11. [PMID: 38433207 PMCID: PMC10910742 DOI: 10.1186/s12991-024-00493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/03/2024] [Indexed: 03/05/2024] Open
Abstract
Epilepsy is one of the most common neurologic conditions. Its clinical manifestations are not restricted to seizures but often include cognitive disturbances and psychiatric disorders. Prospective population-based studies have shown that people with epilepsy have an increased risk of developing mood disorders, and people with a primary mood disorder have an increased risk of developing epilepsy. The existence of common pathogenic mechanisms in epilepsy and mood disorders may explain the bidirectional relation between these two conditions. Recognition of a personal and family psychiatric history at the time of evaluation of people for a seizure disorder is critical in the selection of antiseizure medications: those with mood-stabilizing properties (e.g., lamotrigine, oxcarbazepine) should be favoured as a first option in those with a positive history while those with negative psychotropic properties (e.g., levetiracetam, topiramate) avoided. While mood disorders may be clinically identical in people with epilepsy, they often present with atypical manifestations that do not meet ICD or DSM diagnostic criteria. Failure to treat mood disorders in epilepsy may have a negative impact, increasing suicide risk and iatrogenic effects of antiseizure medications and worsening quality of life. Treating mood disorders in epilepsy is identical to those with primary mood disorders. Yet, there is a common misconception that antidepressants have proconvulsant properties. Most antidepressants are safe when prescribed at therapeutic doses. The incidence of seizures is lower in people randomized to antidepressants than placebo in multicenter randomized placebo-controlled trials of people treated for a primary mood disorder. Thus, there is no excuse not to prescribe antidepressant medications to people with epilepsy.
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Affiliation(s)
- Andres M Kanner
- Epilepsy Division and Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW, 14th Street, Room 1324, Miami, FL, 33136, USA.
| | - Rohit Shankar
- University of Plymouth Peninsula School of Medicine, Truro, UK
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | - Nils G Margraf
- Department of Neurology, Christian-Albrechts University of Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Bettina Schmitz
- Department of Neurology, Vivantes Humboldt-Klinikum, Berlin, Germany
| | - Elinor Ben-Menachem
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, 2103SW, The Netherlands
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
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3
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Boileau C, Deforges S, Peret A, Scavarda D, Bartolomei F, Giles A, Partouche N, Gautron J, Viotti J, Janowitz H, Penchet G, Marchal C, Lagarde S, Trebuchon A, Villeneuve N, Rumi J, Marissal T, Khazipov R, Khalilov I, Martineau F, Maréchal M, Lepine A, Milh M, Figarella-Branger D, Dougy E, Tong S, Appay R, Baudouin S, Mercer A, Smith JB, Danos O, Porter R, Mulle C, Crépel V. GluK2 Is a Target for Gene Therapy in Drug-Resistant Temporal Lobe Epilepsy. Ann Neurol 2023; 94:745-761. [PMID: 37341588 DOI: 10.1002/ana.26723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Temporal lobe epilepsy (TLE) is characterized by recurrent seizures generated in the limbic system, particularly in the hippocampus. In TLE, recurrent mossy fiber sprouting from dentate gyrus granule cells (DGCs) crea an aberrant epileptogenic network between DGCs which operates via ectopically expressed GluK2/GluK5-containing kainate receptors (KARs). TLE patients are often resistant to anti-seizure medications and suffer significant comorbidities; hence, there is an urgent need for novel therapies. Previously, we have shown that GluK2 knockout mice are protected from seizures. This study aims at providing evidence that downregulating KARs in the hippocampus using gene therapy reduces chronic epileptic discharges in TLE. METHODS We combined molecular biology and electrophysiology in rodent models of TLE and in hippocampal slices surgically resected from patients with drug-resistant TLE. RESULTS Here, we confirmed the translational potential of KAR suppression using a non-selective KAR antagonist that markedly attenuated interictal-like epileptiform discharges (IEDs) in TLE patient-derived hippocampal slices. An adeno-associated virus (AAV) serotype-9 vector expressing anti-grik2 miRNA was engineered to specifically downregulate GluK2 expression. Direct delivery of AAV9-anti grik2 miRNA into the hippocampus of TLE mice led to a marked reduction in seizure activity. Transduction of TLE patient hippocampal slices reduced levels of GluK2 protein and, most importantly, significantly reduced IEDs. INTERPRETATION Our gene silencing strategy to knock down aberrant GluK2 expression demonstrates inhibition of chronic seizure in a mouse TLE model and IEDs in cultured slices derived from TLE patients. These results provide proof-of-concept for a gene therapy approach targeting GluK2 KARs for drug-resistant TLE patients. ANN NEUROL 2023;94:745-761.
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Affiliation(s)
| | - Severine Deforges
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | - Didier Scavarda
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Pediatric Neurosurgery, Marseille, France
| | - Fabrice Bartolomei
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | | | - Nicolas Partouche
- Aix-Marseille Univ. INSERM, Marseille, France
- Corlieve Therapeutics SAS, uniQure NV, Paris, France
| | - Justine Gautron
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
- Corlieve Therapeutics SAS, uniQure NV, Paris, France
| | - Julio Viotti
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | | | - Cécile Marchal
- Pellegrin Hospital, Neurosurgery Department, Bordeaux, France
| | - Stanislas Lagarde
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Agnès Trebuchon
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Nathalie Villeneuve
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Julie Rumi
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | | | | | | | | | - Marine Maréchal
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
| | - Anne Lepine
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Mathieu Milh
- APHM, INSERM, Aix Marseille Univ, INS, Timone Hospital, Epileptology Department, Marseille, France
| | - Dominique Figarella-Branger
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Etienne Dougy
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Soutsakhone Tong
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | - Romain Appay
- APHM, CNRS, INP, Inst Neurophysiopathol, CHU Timone, Service d'Anatomie Pathologique et de Neuropathologie, Aix-Marseille Univ, Marseille, France
| | | | | | | | | | | | - Christophe Mulle
- Univ. Bordeaux, CNRS, Interdisciplinary Institute for Neuroscience IINS, UMR 5297, Bordeaux, France
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Pisani F, Pisani LR, Barbieri MA, de Leon J, Spina E. Optimization of Therapy in Patients with Epilepsy and Psychiatric Comorbidities: Key Points. Curr Neuropharmacol 2023; 21:1755-1766. [PMID: 35619263 PMCID: PMC10514544 DOI: 10.2174/1570159x20666220526144314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/24/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
Psychiatric disorder comorbidity in patients with epilepsy (PWE) is very frequent with a mean percentage prevalence of up to 50% and even higher. Such a high frequency suggests that epilepsy and psychiatric disorders might share common pathological pathways. Various aspects contribute in making the matter very complex from a therapeutic point of view. Some antiseizure medications (ASMs), namely valproic acid, carbamazepine, and lamotrigine, have mood-stabilising effects and are routinely used for the treatment of bipolar disorder in patients who do not have epilepsy. Pregabalin and, to a lesser extent, gabapentin, exerts anxiolytic effects. However, several ASMs, in particular levetiracetam, topiramate, and perampanel, may contribute to psychiatric disorders, including depression, aggressive behaviour, and even psychosis. If these ASMs are prescribed, the patient should be monitored closely. A careful selection should be made also with psychotropic drugs. Although most of these can be safely used at therapeutic doses, bupropion, some tricyclic antidepressants, maprotiline, and clozapine may alter seizure threshold and facilitate epileptic seizures. Interactions between ASMs and psychotropic medication may make it difficult to predict individual response. Pharmacokinetic interactions can be assessed with drug monitoring and are consequently much better documented than pharmacodynamic interactions. Another aspect that needs a careful evaluation is patient adherence to treatment. Prevalence of non-adherence in PWE and psychiatric comorbidities is reported to reach values even higher than 70%. A careful evaluation of all these aspects contributes in optimizing therapy with a positive impact on seizure control, psychiatric wellbeing, and quality of life.
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Affiliation(s)
- Francesco Pisani
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | | | | | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA and Psychiatry and Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Italy
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Feyissa AM, Cascino GD. The Argument for a More Patient Attitude Toward a Single Unprovoked Seizure: Wait for It? Mayo Clin Proc 2023; 98:23-30. [PMID: 36464538 DOI: 10.1016/j.mayocp.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/02/2022] [Accepted: 10/10/2022] [Indexed: 12/05/2022]
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Kanner AM. Suicidality in Patients With Epilepsy: Why Should Neurologists Care? Front Integr Neurosci 2022; 16:898547. [PMID: 35712347 PMCID: PMC9196893 DOI: 10.3389/fnint.2022.898547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Adachi N, Ito M. Epilepsy in patients with schizophrenia: Pathophysiology and basic treatments. Epilepsy Behav 2022; 127:108520. [PMID: 34999502 DOI: 10.1016/j.yebeh.2021.108520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/18/2021] [Accepted: 12/19/2021] [Indexed: 11/03/2022]
Abstract
Schizophrenia is a chronic psychiatric disorder that may lead to epilepsy. However, there are limited findings on the issues. This narrative review aimed to provide a practical perspective on epilepsy in patients with schizophrenia using the current treatment systems for epilepsy. While there has been a debate on the relationship between epilepsy and schizophrenia, i.e., antagonism, affinity, and coincidence, recent large cohort studies have revealed a high frequency of epilepsy in patients with schizophrenia (4-5 times higher than that of general population). The high incidence observed is likely to be due to the bidirectionality between epilepsy and schizophrenia and additional schizophrenia-related conditions, e.g., antipsychotic drugs (APD), substance abuse, and head injury. As for symptomatology of epilepsy, only one small-size study showed that seizures of patients with schizophrenia are equivalent to those of patients without schizophrenia. Patients with schizophrenia exhibit the first seizure in their twenties or later, which are mostly focal seizures. Most of seizures in patients with schizophrenia can be controlled with conventional antiepileptic drugs. Few patients with schizophrenia develop treatment-resistant epilepsy. However, since drug interactions can be more complicated due to multiple conditions, such as pre-existing polypharmacy, heavy smoking, irregular eating, and comorbid metabolic disorders, cautious monitoring for clinical symptoms is required. To improve seizure control and adherence, non-pharmacological approaches are also recommended. Thus far, for seizure treatments in patients with schizophrenia, we have to use many empirical findings or substitute certain findings from population without schizophrenia because evidence is insufficient. The accumulation of clinical findings may contribute to the development of efficient treatment systems.
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Affiliation(s)
- Naoto Adachi
- Adachi Mental Clinic, Sapporo, Japan; Jozen Clinic, Sapporo, Japan.
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8
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Guo Y, Xu ZYR, Cai MT, Gong WX, Shen CH. Epilepsy With Suicide: A Bibliometrics Study and Visualization Analysis via CiteSpace. Front Neurol 2022; 12:823474. [PMID: 35111131 PMCID: PMC8802777 DOI: 10.3389/fneur.2021.823474] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 12/22/2021] [Indexed: 01/09/2023] Open
Abstract
Objective:The purpose of this study was to analyze the research status of epilepsy with suicide and to determine the hotspots and frontiers via CiteSpace.Method:We searched the Web of Science Core Collection (WoSCC) for studies related to epilepsy and suicide from inception to September 30, 2021. We used CiteSpace to generate online maps of collaboration between countries, institutions, and authors, and revealed hot spots and frontiers in epilepsy with suicide.Results:A total of 631 publications related to epilepsy with suicide were retrieved from the WoSCC. Andres M. Kanner was the most published author (25 papers). The USA and Columbia University were the leading country and institution in this field, with 275 and 25 papers, respectively. There were active cooperation between institutions, countries, and authors. Hot topics focused on depression, antiseizure medications, pediatric epilepsy, and risk factors of suicide in patients with epilepsy (PWEs).Conclusions:Based on the CiteSpace findings, this study detected active collaboration among countries, institutions and authors. The main current research trends include suicide caused by depression, suicide caused by the use of antiseizure medications, suicide in children with epilepsy, and risk factors for suicide in PWEs. Thus, more attention should be paid to the psychiatric comorbidity of PWEs (especially pediatric epilepsy), the suicidal tendency of PWEs, and the rational use of antiseizure medications in the future.
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Affiliation(s)
- Yi Guo
- Department of General Practice and International Medicine, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
- Department of Neurology, Epilepsy Center, School of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Yi Guo
| | - Zheng-Yan-Ran Xu
- Department of Neurology, Epilepsy Center, School of Medicine, Zhejiang University, Hangzhou, China
| | - Meng-Ting Cai
- Department of Neurology, Epilepsy Center, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wen-Xin Gong
- Department of General Practice and International Medicine, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chun-Hong Shen
- Department of Neurology, Epilepsy Center, School of Medicine, Zhejiang University, Hangzhou, China
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Bornovski Y, Jackson-Shaheed E, Argraves S, Hitchins A, Tolchin B, Galluzzo D, Cheung KH, Goulet J, Skanderson M, Brandt CA, Pugh MJ, Altalib H. Suicide and Seizures: A National Cohort Study in Veterans. Neurol Clin Pract 2021; 11:372-376. [PMID: 34840864 DOI: 10.1212/cpj.0000000000001070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/18/2021] [Indexed: 11/15/2022]
Abstract
Objective The increased rate of suicide associated with epilepsy has been described, but no studies have reported the rates of suicide and suicide-related behavior (SRB) associated with psychogenic nonepileptic seizures (PNESs). Methods This retrospective cohort study analyzed data from October 2002 to October 2017 within Veterans Health Administration services. Of 801,734 veterans, 0.09% had PNES, 1.37% had epilepsy, and 98.5% had no documented seizures. Veterans coded for completed suicide, suicide attempts, and suicidal ideation were identified from electronic health records. The primary measure was the suicide-specific standardized mortality ratio (SMR) based on the number of suicide deaths and CDC national suicide mortality database. A Poisson regression was used to calculate the relative risk (RR) of suicide across groups. Results A total of 1,870 veterans (mean age [SD] 33.76 [7.81] years) completed suicide. Veterans with PNES (RR = 1.75, 95% confidence interval [CI] 0.84-4.24) and veterans with epilepsy (RR = 2.19, 95% CI 2.10-2.28) had a higher risk of suicide compared with the general veteran population. Veterans with PNES or epilepsy had a higher risk of suicide and SRB if they had comorbid alcohol abuse, illicit drug abuse, major depression, posttraumatic stress disorder, and use of psychotropic medications. Conversely, those who were married or attained higher education were at a decreased risk. The SMR for completed suicide for PNES, epilepsy, and the comparison group was 2.65 (95% CI 1.95-5.52), 2.04 (95% CI 1.60-2.55), and 0.70 (95% CI 0.67-0.74), respectively. Conclusions Veterans with seizures (both psychogenic and epileptic) are at a greater risk of death by suicide and SRB than the comparison group. These findings suggest that although the pathophysiology of PNES and epilepsy is different, the negative impact of seizures is evident in the psychosocial outcomes in both groups.
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Affiliation(s)
- Yarden Bornovski
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Ebony Jackson-Shaheed
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Stephanie Argraves
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Adrianna Hitchins
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Benjamin Tolchin
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Daniela Galluzzo
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Kei-Hoi Cheung
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Joseph Goulet
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Melissa Skanderson
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Cynthia A Brandt
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Mary Jo Pugh
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
| | - Hamada Altalib
- Department of Neurology (YB, EJ-S, SA, BT, HA), Yale School of Medicine, New Haven, CT; University of Rochester Medical Center (AH); Westchester Medical Center (DG), NY; Connecticut VA Healthcare System (K-HC, JG, MS, CAB), West Haven; Department of Emergency Medicine (K-HC, JG, CAB), Yale School of Medicine, New Haven; and VA Salt Lake City Healthcare System (MJP), University of Utah
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10
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Edward F. Suicidality: Once Again, Don’t Blame the Drug Class. Epilepsy Curr 2021. [PMCID: PMC8832346 DOI: 10.1177/15357597211053193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Importance Mostantiseizure medications (ASMs) carry a US Food and Drug Administration–mandated class label warning of increased suicidality risk, based on a meta-analysis comparing suicidality between individuals treated with medications vs placebo in randomized clinical trials done before 2008. ASMs approved since then carry this warning although they were not similarly studied. Objective To review all placebo-controlled phase 2 and 3 studies of 10 ASMs approved since 2008 to evaluate the risk of suicidality of these drugs compared with placebo. Data Sources Primary publications and secondary safety analyses in PubMed of all phase 2 and 3 randomized placebo-controlled epilepsy trials of ASMs approved since 2008, using keywords epilepsy, antiepileptic drugs, seizures, suicidality, suicidal ideation, and the names of individual drugs. Study Selection All phase 2 and 3 randomized clinical trials of adjunctive treatment of drug-resistant epilepsy and their secondary safety analyses. Data Extraction and Synthesis Articles were reviewed for frequency of suicidality (ideation, attempts, and completed suicides). Mode of suicidality ascertainment included treatment-emergent adverse event reports, Standardized Medical Dictionary for Regulatory Activities queries for events in prespecified categories including suicidal ideation and behavior, prospective collection of suicidality data as a prespecified safety outcome using the Columbia-Suicide Severity Rating Scale, and retrospective evaluation by blinded review using the Columbia-Classification Algorithm of Suicide Assessment. A meta-analysis compared risk for drugs vs placebo of each outcome for all drugs overall and by individual drugs and trials. Main Outcomes and Measures Suicidality (total and by ideation), attempts, and completed suicides. Results Excluding studies that did not evaluate suicidality (everolimus and fenfluramine) or did not evaluate it prospectively (lacosamide, ezogabine, and clobazam), 5 drugs were analyzed: eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Suicidality was evaluated in 17 randomized clinical trials of these drugs, involving 5996 patients, of whom 4000 patients were treated with ASMs and 1996 with placebo. There was no evidence of increased risk of suicidal ideation (drugs vs placebo overall risk ratio, .75; 95% CI, .35–1.60) or attempt (risk ratio, .75; 95% CI, .30–1.87) overall or for any individual drug. Suicidal ideation occurred in 12 of 4000 patients treated with ASMs (.30%) vs 7 of 1996 patients treated with placebo (.35%) ( P = .74). Three patients treated with ASMs and no patients treated with placebo attempted suicide ( P = .22). There were no completed suicides. Conclusions and Relevance There is no current evidence that the 5 ASMs evaluated in this study increase suicidality in epilepsy and merit a suicidality class warning
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Kløvgaard M, Lynge TH, Tsiropoulos I, Uldall PV, Banner J, Winkel BG, Ryvlin P, Tfelt-Hansen J, Sabers A. Sudden unexpected death in epilepsy in persons younger than 50 years: A retrospective nationwide cohort study in Denmark. Epilepsia 2021; 62:2405-2415. [PMID: 34418071 DOI: 10.1111/epi.17037] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Persons with epilepsy have an increased mortality including a high risk of sudden unexplained death (SUD), also referred to as sudden unexpected death in epilepsy (SUDEP). We aimed to evaluate the risk of SUDEP in comparison to other causes of death and the risk of SUD in persons with and without epilepsy. METHODS We undertook a retrospective population-based cohort study of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. All deaths in the population were evaluated, and all cases of SUD identified. Primary causes of death in persons with epilepsy were evaluated independently by three neurologists and one neuropediatrician, using the unified SUDEP criteria. RESULTS The three most frequent causes of death in persons with epilepsy were cancer (2.38 per 1000 person-years), SUDEP (1.65 per 1000 person-years), and pneumonia (1.09 per 1000 person-years) compared with cancer (.17 per 1000 person-years), accident-related deaths (.14 per 1000 person-years), and cardiovascular disease (.09 per 1000 person-years) in persons without epilepsy. Considering definite, definite plus, and probable cases, the SUDEP incidence was .27 per 1000 person-years (95% confidence interval [CI] = .11-.64) in children aged 1-17 years and 1.21 per 1000 person-years (95% CI = .96-1.51) in adults aged 18-49 years. Adjusted for age and sex, persons with epilepsy younger than 50 years had a 10.8-fold (95% CI = 9.97-11.64, p < .0001) increased all-cause mortality and a 34.4-fold (95% CI = 23.57-50.28, p < .0001) increased risk of SUD compared with persons without epilepsy. SUDEP accounted for 23.3% of all SUD. SIGNIFICANCE This nationwide study of all deaths in persons with epilepsy younger than 50 years found a lower SUDEP risk in children compared with adults, and that epilepsy was a major risk factor for SUD in the background population. This underlines the importance of addressing risk factors for SUDEP to prevent premature death.
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Affiliation(s)
- Marius Kløvgaard
- Department of Neurology, Epilepsy Clinic, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Thomas H Lynge
- Department of Cardiology, Heart Center, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Ioannis Tsiropoulos
- Department of Neurology, Epilepsy Clinic, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Peter V Uldall
- Department of Pediatrics, Neuropediatric Clinic, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark.,Danish Epilepsy Center, Dianalund, Denmark
| | - Jytte Banner
- Section of Forensic Pathology, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo G Winkel
- Department of Cardiology, Heart Center, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Heart Center, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark.,Section of Forensic Pathology, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Sabers
- Department of Neurology, Epilepsy Clinic, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark
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Klein P, Devinsky O, French J, Harden C, Krauss GL, McCarter R, Sperling MR. Suicidality Risk of Newer Antiseizure Medications: A Meta-analysis. JAMA Neurol 2021; 78:1118-1127. [PMID: 34338718 DOI: 10.1001/jamaneurol.2021.2480] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Most antiseizure medications (ASMs) carry a US Food and Drug Administration-mandated class label warning of increased suicidality risk, based on a meta-analysis comparing suicidality between individuals treated with medications vs placebo in randomized clinical trials done before 2008. ASMs approved since then carry this warning although they were not similarly studied. Objective To review all placebo-controlled phase 2 and 3 studies of 10 ASMs approved since 2008 to evaluate the risk of suicidality of these drugs compared with placebo. Data Sources Primary publications and secondary safety analyses in PubMed of all phase 2 and 3 randomized placebo-controlled epilepsy trials of ASMs approved since 2008, using keywords epilepsy, antiepileptic drugs, seizures, suicidality, suicidal ideation, and the names of individual drugs. Study Selection All phase 2 and 3 randomized clinical trials of adjunctive treatment of drug-resistant epilepsy and their secondary safety analyses. Data Extraction and Synthesis Articles were reviewed for frequency of suicidality (ideation, attempts, and completed suicides). Mode of suicidality ascertainment included treatment-emergent adverse event reports, Standardized Medical Dictionary for Regulatory Activities queries for events in prespecified categories including suicidal ideation and behavior, prospective collection of suicidality data as a prespecified safety outcome using the Columbia-Suicide Severity Rating Scale, and retrospective evaluation by blinded review using the Columbia-Classification Algorithm of Suicide Assessment. A meta-analysis compared risk for drugs vs placebo of each outcome for all drugs overall and by individual drugs and trials. Main Outcomes and Measures Suicidality (total and by ideation), attempts, and completed suicides. Results Excluding studies that did not evaluate suicidality (everolimus and fenfluramine) or did not evaluate it prospectively (lacosamide, ezogabine, and clobazam), 5 drugs were analyzed: eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Suicidality was evaluated in 17 randomized clinical trials of these drugs, involving 5996 patients, of whom 4000 patients were treated with ASMs and 1996 with placebo. There was no evidence of increased risk of suicidal ideation (drugs vs placebo overall risk ratio, 0.75; 95% CI, 0.35-1.60) or attempt (risk ratio, 0.75; 95% CI, 0.30-1.87) overall or for any individual drug. Suicidal ideation occurred in 12 of 4000 patients treated with ASMs (0.30%) vs 7 of 1996 patients treated with placebo (0.35%) (P = .74). Three patients treated with ASMs and no patients treated with placebo attempted suicide (P = .22). There were no completed suicides. Conclusions and Relevance There is no current evidence that the 5 ASMs evaluated in this study increase suicidality in epilepsy and merit a suicidality class warning.
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Affiliation(s)
- Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, Maryland
| | - Orrin Devinsky
- NYU Langone School of Medicine, Department of Neurology, New York, New York
| | - Jacqueline French
- NYU Langone School of Medicine, Department of Neurology, New York, New York
| | - Cynthia Harden
- Xenon Pharmaceuticals, Burnaby, British Columbia, Canada
| | - Gregory L Krauss
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, Maryland
| | - Robert McCarter
- Children's National Medical Center, Bioinformatics, Washington, DC
| | - Michael R Sperling
- Thomas Jefferson University, Department of Neurology, Philadelphia, Pennsylvania
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Jia G, Wang X, Lv H, Nonyane MSC, Hou H, Ma L, Shan P, Wu X. The efficacy and safety of antiepileptics in the prophylaxis of pediatric migraine: the meta-analysis of randomized controlled trials. Transl Pediatr 2021; 10:1779-1791. [PMID: 34430426 PMCID: PMC8349954 DOI: 10.21037/tp-20-478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Migraine is the most common primary headache among children and adolescents. The aim of this meta-analysis was to evaluate the efficacy and safety of antiepileptic drugs in the prevention of pediatric migraine. METHODS PubMed, Cochrane Library, EMBASE and Chinese National Knowledge Infrastructure (CNKI) databases were searched for eligible published RCTs from January 1970 to June 2020. Migraine frequency and ≥50% response rate were measured as the efficacy outcomes. We used "Risk of Bias" tool for quality assessment and RevMan5.3 software for statistical analysis. RESULTS Four articles containing 7 RCTs with 794 participants compared the efficacy of AEDs with placebo. Four RCTs assessed topiramate vs. placebo and 3 RCTs evaluated divalproex sodium extended-release (DVPX ER) vs. placebo. The results demonstrated that children receiving antiepileptic drugs had a significant advantage in remitting the mean monthly migraine days compared to those who received placebo, with an MD of -0.48 (n=930, 95% CI: -0.84 to -0.12, Z=2.60, P=0.009). Topiramate significantly reduced monthly migraine days (MD =-0.70, n=489, 95% CI: -1.16 to -0.25, Z=3.01, P=0.003) but failed to improve the ≥50% response rate (MD =-1.50, n=489, 95% CI: 0.70 to 3.22, Z=1.05, P=0.30). DVPX ER did not significantly reduce monthly headache frequency (n=441, 95% CI: -0.70 to 0.47, Z=0.38, P=0.70) or improve the ≥50% response rate (n=441, 95% CI: 0.59 to 1.25, Z=0.82, P=0.41) compared with placebo. Topiramate and DVPX ER were related to higher rates of side effects and adverse reactions. DISCUSSION Topiramate can reduce monthly headache days in children and adolescents with migraine. However, it failed to improve the ≥50% response rate. DVPX ER showed no difference from placebo in the prophylactic treatment pediatric migraine. Side effects seemed to be more frequent in topiramate and DVPX ER treated children but generally well-tolerated.
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Affiliation(s)
- Guoyong Jia
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xingbang Wang
- Department of Geriatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hongbo Lv
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Haiguang Hou
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | - Lin Ma
- Department of Geriatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peiyan Shan
- Department of Geriatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xinwei Wu
- Department of Geriatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Zhao Y, Liu X, Xiao Z. Effects of perceived stigma, unemployment and depression on suicidal risk in people with epilepsy. Seizure 2021; 91:34-39. [PMID: 34077877 DOI: 10.1016/j.seizure.2021.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/18/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Stigma toward people with epilepsy (PWE) is common around the globe. Perceived stigma produced by mental or physical disorders may represent a significant risk factor for suicide.This study examines whether and how perceived stigma, unemployment and depression interact to influence suicidal risk in PWE. METHODS A consecutive cohort of people with epilepsy (PWE) was recruited from the First Affiliated Hospital of Chongqing Medical University. Each patient completed the Stigma Scale for Epilepsy (SSE), the Neurological Disorders Depression Inventory for Epilepsy scale (NDDI-E) and the suicidality module of Mini-International Neuropsychiatric Interview(MINI) v.5.0.0. Spearman's correlation and moderated mediation analysis were used to examine the associations among perceived stigma, depression, unemployment and suicidal risk. RESULTS Perceived stigma was positively associated with depression severity and suicidal risk. Depression severity mediated the association between perceived stigma and suicidal risk. The indirect effect of perceived stigma on suicidal risk through depression severity was positively moderated by unemployment. CONCLUSIONS The effect of perceived stigma on suicidal risk can be explained by the mediation of depression severity, At the same time, getting out from the shadow of perceived stigma may help reducing suicidal risk in PWE. In addition, improving employment status of PWE may attenuate the indirect effect of perceived stigma on suicidal risk through depression severity.
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Affiliation(s)
- Yuping Zhao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xing Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Neurology, The Fourth People's Hospital of Zigong, Sichuan, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Abstract
BACKGROUND Depressive disorders are the most common psychiatric comorbidity in people with epilepsy, affecting around one-third, with a significant negative impact on quality of life. There is concern that people may not be receiving appropriate treatment for their depression because of uncertainty regarding which antidepressant or class works best, and the perceived risk of exacerbating seizures. This review aimed to address these issues, and inform clinical practice and future research. This is an updated version of the original Cochrane Review published in Issue 12, 2014. OBJECTIVES To evaluate the efficacy and safety of antidepressants in treating depressive symptoms and the effect on seizure recurrence, in people with epilepsy and depression. SEARCH METHODS For this update, we searched CRS Web, MEDLINE, SCOPUS, PsycINFO, and ClinicalTrials.gov (February 2021). We searched the World Health Organization Clinical Trials Registry in October 2019, but were unable to update it because it was inaccessible. There were no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) and prospective non-randomised studies of interventions (NRSIs), investigating children or adults with epilepsy, who were treated with an antidepressant and compared to placebo, comparative antidepressant, psychotherapy, or no treatment for depressive symptoms. DATA COLLECTION AND ANALYSIS: The primary outcomes were changes in depression scores (proportion with a greater than 50% improvement, mean difference, and proportion who achieved complete remission) and change in seizure frequency (mean difference, proportion with a seizure recurrence, or episode of status epilepticus). Secondary outcomes included the number of participants who withdrew from the study and reasons for withdrawal, quality of life, cognitive functioning, and adverse events. Two review authors independently extracted data for each included study. We then cross-checked the data extraction. We assessed risk of bias using the Cochrane tool for RCTs, and the ROBINS-I for NRSIs. We presented binary outcomes as risk ratios (RRs) with 95% confidence intervals (CIs) or 99% CIs for specific adverse events. We presented continuous outcomes as standardised mean differences (SMDs) with 95% CIs, and mean differences (MDs) with 95% CIs. MAIN RESULTS: We included 10 studies in the review (four RCTs and six NRSIs), with 626 participants with epilepsy and depression, examining the effects of antidepressants. One RCT was a multi-centre study comparing an antidepressant with cognitive behavioural therapy (CBT). The other three RCTs were single-centre studies comparing an antidepressant with an active control, placebo, or no treatment. The NRSIs reported on outcomes mainly in participants with focal epilepsy before and after treatment for depression with a selective serotonin reuptake inhibitor (SSRI); one NRSI compared SSRIs to CBT. We rated one RCT at low risk of bias, three RCTs at unclear risk of bias, and all six NRSIs at serious risk of bias. We were unable to conduct any meta-analysis of RCT data due to heterogeneity of treatment comparisons. We judged the certainty of evidence to be moderate to very low across comparisons, because single studies contributed limited outcome data, and because of risk of bias, particularly for NRSIs, which did not adjust for confounding variables. More than 50% improvement in depressive symptoms ranged from 43% to 82% in RCTs, and from 24% to 97% in NRSIs, depending on the antidepressant given. Venlafaxine improved depressive symptoms by more than 50% compared to no treatment (mean difference (MD) -7.59 (95% confidence interval (CI) -11.52 to -3.66; 1 study, 64 participants; low-certainty evidence); the results between other comparisons were inconclusive. Two studies comparing SSRIs to CBT reported inconclusive results for the proportion of participants who achieved complete remission of depressive symptoms. Seizure frequency data did not suggest an increased risk of seizures with antidepressants compared to control treatments or baseline. Two studies measured quality of life; antidepressants did not appear to improve quality of life over control. No studies reported on cognitive functioning. Two RCTs and one NRSI reported comparative data on adverse events; antidepressants did not appear to increase the severity or number of adverse events compared to controls. The NSRIs reported higher rates of withdrawals due to adverse events than lack of efficacy. Reported adverse events for antidepressants included nausea, dizziness, sedation, headache, gastrointestinal disturbance, insomnia, and sexual dysfunction. AUTHORS' CONCLUSIONS: Existing evidence on the effectiveness of antidepressants in treating depressive symptoms associated with epilepsy is still very limited. Rates of response to antidepressants were highly variable. There is low certainty evidence from one small RCT (64 participants) that venlafaxine may improve depressive symptoms more than no treatment; this evidence is limited to treatment between 8 and 16 weeks, and does not inform longer-term effects. Moderate to low evidence suggests neither an increase nor exacerbation of seizures with SSRIs. There are no available comparative data to inform the choice of antidepressant drug or classes of drug for efficacy or safety for treating people with epilepsy and depression. RCTs of antidepressants utilising interventions from other treatment classes besides SSRIs, in large samples of patients with epilepsy and depression, are needed to better inform treatment policy. Future studies should assess interventions across a longer treatment duration to account for delayed onset of action, sustainability of treatment responses, and to provide a better understanding of the impact on seizure control.
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Affiliation(s)
| | - Anthony G Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Singh T, Goel RK. Epilepsy Associated Depression: An Update on Current Scenario, Suggested Mechanisms, and Opportunities. Neurochem Res 2021; 46:1305-1321. [PMID: 33665775 DOI: 10.1007/s11064-021-03274-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/21/2022]
Abstract
Depression is one of the most frequent psychiatric comorbidities associated with epilepsy having a major impact on the patient's quality of life. Several screening tools are available to identify and follow up psychiatric disorders in epilepsy. Out of various psychiatric disorders, people with epilepsy (PWE) are at greater risk of developing depression. This bidirectional relationship further hinders pharmacotherapy of comorbid depression in PWE as some antiepileptic drugs (AEDs) worsen associated depression and coadministration of existing antidepressants (ADs) to alleviate comorbid depression has been reported to worsen seizures. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) are first choice of ADs and are considered safe in PWE, but there are no high-quality evidences. Similar to observations in people with depression, PWE also showed pharmacoresistant to available SSRI/SNRIs, which further complicates the disease prognosis. Randomized double-blind placebo-controlled clinical trials are necessary to report efficacy and safety of available ADs in PWE. We should also move beyond ADs, and therefore, we reviewed common pathological mechanisms such as neuroinflammation, dysregulated hypothalamus pituitary adrenal (HPA) axis, altered neurogenesis, and altered tryptophan metabolism responsible for coexistent relationship of epilepsy and depression. Based on these common pertinent pathways involved in the genesis of epilepsy and depression, we suggested novel targets and therapeutic approaches for safe management of comorbid depression in epilepsy.
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Affiliation(s)
- Tanveer Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India
| | - Rajesh Kumar Goel
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, 147002, India.
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Suicidality in Epilepsy: Does It Share Common Pathogenic Mechanisms with Epilepsy? Curr Top Behav Neurosci 2021; 55:209-250. [PMID: 33683680 DOI: 10.1007/7854_2021_220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Suicidality presents a major global health concern and its association with epilepsy has been suggested. The body of evidence is growing due to targeted epidemiological studies, genetic findings, and neuroimaging data, use of specific neuropsychiatric inventories, neuropsychological tests, and metabolic and immunological studies.Suicide tendencies and psychiatric comorbidity such as depression are not uncommon in chronic diseases, especially in epilepsy. Suicide is an important cause of death in epilepsy, and is usually underestimated. Persons with epilepsy have higher risk for suicide than healthy controls. It appears that some epilepsy types have stronger tendencies for suicide, in particular temporal lobe epilepsy. The suicidal risk factors in persons with epilepsy include difficult to treat epilepsies, onset of epilepsy at an earlier age, and comorbid depression.This clinical evidence is mostly based on observational studies in which we found an increased risk of suicidal ideation, suicidal attempts, and completed suicides in persons with epilepsy. However, we lack prospective and longitudinal studies on suicide in epilepsy. In this chapter we will examine recent research in neurobiological mechanisms between suicidality and epilepsy, and comorbid depression.
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Besag FMC, Vasey MJ, Sharma AN, Lam ICH. Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan: a systematic review. Ther Adv Psychopharmacol 2021; 11:20451253211045870. [PMID: 34646439 PMCID: PMC8504232 DOI: 10.1177/20451253211045870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/25/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Bipolar disorder (BD) is a cyclic mood disorder characterised by alternating episodes of mania/hypomania and depression interspersed with euthymic periods. Lamotrigine (LTG) demonstrated some mood improvement in patients treated for epilepsy, leading to clinical studies in patients with BD and its eventual introduction as maintenance therapy for the prevention of depressive relapse in euthymic patients. Most current clinical guidelines include LTG as a recommended treatment option for the maintenance phase in adult BD, consistent with its global licencing status. AIMS To review the evidence for the efficacy and safety of LTG in the treatment of all phases of BD. METHODS PubMed was searched for double-blind, randomised, placebo-controlled trials using the keywords: LTG, Lamictal, 'bipolar disorder', 'bipolar affective disorder', 'bipolar I', 'bipolar II', cyclothymia, mania, manic, depression, depressive, 'randomised controlled trial', 'randomised trial', RCT and 'placebo-controlled' and corresponding MeSH terms. Eligible articles published in English were reviewed. RESULTS Thirteen studies were identified. The strongest evidence supports utility in the prevention of recurrence and relapse, particularly depressive relapse, in stabilised patients. Some evidence suggests efficacy in acute bipolar depression, but findings are inconsistent. There is little or no strong evidence in support of efficacy in acute mania, unipolar depression, or rapid-cycling BD. Few controlled trials have evaluated LTG in bipolar II or in paediatric patients. Indications for safety, tolerability and patient acceptability are relatively favourable, provided there is slow dose escalation to reduce the probability of skin rash. CONCLUSION On the balance of efficacy and tolerability, LTG might be considered a first-line drug for BD, except for acute manic episodes or where rapid symptom control is required. In terms of efficacy alone, however, the evidence favours other medications.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, 9 Rush Court, Bedford MK40 3JT, UK
| | | | - Aditya N Sharma
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ivan C H Lam
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Abstract
PURPOSE OF REVIEW Psychiatric comorbidities are close to 5-times higher in children and youth with epilepsy (CYE) compared to general population. With epilepsy being one of the most common neurological disorders in children, we provide a timely review of psychiatric issues in CYE. RECENT FINDINGS A meta-analysis found a pooled prevalence of anxiety in 18.9% and depression in 13.5% of CYE. Attention deficit hyperactivity disorder (ADHD) is 2.5 to 5.5 times higher in CYE compared to healthy counterparts. Recent evidence highlights that behavioral adverse effects may lead to discontinuation of anti-epileptic drugs (AEDs) in more than 10% of CYE. Up to 70% CYE shows elevation in baseline psychological symptoms after AED initiation. Identifying psychiatric symptoms can be easily accomplished by the routine use of psychiatric screening instruments in CYE clinics, which is associated with improved health-related quality of life (HRQOL). Psychoeducation is a key component for any visit with CYE. There is some evidence of the effectiveness of behavioral psychological interventions for CYE. There are no therapeutic trials of psychotropics in CYE, but treatment recommendations based on the experience in adults with epilepsy and general population are applicable. Early diagnosis and management of psychiatric comorbidities leads to improvement in HRQOL of CYE. This requires routine screening and a multidisciplinary teamwork.
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Affiliation(s)
- Anjali Dagar
- Department of Psychiatry and Epilepsy, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, P57, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Tatiana Falcone
- Department of Psychiatry and Epilepsy, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, P57, Cleveland Clinic, Cleveland, OH, 44195, USA.
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Błaszczyk B, Walczak A, Ścirka N, Konarzewska A, Miziak B, Czuczwar SJ. Pharmacological and non-pharmacological approaches to life threatening conditions in epilepsy. JOURNAL OF EPILEPTOLOGY 2020. [DOI: 10.21307/jepil-2020-002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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21
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Liu X, Chen H, Zheng X. Effects of seizure frequency, depression and generalized anxiety on suicidal tendency in people with epilepsy. Epilepsy Res 2020; 160:106265. [PMID: 31981793 DOI: 10.1016/j.eplepsyres.2020.106265] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/30/2019] [Accepted: 01/01/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The highest risk of suicide was identified among patients diagnosed with both epilepsy and comorbid psychiatric disease. The most common comorbid psychiatric conditions of epilepsy are anxiety and depression. This study examines whether and how seizure frequency, depression and generalized anxiety interact to influence suicidal tendency. METHODS A consecutive cohort of PWE was recruited from the First Affiliated Hospital of Chongqing Medical University. Each patient completed the Neurological Disorders Depression Inventory for Epilepsy scale[NDDI-E], the Generalized Anxiety Disorder-7 (GAD-7), and the suicidality module of Mini-International Neuropsychiatric Interview(MINI) v.5.0.0. Spearman's correlation and moderated mediation analysis were used to examine the associations among seizure frequency, depression, generalized anxiety and suicidal tendency. RESULTS Seizure frequency was positively associated with suicidal tendency. Depression severity partially mediated the relationship between seizure frequency and suicidal tendency. The indirect effect of seizure frequency on suicidal tendency was positive, and accounted for 50.2 % of the total effect of seizure frequency on suicidal tendency. The indirect effect of seizure frequency on suicidal tendency through depression severity was positively moderated by generalized anxiety severity. CONCLUSIONS Reducing seizure frequency may be the basis of suicide prevention in PWE. At the same time, the effect of seizure frequency on suicidal tendency can be partially explained by the mediation of depression severity, and the magnitude of the indirect effect of seizure frequency on suicidal tendency was contingent upon generalized anxiety severity. In addition to depression severity, generalized anxiety severity also exerts an important effect on suicidal tendency in PWE.
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Affiliation(s)
- Xing Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, NO.1 Yixueyuan Rd. Yuzhong District, 400016, Chongqing, China
| | - Hongnian Chen
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, NO.1 Yixueyuan Rd. Yuzhong District, 400016, Chongqing, China
| | - Xiao Zheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, NO.1 Yixueyuan Rd. Yuzhong District, 400016, Chongqing, China.
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Zapata Barco AM, Restrepo-Martínez M, Restrepo D. Depression in People with Epilepsy. What is the Connection? REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 49:53-61. [PMID: 32081210 DOI: 10.1016/j.rcp.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/25/2017] [Accepted: 10/22/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Depression is the most common psychiatric comorbidity in people with epilepsy. It worsens the prognosis and quality of life of these patients. Despite this, depression is poorly diagnosed and when the treatment is given, it is frequently suboptimal. OBJECTIVE To perform a narrative review of the medical literature, seeking to collect useful information regarding the relationship between epilepsy and depression. RESULTS Narrative reviews, systematic reviews, meta-analyses, clinical trials, and follow-up studies were identified in English and Spanish with no time limit, including epidemiological, clinical, associated factors, etiological explanations, diagnostic and therapeutic approaches to comorbid depression in epilepsy. CONCLUSION The relationship between epilepsy and depression is complex. The available scientific evidence suggests the possibility of a bidirectional relationship that could be explained from common aetiopathogenic mechanisms. Despite the high prevalence of depression in epileptic patients, this mental disorder continues to be poorly identified by clinicians. To improve this, we have easy-to-apply instruments that routinely screen this patient population and contribute substantially to making the problem more visible and seek to improve the quality of life for this population.
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The psychopharmacology of epilepsy. HANDBOOK OF CLINICAL NEUROLOGY 2019. [PMID: 31727213 DOI: 10.1016/b978-0-444-64012-3.00012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Epilepsy affects 1% of the world's population and is defined as two or more unprovoked seizures. Psychiatric conditions (depression, psychosis, anxiety, and attention deficit hyperactivity disorder (ADHD)) may coexist and are linked to negative seizure outcomes and poorer quality of life. There is an increasing body of evidence to suggest a bidirectional relationship between epilepsy and psychiatric disorders, which may imply shared pathophysiologic mechanisms. Extensive research has examined neurobiologic and neuroanatomic substrates for this association revealing some interesting similarities. Psychiatric disorders in people with epilepsy often go underdiagnosed and undertreated, due to fears of exacerbating psychiatric symptoms or provoking seizures, which may cause delays in optimal management. This chapter covers psychiatric conditions in epilepsy largely focusing on depressive disorders and psychotic disorders. Anxiety and ADHD in association with epilepsy are also discussed. Epidemiology, pathophysiologic mechanisms, and pharmacotherapies used to treat epilepsy and psychiatric disorders are also covered.
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Dreier JW, Pedersen CB, Gasse C, Christensen J. Antiepileptic Drugs and Suicide: Role of Prior Suicidal Behavior and Parental Psychiatric Disorder. Ann Neurol 2019; 86:951-961. [DOI: 10.1002/ana.25623] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/06/2019] [Accepted: 10/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Julie W. Dreier
- National Center for Register‐Based ResearchAarhus University Aarhus Denmark
- Center for Integrated Register‐Based ResearchAarhus University Aarhus Denmark
| | - Carsten B. Pedersen
- National Center for Register‐Based ResearchAarhus University Aarhus Denmark
- Center for Integrated Register‐Based ResearchAarhus University Aarhus Denmark
- Lundbeck Foundation Initiative for Integrative Psychiatric Research Aarhus Denmark
| | - Christiane Gasse
- National Center for Register‐Based ResearchAarhus University Aarhus Denmark
- Department of Depression and Anxiety and Psychosis Research UnitAarhus University Hospital–Psychiatry Aarhus Denmark
| | - Jakob Christensen
- National Center for Register‐Based ResearchAarhus University Aarhus Denmark
- Department of NeurologyAarhus University Hospital Aarhus Denmark
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Risk factors for suicidal tendency in adult patients with epilepsy in China. Epilepsy Behav 2019; 97:118-122. [PMID: 31234043 DOI: 10.1016/j.yebeh.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/01/2019] [Accepted: 06/02/2019] [Indexed: 01/18/2023]
Abstract
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.
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Li Q, Zhu LN, Wang HJ, Lin X, Xu D, Chen D, Zhang Y, Liu L. Validation of the Neurological Disorders Depression Inventory for Epilepsy (NDDIE) as a rapid suicidality screening tool in Chinese people with epilepsy. Epilepsy Behav 2019; 94:216-221. [PMID: 30974350 DOI: 10.1016/j.yebeh.2019.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/17/2019] [Accepted: 03/17/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to validate the Chinese version of the Neurological Disorders Depression Inventory for Epilepsy (NDDIE) as a suicidality screening tool in Chinese people with epilepsy (PWE). METHODS A consecutive cohort of PWE was recruited from West China Hospital and 363 Hospital. Each patient received a psychiatric evaluation with the Mini International Neuropsychiatric Interview (MINI) and the Chinese version of the NDDIE (C-NDDIE). Demographic and clinical characteristics were collected. Receiver operating characteristic (ROC) curve analysis was conducted. The best possible cutoff was identified with the highest Youden index. Specificity, sensitivity, positive, and negative predictive values were calculated. RESULTS Among a total of 355 participants, 41 (11.5%) had a moderate to high suicide risk according to the Suicidality Module (SM) of the MINI. Receiver operating characteristic (ROC) curve analysis showed that item 4 ("I'd be better off dead") of the NDDIE had an area under the curve (AUC) of 0.930 (95% confidence interval [CI] = 0.884-0.977), a sensitivity of 80.5%, a specificity of 94.9%, a positive predictive value (PPV) of 68.0%, a negative predictive value (NPV) of 97.7%, and the largest Youden index of 0.754 for a cutoff score of >2. CONCLUSION Item 4 of the NDDIE is a valuable tool for screening suicidality in Chinese PWE.
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Affiliation(s)
- Qian Li
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China; Department of Neurology, 363 Hospital, Daosangshu Road 108#, Chengdu, Sichuan 610041, China
| | - Li-Na Zhu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China
| | - Hai-Jiao Wang
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China
| | - Xu Lin
- Department of Neurology, 363 Hospital, Daosangshu Road 108#, Chengdu, Sichuan 610041, China
| | - Da Xu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China
| | - Yu Zhang
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37#, Chengdu, Sichuan 610041, China.
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Kwon OY, Park SP. Usefulness of the Liverpool Adverse Events Profile for predicting a high risk of suicidality in people with drug-resistant epilepsy. Seizure 2019; 67:65-70. [PMID: 30909164 DOI: 10.1016/j.seizure.2019.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/16/2019] [Accepted: 03/19/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Suicidality including suicidal ideation and attempt has been a critical issue in people with epilepsy, especially in people with drug-resistant epilepsy (PWDRE). Clinicians commonly ask about adverse effects of antiepileptic drugs (AEDs) using something like the Liverpool Adverse Events Profile (LAEP) at epilepsy clinics, but suicide is usually not of interest. A high risk of suicidality can increase mortality by committing suicide in PWDRE. This study aimed to investigate whether clinicians can discern a high risk of suicidality in PWDRE by referring to the LAEP. METHODS We recruited PWDRE, aged from 19 to 68. They completed the 21-item LAEP, the suicidality module of the Mini International Neuropsychiatric Interview, and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Through receiver operating characteristic curve analysis, we tested the usefulness of LAEP to detect a high risk of suicide. By this, we determined each cutoff point of the total LAEP score and the number of severe LAEP items, for detecting the risk. RESULTS A hundred forty-four PWDRE participated in this study. Among them, 36 PWDRE (25.0%) had a high risk of suicidality. Either >45 of the total LAEP score or >8 of the number of severe LAEP items was a suggested optimal cutoff point for discerning the high risk of suicidality. LAEP had a correlation with the suicidality item of the NDDI-E. CONCLUSION The LAEP may inform a high risk of suicidality in PWDRE. Referring to this, clinicians can discern suicidal problems in their epilepsy clinics.
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Affiliation(s)
- Oh-Young Kwon
- Department of Neurology and Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Sung-Pa Park
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
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Abstract
The aims of this study were to assess the association between gabapentin and suicidality in patients diagnosed with bipolar disorder (BD) and to determine whether the risk is greater relative to patients prescribed lithium. This retrospective observational study utilizes US population-based claims data assembled by PharMetrics Inc., comprising 47 918 patients diagnosed with BD. Patients were included if they were at least 18 years old and initiated a new monotherapy prescription of either gabapentin (n=2421) or lithium (n=3101). Patients were followed for up to 1 year. Gabapentin patients contributed 915.8 person-years (PY) of follow-up time; lithium patients contributed 1421.3 PY. There were 21 suicide/self-harm events in the gabapentin group and 16 in the lithium group. Unadjusted incidence rates were 22.9 and 11.3/1000 PY in the gabapentin and lithium groups, respectively (P=0.03). After adjusting for concomitant medications, comorbid diagnoses, age, sex, and history of suicide/self-harm, the hazard ratio was 2.3 (95% confidence interval: 1.2-4.5). A propensity score-matched analysis accounting for pre-existing illnesses and medications supports this finding, with an adjusted hazard ratio of 2.1 (95% confidence interval: 1.02-4.5). Relative to lithium, the use of gabapentin is significantly associated with a doubling of the risk of suicidality in patients diagnosed with BD.
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Raju Sagiraju HK, Wang CP, Amuan ME, Van Cott AC, Altalib HH, Pugh MJV. Antiepileptic drugs and suicide-related behavior: Is it the drug or comorbidity? Neurol Clin Pract 2018; 8:331-339. [PMID: 30140585 DOI: 10.1212/cpj.0000000000000489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/11/2018] [Indexed: 11/15/2022]
Abstract
Background We sought to compare trends of suicide-related behavior (SRB) before and after initiation of antiepileptic drug (AED) therapy among AED users (with and without epilepsy) to that of individuals without AED use controlling for sociodemographic characteristics and mental health comorbidity. Methods We used national Veterans Health Administration (VHA) data for post-9/11 veterans who received VHA care (2013-2014) without prior AED use. We conducted generalized estimation equation (GEE) analyses, stratified by epilepsy status and type of AED received, to assess the trend of SRB prevalence the year prior to and after the index date (date of first AED prescription/date of first health care encounter for non-AED users) controlling for sociodemographic factors and mental health comorbidity. Results The GEE analysis showed significant curvilinear trends of SRB prevalence over the 24-month study period among the AED users, indicating that the probability of SRB diagnoses increased over time with a peak before the index month and decreased thereafter. Similar patterns were observed among non-AED users, but significantly lower odds for SRB. Among AED users, there were no significant differences by epilepsy status; however, higher SRB prevalence and differential SRB trajectory measures were observed among those who received AEDs with mood-stabilizing action. Conclusions The peak of SRB prior to and rapid reduction in SRB after initiation of AED, and the finding that individuals eventually prescribed a mood-stabilizing AED (vs other AED or levetiracetam) had higher odds of SRB, suggests a strong possibility that the relationship of AED and SRB is one of residual confounding.
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Affiliation(s)
- Hari K Raju Sagiraju
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Chen-Pin Wang
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Megan E Amuan
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Anne C Van Cott
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Hamada H Altalib
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
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Abstract
Epilepsy affects all age groups and is one of the most common and most disabling neurological disorders. The accurate diagnosis of seizures is essential as some patients will be misdiagnosed with epilepsy, whereas others will receive an incorrect diagnosis. Indeed, errors in diagnosis are common, and many patients fail to receive the correct treatment, which often has severe consequences. Although many patients have seizure control using a single medication, others require multiple medications, resective surgery, neuromodulation devices or dietary therapies. In addition, one-third of patients will continue to have uncontrolled seizures. Epilepsy can substantially impair quality of life owing to seizures, comorbid mood and psychiatric disorders, cognitive deficits and adverse effects of medications. In addition, seizures can be fatal owing to direct effects on autonomic and arousal functions or owing to indirect effects such as drowning and other accidents. Deciphering the pathophysiology of epilepsy has advanced the understanding of the cellular and molecular events initiated by pathogenetic insults that transform normal circuits into epileptic circuits (epileptogenesis) and the mechanisms that generate seizures (ictogenesis). The discovery of >500 genes associated with epilepsy has led to new animal models, more precise diagnoses and, in some cases, targeted therapies.
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Affiliation(s)
- Orrin Devinsky
- Departments of Neurology, Neuroscience, Neurosurgery and Psychiatry, NYU School of Medicine, New York, NY, USA
| | - Annamaria Vezzani
- Laboratory of Experimental Neurology, Department of Neuroscience, IRCCS 'Mario Negri' Institute for Pharmacological Research, Milan, Italy
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Departments of Neurology and Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nathalie Jette
- Department of Neurology and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, Austin Health, The University of Melbourne, Melbourne, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, and Department of Neurology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Departments of Neurology and Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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Gasse C, Danielsen AA, Pedersen MG, Pedersen CB, Mors O, Christensen J. Positive predictive value of a register-based algorithm using the Danish National Registries to identify suicidal events. Pharmacoepidemiol Drug Saf 2018; 27:1131-1138. [DOI: 10.1002/pds.4433] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/04/2017] [Accepted: 03/06/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Christiane Gasse
- National Centre for Register-based Research; Aarhus University; Aarhus Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH); Aarhus Denmark
| | - Andreas Aalkjaer Danielsen
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH); Aarhus Denmark
- Psychosis Research Unit; Aarhus University Hospital; Risskov Denmark
| | - Marianne Giørtz Pedersen
- National Centre for Register-based Research; Aarhus University; Aarhus Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH); Aarhus Denmark
| | - Carsten Bøcker Pedersen
- National Centre for Register-based Research; Aarhus University; Aarhus Denmark
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH); Aarhus Denmark
- Centre for Integrated Register-Based Research at Aarhus University (CIRRAU); Aarhus Denmark
| | - Ole Mors
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH); Aarhus Denmark
- Psychosis Research Unit; Aarhus University Hospital; Risskov Denmark
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Kellermann TS, Mueller M, Carter EG, Brooks B, Smith G, Kopp OJ, Wagner JL. Prediction of specific depressive symptom clusters in youth with epilepsy: The NDDI-E-Y versus Neuro-QOL SF. Epilepsia 2017; 58:1370-1379. [DOI: 10.1111/epi.13808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Tanja S. Kellermann
- Department of Neurosurgery; Medical University of South Carolina; Charleston South Carolina U.S.A
| | - Martina Mueller
- College of Nursing; Medical University of South Carolina; Charleston South Carolina U.S.A
| | - Emma G. Carter
- Department of Neurology; Medical University of South Carolina; Charleston South Carolina U.S.A
| | - Byron Brooks
- Department of Psychology; East Tennessee State University; Johnson City Tennessee U.S.A
| | - Gigi Smith
- College of Nursing; Medical University of South Carolina; Charleston South Carolina U.S.A
- Comprehensive Epilepsy Program; Medical University of South Carolina; Charleston South Carolina U.S.A
- Department of Pediatrics; Medical University of South Carolina; Charleston South Carolina U.S.A
| | | | - Janelle L. Wagner
- College of Nursing; Medical University of South Carolina; Charleston South Carolina U.S.A
- Comprehensive Epilepsy Program; Medical University of South Carolina; Charleston South Carolina U.S.A
- Department of Pediatrics; Medical University of South Carolina; Charleston South Carolina U.S.A
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Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, Kasper S, Moeller HJ. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 2: Review, Grading of the Evidence, and a Precise Algorithm. Int J Neuropsychopharmacol 2017; 20:121-179. [PMID: 27816941 PMCID: PMC5409012 DOI: 10.1093/ijnp/pyw100] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 02/05/2023] Open
Abstract
Background The current paper includes a systematic search of the literature, a detailed presentation of the results, and a grading of treatment options in terms of efficacy and tolerability/safety. Material and Methods The PRISMA method was used in the literature search with the combination of the words 'bipolar,' 'manic,' 'mania,' 'manic depression,' and 'manic depressive' with 'randomized,' and 'algorithms' with 'mania,' 'manic,' 'bipolar,' 'manic-depressive,' or 'manic depression.' Relevant web pages and review articles were also reviewed. Results The current report is based on the analysis of 57 guideline papers and 531 published papers related to RCTs, reviews, posthoc, or meta-analysis papers to March 25, 2016. The specific treatment options for acute mania, mixed episodes, acute bipolar depression, maintenance phase, psychotic and mixed features, anxiety, and rapid cycling were evaluated with regards to efficacy. Existing treatment guidelines were also reviewed. Finally, Tables reflecting efficacy and recommendation levels were created that led to the development of a precise algorithm that still has to prove its feasibility in everyday clinical practice. Conclusions A systematic literature search was conducted on the pharmacological treatment of bipolar disorder to identify all relevant random controlled trials pertaining to all aspects of bipolar disorder and graded the data according to a predetermined method to develop a precise treatment algorithm for management of various phases of bipolar disorder. It is important to note that the some of the recommendations in the treatment algorithm were based on the secondary outcome data from posthoc analyses.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Lakshmi Yatham
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Heinz Grunze
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Eduard Vieta
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Allan Young
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Pierre Blier
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Siegfried Kasper
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Hans Jurgen Moeller
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
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Grimaldi-Bensouda L, Nordon C, Rossignol M, Jardon V, Boss V, Warembourg F, Reynolds R, Kurz X, Rouillon F, Abenhaim L. Antiepileptic drugs and risk of suicide attempts: a case-control study exploring the impact of underlying medical conditions. Pharmacoepidemiol Drug Saf 2017; 26:239-247. [DOI: 10.1002/pds.4160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 10/05/2016] [Accepted: 12/05/2016] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Michel Rossignol
- Department of Epidemiology, Biostatistics and Occupational Health; McGill University; Montreal Canada
| | - Vincent Jardon
- Service de Psychiatrie; Centre Hospitalier Régional Universitaire de Lille; Lille France
| | - Virginie Boss
- Service de Psychiatrie; Centre Hospitalier Régional Universitaire de Lille; Lille France
| | - Frédérique Warembourg
- Service de Psychiatrie; Centre Hospitalier Régional Universitaire de Lille; Lille France
| | | | - Xavier Kurz
- Inspections & Human Medicines, Monitoring & Incident Management; European Medicines Agency; London UK
| | - Frédéric Rouillon
- Clinique des Maladies Mentales et de l'Encéphale, Centre Hospitalier Sainte Anne; Université Paris V René Descartes; Paris France
| | - Lucien Abenhaim
- LASER Research; Paris France
- Department of Epidemiology; London School of Hygiene & Tropical Medicine; London UK
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Cai L. Traditional Chinese Herbal Medicine for Epilepsy Treatment Should Be Administered According to the Seizure Type and Epileptic Syndrome. Health (London) 2017. [DOI: 10.4236/health.2017.98087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Mood disorders associated with epilepsy are very common and overrepresented compared with other chronic medical conditions. Depression is a particularly common and worrisome comorbidity, especially because suicidality seems to be increased significantly in the context of epilepsy. Although psychosocial stressors commonly are associated, intrinsic characteristics of seizure disorders may contribute to the expression of depressive symptoms. Depression and epilepsy may exacerbate each other. Epilepsy with seizure foci in the temporal lobe may represent a higher risk of developing depression, especially if the seizures do not generalize. Treatment of depression is multifaceted and includes psychotherapy and sophisticated regimens of anticonvulsants. Most antidepressants may be used safely and effectively in the context of depression, although high-quality evidence is lacking. Ultimately, treatment of comorbid mood disorder has important implications for outcome and quality of life, perhaps even more than treatment of epilepsy itself.
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Affiliation(s)
- Jay Salpekar
- Dr. Salpekar is director of the Neuropsychiatry and Epilepsy Program, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore (e-mail: )
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Thibault DP, Mendizabal A, Abend NS, Davis KA, Crispo J, Willis AW. Hospital care for mental health and substance abuse in children with epilepsy. Epilepsy Behav 2016; 57:161-166. [PMID: 26963820 PMCID: PMC5347535 DOI: 10.1016/j.yebeh.2016.01.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/18/2016] [Accepted: 01/30/2016] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Dylan P Thibault
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States
| | | | - Nicholas S Abend
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; The Children's Hospital of Philadelphia, United States
| | - Kathryn A Davis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Penn Epilepsy Center, United States
| | - James Crispo
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States; McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
| | - Allison W Willis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, United States
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Mula M, McGonigal A, Micoulaud-Franchi JA, May TW, Labudda K, Brandt C. Validation of rapid suicidality screening in epilepsy using the NDDIE. Epilepsia 2016; 57:949-55. [PMID: 27012840 DOI: 10.1111/epi.13373] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Marco Mula
- Epilepsy Group; Atkinson Morley Regional Neuroscience Centre; St. George's University Hospitals NHS Foundation Trust; London United Kingdom
- South West London & St. George's Mental Health Trust; London United Kingdom
- Institute of Medical and Biomedical Sciences; St. George's University of London; London United Kingdom
| | - Aileen McGonigal
- Aix Marseille University; Inserm; INS UMR_S 1106; Marseille France
- Clinical Neurophysiology Department; Timone Hospital; Marseille France
| | - Jean-Arthur Micoulaud-Franchi
- Neurophysiological Unit, Sleep Clinic; Bordeaux University Hospital; CHU Pellegrin; Bordeaux France
- USR CNRS 3413 SANPSY; Bordeaux University; CHU Pellegrin; Bordeaux France
| | | | - Kirsten Labudda
- Department of Clinical Neuropsychology and Epilepsy Research; University of Bielefeld; Bielefeld Germany
- Bethel Epilepsy Center; Mara Hospital; Bielefeld Germany
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Abstract
The treatment of epileptic seizure disorders is not restricted to the achievement of seizure-freedom, but must also include the management of comorbid medical, neurological, psychiatric and cognitive comorbidities. Psychiatric and neurological comorbidities are relatively common and often co-exist in people with epilepsy (PWE). For example, depression and anxiety disorders are the most common psychiatric comorbidities in PWE, and they are particularly common in PWE who also have a neurological comorbidity, such as migraine, stroke, traumatic brain injury or dementia. Moreover, psychiatric and neurological comorbodities often have a more severe impact on the quality of life in patients with treatment-resistant focal epilepsy than do the actual seizures. Epilepsy and psychiatric and neurological comorbidities have a complex relationship, which has a direct bearing on the management of both seizures and the comorbidities: the comorbidities have to be factored into the selection of antiepileptic drugs, and the susceptibility to seizures has to be considered when choosing the drugs to treat comorbidities. The aim of this Review is to highlight the complex relationship between epilepsy and common psychiatric and neurological comorbidities, and provide an overview of how treatment strategies for epilepsy can positively and negatively affect these comorbidities and vice versa.
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Abstract
OBJECTIVES To establish which non-psychotropic medications have been assessed in relation to risk of suicide or attempted suicide in observational studies, document reported associations and consider study strengths and limitations. DESIGN Systematic review. METHODS Four databases (Embase, Medline, PsycINFO and International Pharmaceutical Abstracts) were searched from 1990 to June 2014, and reference lists of included articles were hand-searched. Case-control, cohort and case only studies which reported suicide or attempted suicide in association with any non-psychotropic medication were included. OUTCOME MEASURES The outcomes eligible for inclusion were suicide and attempted suicide, as defined by the authors of the included study. RESULTS Of 11,792 retrieved articles, 19 were eligible for inclusion. Five studies considered cardiovascular medication and antiepileptics; two considered leukotriene receptor antagonists, isotretinoin and corticosteroids; one assessed antibiotics and another assessed varenicline. An additional study compared multiple medications prescribed to suicide cases versus controls. There was marked heterogeneity in study design, outcome and exposure classification, and control for confounding factors; particularly comorbid mental and physical illness. No increased risk was associated with cardiovascular medications, but associations with other medications remained inconclusive and meta-analysis was inappropriate due to study heterogeneity. CONCLUSIONS Whether non-psychotropic medications are associated with increased risk of suicide or attempted suicide remains largely unknown. Robust identification of suicide outcomes and control of comorbidities could improve quantification of risk associated with non-psychotropic medication, beyond that conferred by underlying physical and mental illnesses.
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Affiliation(s)
- Hayley C Gorton
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Roger T Webb
- Centre for Suicide Prevention, Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Navneet Kapur
- Centre for Suicide Prevention, Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
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Knott S, Forty L, Craddock N, Thomas RH. Epilepsy and bipolar disorder. Epilepsy Behav 2015; 52:267-74. [PMID: 26316422 DOI: 10.1016/j.yebeh.2015.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 01/30/2023]
Abstract
It is well recognized that mood disorders and epilepsy commonly co-occur. Despite this, our knowledge regarding the relationship between epilepsy and bipolar disorder is limited. Several shared features between the two disorders, such as their episodic nature and potential to run a chronic course, and the efficacy of some antiepileptic medications in the prophylaxis of both disorders, are often cited as evidence of possible shared underlying pathophysiology. The present paper aims to review the bidirectional associations between epilepsy and bipolar disorder, with a focus on epidemiological links, evidence for shared etiology, and the impact of these disorders on both the individual and wider society. Better recognition and understanding of these two complex disorders, along with an integrated clinical approach, are crucial for improved evaluation and management of comorbid epilepsy and mood disorders.
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Affiliation(s)
- Sarah Knott
- MRC Centre for Neuropsychiatric Genetics and Genomics, Haydn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK.
| | - Liz Forty
- MRC Centre for Neuropsychiatric Genetics and Genomics, Haydn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK.
| | - Nick Craddock
- MRC Centre for Neuropsychiatric Genetics and Genomics, Haydn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK.
| | - Rhys H Thomas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Haydn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK.
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Tuft M, Gjelsvik B, Nakken KO. Ian Curtis: Punk rock, epilepsy, and suicide. Epilepsy Behav 2015; 52:218-21. [PMID: 26496010 DOI: 10.1016/j.yebeh.2015.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/12/2015] [Accepted: 08/13/2015] [Indexed: 11/28/2022]
Abstract
Ian Curtis was the front man of the post-punk band Joy Division. He suffered from epilepsy and actively incorporated his experiences of the disease in his lyrics. Curtis had frequent epileptic seizures, both on and off stage. After dying from suicide in 1980, he became a legend in the post-punk milieu. The impact which the epilepsy, the epilepsy treatment, and comorbid depression had on his artistic life and premature death is not well known.
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Affiliation(s)
- Mia Tuft
- Neuropsychology Centre, Oslo, Norway.
| | - Bergljot Gjelsvik
- University of Oxford, Department of Psychiatry, Oxford Mindfulness Centre, Warneford Hospital, United Kingdom.
| | - Karl O Nakken
- National Centre for Epilepsy, Oslo University Hospital, Norway.
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Comorbidity of childhood epilepsy. J Formos Med Assoc 2015; 114:1031-8. [PMID: 26341150 DOI: 10.1016/j.jfma.2015.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 07/02/2015] [Accepted: 07/02/2015] [Indexed: 11/20/2022] Open
Abstract
Epilepsy in children is occasionally associated with variable comorbidities although the frequency of such comorbidity is often difficult to determine. They can be divided into three categories: neurological, psychological, and physical comorbidities. The goal of the present review is to discuss the reported comorbidities of epilepsy in children. The possible mechanisms and associated risk factors-including the effect of seizure frequency and seizure control, types of epilepsy, age of seizure onset, duration of illness, and the possible detrimental effect of antiepileptic drugs-will be described.
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Mula M, Sander JW. Suicide and epilepsy: do antiepileptic drugs increase the risk? Expert Opin Drug Saf 2015; 14:553-8. [DOI: 10.1517/14740338.2015.1010506] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vagus Nerve Stimulation has Antidepressant Effects in the Kainic Acid Model for Temporal Lobe Epilepsy. Brain Stimul 2015; 8:13-20. [DOI: 10.1016/j.brs.2014.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 09/04/2014] [Accepted: 09/22/2014] [Indexed: 11/22/2022] Open
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Fountoulakis KN, Gonda X, Baghai TC, Baldwin DS, Bauer M, Blier P, Gattaz W, Hasler G, Möller HJ, Tandon R, Vieta E, Kasper S. Report of the WPA section of pharmacopsychiatry on the relationship of antiepileptic drugs with suicidality in epilepsy. Int J Psychiatry Clin Pract 2015; 19:158-67. [PMID: 25547437 DOI: 10.3109/13651501.2014.1000930] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This report from the World Psychiatric Association Section on Pharmacopsychiatry examines the possible relationship of antiepileptic drugs with suicide-related clinical features and behaviors in patients with epilepsy. MATERIALS AND METHODS A systematic review of the MEDLINE search returned 1039 papers, of which only 8 were considered relevant. A critical analysis of the Food and Drug Administration (FDA) report on the increase risk for patients under antiepileptics to manifest suicidality is also included in this report. RESULTS The analysis of these studies revealed that the data are not supportive of the presence of a "class effect" on suicide-related behavior; on the contrary, there are some data suggesting such an effect concerning treatment with topiramate, lamotrigine, and levetiracetam for which further research is needed. DISCUSSION For the majority of people with epilepsy, anticonvulsant treatment is necessary and its failure for any reason is expected to have deleterious consequences. Therefore, clinicians should inform patients and their families of this increased risk of suicidal ideation and behavior, but should not overemphasize the issue. Specific subgroups of patients with epilepsy might be at a higher risk, and deserve closer monitoring and follow-up. Future research with antiepileptics should specifically focus on depression and suicidal thoughts.
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Abstract
BACKGROUND Depressive disorders are the most common psychiatric comorbidity in patients with epilepsy, affecting around one-third, with a significant negative impact on quality of life. There is concern that patients may not be receiving appropriate treatment for their depression because of uncertainty regarding which antidepressant or class works best and the perceived risk of exacerbating seizures. This review aims to address these issues and inform clinical practice and future research. OBJECTIVES We aimed to review and synthesise evidence from randomised controlled trials of antidepressants and prospective non-randomised studies of antidepressants used for treating depression in patients with epilepsy. The primary objectives were to evaluate the efficacy and safety of antidepressants in treating depressive symptoms and the effect on seizure recurrence. SEARCH METHODS We conducted a search of the following databases: the Cochrane Epilepsy Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (Ovid), SCOPUS, PsycINFO, www.clinicaltrials.gov and conference proceedings, including studies published up to 31 May 2014. There were no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) and prospective non-randomised cohort controlled and uncontrolled studies investigating children or adults with epilepsy treated with an antidepressant for depressive symptoms. The intervention group consisted of patients receiving an antidepressant drug in addition to an existing antiepileptic drug regimen. The control group(s) consisted of patients receiving a placebo, comparative antidepressant, psychotherapy or no treatment in addition to an existing antiepileptic drug regimen. DATA COLLECTION AND ANALYSIS We extracted data on trial design factors, patient demographics and outcomes for each study. The primary outcomes were changes in depression scores (proportion with a greater than 50% improvement or mean difference) and change in seizure frequency (mean difference or proportion with a seizure recurrence or episode of status epilepticus, or both). Secondary outcomes included the number of patients withdrawing from the study and reasons for withdrawal, as well as any adverse events. Two authors undertook data extraction separately for each included study. We then cross-checked the data extraction. We assessed risk of bias using a version of the extended Cochrane Collaboration tool for assessing risk of bias in both randomised and non-randomised studies. We presented binary outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We presented continuous outcomes as standardised mean differences (SMDs) with 95% CIs, and mean differences (MDs) with 95% CIs. If possible we intended to use meta-regression techniques to investigate possible sources of heterogeneity however this was not possible due to lack of data. MAIN RESULTS We included in the review eight studies (three RCTs and five prospective cohort studies) including 471 patients with epilepsy treated with an antidepressant. The RCTs were all single-centre studies comparing an antidepressant versus active control, placebo or no treatment. The five non-randomised prospective cohort studies reported on outcomes mainly in patients with partial epilepsy treated for depression with a selective serotonin reuptake inhibitor (SSRI). We rated all the RCTs and one prospective cohort study as having unclear risk of bias. We rated the four other prospective cohort studies as having high risk of bias. We were unable to perform any meta-analysis for the proportion with a greater than 50% improvement in depression scores because the studies reported on different treatment comparisons. The results are presented descriptively and show a varied responder rate of between 24% and 97%, depending on the antidepressant given. For the mean difference in depression score we were able to perform a limited meta-analysis of two prospective cohort studies of citalopram, including a total of 88 patients. This gave low quality evidence for the effect estimate of 1.17 (95% CI 0.96 to 1.38) in depression scores. Seizure frequency data were not reported in any RCTs and we were unable to perform any meta-analysis for prospective cohort studies due to the different treatment comparisons. The results are presented descriptively and show that treatment in three studies with a selective serotonin reuptake inhibitor did not significantly increase seizure frequency. Patients given an antidepressant were more likely to withdraw due to adverse events than inefficacy. Reported adverse events for SSRIs included nausea, dizziness, sedation, gastrointestinal disturbance and sexual dysfunction. Across three comparisons we rated the evidence as moderate quality due to the small sizes of the contributing studies and only one study each contributing to the comparisons. We rated the evidence for the final comparison as low quality as there was concern over the study methods in the two contributing studies. AUTHORS' CONCLUSIONS Existing evidence on the effectiveness of antidepressants in treating depressive symptoms associated with epilepsy is very limited. Only one small RCT demonstrated a statistically significant effect of venlafaxine on depressive symptoms. We have no high quality evidence to inform the choice of antidepressant drug or class of drug in treating depression in people with epilepsy. This review provides low quality evidence of safety in terms of seizure exacerbation with SSRIs, but there are no available comparative data on antidepressant classes and safety in relation to seizures. There are currently no comparative data on antidepressants and psychotherapy in treating depression in epilepsy, although psychotherapy could be considered in patients unwilling to take antidepressants or where there are unacceptable side effects. Further comparative clinical trials of antidepressants and psychotherapy in large cohorts of patients with epilepsy and depression are required to better inform treatment policy in the future.
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Affiliation(s)
- Melissa J Maguire
- Department of Neurology, Leeds General Infirmary, Great George Street, Leeds, UK. .
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Mula M. Comments on Jones JE et al. Rates and risk factors for suicide, suicidal ideation, and suicide attempts in chronic epilepsy. Epilepsy & Behavior 2003;4(Suppl. 3):S31-38. Epilepsy Behav 2014; 40:16-7. [PMID: 25440831 DOI: 10.1016/j.yebeh.2014.08.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/30/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Marco Mula
- Epilepsy Group, Atkinson Morley Regional Neuroscience Centre, St. George's Hospital, UK; Institute of Medical and Biomedical Sciences, St. George's University of London, UK.
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