Suicide and Seizures: A National Cohort Study in Veterans

Psychosocial Burden and Suicidality in Epilepsy: A Public Health Concern

The increased risk for psychosocial burden and suicidality in people with epilepsy compared to the general population is a well-established global public health concern. Suicidality risk is also increased in patients with functional seizures. The timely identification of patients at highest risk for psychosocial burden and self-harm is vital. This can pose a significant challenge for multidisciplinary clinicians caring for people with epilepsy. Early identification of social stressors and comorbid psychiatric contributors via screening are required to assist with the development of predictive models for self-harm in epilepsy; and subsequent options for treatment and the provision of adjunct supports in the community may help lead to evidence-based suicide prevention strategies for people with epilepsy. Too often, pervasive and common social stressors leading to self-harm go unrecognized and undertreated. Elevating clinician awareness of patient subpopulations at highest risk for suicide, and informing on the advent of evidence-based self-management programs targeting depression and self-harm presents an opportunity to increase suicide prevention in epilepsy.

Elevated suicide risk in individuals with epilepsy: a systematic review and meta-analysis

OBJECTIVE

Suicide is among the top 10 leading causes of death. Epilepsy is associated with increased diagnoses of psychiatric conditions. Approximately 5% of deaths in people with epilepsy (PwE) are caused by suicide. We aim to compare the suicide incidence in PwE vs. people without epilepsy.

METHODS

A systematic review was performed looking at suicide incidence among PwE compared to persons without epilepsy. The reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed in this study. The search included records until February 2024 in Ovid® MEDLINE, Embase®, and PsycINFO. Abstracts were screened in duplicate and extracted using standard proforma. Data were recorded on the incidence of suicide ideation, attempt, or completed suicide in PwE compared to persons without epilepsy. Meta-analyses were performed along with descriptive analyses.

RESULTS

Out of a total of 7,371 records identified from the systematic search, 13 met the eligibility criteria. Meta-analysis showed a significantly higher incidence proportion of suicide ideation in PwE than those without epilepsy (risk ratio [RR]: 2.06, 95% CI 1.47-2.89). For suicide attempts, incidence proportion (RR: 3.62, 95% CI 2.88-4.55), incidence rate (incidence rate ratio [IRR]: 4.94, 95% CI 4.44-5.50) and hazard (adjusted hazard ratio [HR]: 2.32, 95% CI 2.17-2.48) were all significantly higher in PwE vs. people without epilepsy. Lastly, incidence proportion (RR: 2.39, 95% CI 1.28-4.47), incidence rate (IRR: 2.26, 95% CI 2.13-2.40), and hazard (adjusted HR: 2.50, 95% CI 1.99-3.16) of completed suicide were all significantly higher in PwE than those without epilepsy.

SIGNIFICANCE

The incidence of suicide ideation, suicide attempt, and completed suicide were significantly higher in PwE compared to people without epilepsy. Comprehensive support systems to educate, diagnose, and manage epilepsy and concurrent psychiatric conditions in PwE are highly suggested.

Depression, anxiety, stress, and suicide risk in patients with functional seizures vs. those with epilepsy

BACKGROUND

We aimed to investigate the rates of positive screening for depression, anxiety, stress, and suicide risk in adults with seizures [i.e., well-matched groups of patients with focal epilepsy vs. idiopathic generalized epilepsy (IGE) vs. functional seizures (FS)].

METHODS

This was a cross sectional study. Patients, 19-55 years of age, with a diagnosis of IGE, focal epilepsy or FS were investigated at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from September 2022 until January 2023 and during their follow-up visits. We used the validated Farsi version of DASS-21 (Depression-Anxiety-Stress Scale) to investigate and screen for depression, anxiety, and stress in these patients. We also used the Beck Scale for Suicide Ideation (BSSI).

RESULTS

Forty patients with focal epilepsy, 40 persons with IGE, and 40 individuals with FS were included. Depression and anxiety were more prevalent among patients with FS compared with those with epilepsy. The rate of stress among patients with FS was not significantly different compared with that in patients with epilepsy. The suicide risks were not significantly different between the groups either.

CONCLUSION

Patients with FS are at high risk for psychiatric comorbidities that is comparable or even worse than that in patients with epilepsy. Specific validated scales to screen for psychiatric comorbidities and suicide risk should be integral components of the evaluation and treatment of all patients with seizures.

Severity features of suicide attempters with epilepsy

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Increased suicide attempt risk in people with epilepsy in the presence of concurrent psychogenic nonepileptic seizures

OBJECTIVES

To test the hypothesis that people with concurrent diagnosis of epilepsy and psychogenic nonepileptic seizures (PNES) are at increased risk of attempting suicide as compared to people with epilepsy or PNES alone. To report on suicide rates.

METHODS

Retrospective cohort study from the UK largest tertiary mental health care provider, with linked nationwide admission and mortality data from the Hospital Episode Statistics and Office for National Statistics. Participants were 2460 people with a primary or secondary diagnosis of epilepsy, PNES or concurrent epilepsy and PNES attending between 1 January 2007 and 18 June 2021. The primary outcome was a first hospital admission for suicide attempt (International Classification of Diseases, version 10 X60-X84).

RESULTS

9% of participants had at least one suicide attempt-related hospital admission. For people with concurrent diagnosis of epilepsy and PNES, the odds for suicide attempt-related admissions were 2.52 times the odds of people with epilepsy alone (OR 0.40; 95% CI 0.21 to 0.79; p=0.01). Odds were comparable between people with concurrent diagnosis and people with PNES alone (OR 0.75; 95% CI 0.41 to 1.48; p=0.40). Post hoc analyses revealed that the odds of people with PNES alone were 1.93 times the odds of people with epilepsy alone (OR 0.52; 95% CI 0.38 to 0.70; p<0.001).

CONCLUSIONS

People with concurrent diagnosis of epilepsy and PNES or PNES alone have significantly increased odds of hospitalisation due to suicide attempt as compared to people with epilepsy alone (152% and 93% increase, respectively). These findings have direct implications for the clinical management of suicide risk in people with epilepsy.